AAA QUALITY RESIDENTIAL CARE FACILITY

Official classification

Type A

Official code

87633(a)(3)

Regulation authority

CCR

What the official deficiency says

87633(a)(3) Hospice Care of Terminally Ill Residents (a)The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon …(3) Hospice agency services are contracted for by each terminally ill resident or prospective resident individually, or the resident’s or prospective resident's Health Care Surrogate Decision Maker if the resident or prospective resident is incapacitated, not by the licensee on behalf of a resident or prospective resident. These hospice agency services must be provided by a hospice agency both licensed by the state and certified by the federal Medicare program. This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above. Licensee did not notify R1’s conservator (LAPG) that R1 was placed on hospice, which posed an immediate health and safety risk to residents in care.

Official plan of correction

The licensee will review regulations and will submit letter of acknowledgment to LPA Urena via email.

Deadline recorded: Jul 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above as 1 of 4 resident medications reviewed contained inconsistencies with their medication amounts remaining and amounts documented as administered on the centrally stored which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2023 Plan of Correction Administrator agreed to do a complete medication audit for the facility and training for all medication staff and submit documentation to CCL by POC due date.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the above cited section, as medications were observed to be accessible inside the refrigerator, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/21/2023 Plan of Correction Licensee stated they will obtain a lock for the medications that are stored in the refrigerator and ensure all other medications remain locked. Proof of locked medications will be sent to CCL by POC due date.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

87202(a)(2) Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city... Prior to accepting or retaining any of the following types of persons... licensee shall notify the licensing agency...(2) Bedridden persons. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above, R1 is bedridden and does not reside in the bedridden room, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/21/2023 Plan of Correction The Licensee agreed to do the following: 1. Within 24 hours, the licensee will relocate R1 to the bedridden room. Proof to be submitted to CCL by 06/21/2023 - end of day. This is a zero-tolerance violation, resulting in a civil penalty in the amount of $500.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

87457Pre-Admission Appraisal - General(c)Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in which 1 out of 2 residents did not have a pre-admission appraisal completed which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to submit a completed appraisal for Resident #1 to LPA by 09/29/2021.

Deadline recorded: Sep 29, 2021. A deadline is not proof that correction was completed.