HAMPTON GUEST HOME, INC.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above: 1) all staff records are incomplete, either missing LIC 501, 503...etc. 2) Staff#1 and Staff# 2 records were not available for review during visit, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/06/2026 Plan of Correction Administrator agreed to ensure staff records are complete by POC due date

Official classification

Type B

Official code

87506(b)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above as all residents files are missing admission agreement, and the other files were incomplete, either missing TB test result, Personal rights, concent forms, phyisican presciption...etc, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/06/2026 Plan of Correction Administrator agreed to ensure residents records are complete by POC due date

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above: 1) the left, back burner of the stove in the kitchen was not working, 2) the paint on the ceiling at room #4 doorway is peeling, 3) the bathroom cabinet in room #3 has an opening (missing a drawer), which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/06/2026 Plan of Correction Administrator agreed to fix the back burner to make it operatable, repaint the celiing at room #4 doorway, and repair the bathroom cabinet drawer to cover the opening by the POC due date.

Official classification

Type A

Official code

87606(c)

Regulation authority

CCR

What the official deficiency says

(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). 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 in resident #4 is noted as bedridden in physician's report which poses an immediate health, safety or personal rights risk to persons in care. *Immediate $500 Civil Penalties were assess*

Official plan of correction

POC Due Date: 03/01/2024 Plan of Correction Administrator will submit to the department documents for hospice exception request for resident #4 by POC due date 3/1/24.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in staff #4 and #5 do not have a TB clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/14/2024 Plan of Correction Administrator will submit to the department a TB clearance for staff #4 and #5 by POC due date 3/14/24.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in staff #4 does not have current CPR training on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/14/2024 Plan of Correction Administrator will submit to the department a copy of First Aid/CPR training for staff #4 by POC due date 3/14/23.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: 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 in files for staff #4 and #5 were not available for review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/14/2024 Plan of Correction Administrator will submit to the department a copy of health screening/LIC503, LIC 501, employee rights, and training.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 5 out of 5 staff did not have 20 hours of training within the last 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/14/2024 Plan of Correction Administrator will provide 20 hours of training on the topics above for each staff and will submit a copy to the department of sign-in log, duration of training, and topic by POC due date 3/14/24.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in last emergency drill was conducted on 8/1/21 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/07/2024 Plan of Correction Administrator will conduct an emergency drill and submit a copy of log to the department by POC due date 3/7/24.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in resident #5 does not have a current physician report, last physician report dated: 7/22/22 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/14/2024 Plan of Correction Administrator will obtain and submit a copy of physician's report for resident #5 by POC due date 3/14/24.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia: (c) Licensees who accept and retain residents with dementia shall...: (5) ... have an annual medical assessment as specified in Section 87458, Medical Assessment,... done at least annually... This requirement is not met as evidence by: Based on documents review licensee failed to obtain an annual medical assessment for R1 which poses a potential risk to the health, safety, or personal rights to the persons in care.

Official plan of correction

Administrator will ensure to conduct annual medical assessments for residents with dementia and will certify this on a LIC 9098, and will submit current residents medical assessments to the department by POC due date 6/13/23.

Deadline recorded: Jun 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in staff file for S5 was not available at the time of the visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2023 Plan of Correction Administrator will ensure files for each staff are updated and available for review for each staff at all times and will submit personnel record, health screening, tb test, residents personal rights, employee rights for S6 to the department by POC due date 3/31/23.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 5 out of 5 staff files review did not have annual training on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2023 Plan of Correction Administrator will provided additional 20 hours of training for each staff listed on LIC 500 in dementia care, postural support, resctrited health conditions, hospice care and will submit a copy of training to the department by POC due date 3/31/23.

Official classification

Type B

Official code

87507(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 5 out of 5 resident files reviewed did not have an admission agreement available for review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2023 Plan of Correction Administrator will submit a copy of admission agreement for (5) residents to the department by POC due date 3/31/23.

Official classification

Type B

Official code

87555(b)(7)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview, the licensee did not comply with the section cited above in 1 out of 5 residents receives a modified diet as requested by physician which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2023 Plan of Correction Administrator will ensure that R1's special diet needs are met and staff are knowledgeable of the diet needs of resident to ensure preparation of meals is appropiate. Administrator will submit a written acknowledgement of special diet with procedures to ensure special diet needs are met and signed by staff and administrator by POC due date 3/31/23.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 1 out of 5 resident files review, for R4 last physician's report is dated 3/20/19 on file which poses/posed a potential health, safety or personal rights risk o persons in care.

Official plan of correction

POC Due Date: 03/31/2023 Plan of Correction Administrator will obtain a current physician report and will submit a copy to the department by POC due date 3/31/23.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPA observed 2 Lysol sprays, Clorox wipes container, and a hydrogen peroxide in an unlocked hallway closet which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/29/2022 Plan of Correction Administrator will ensure that all cleaning and disinfecting supplies are inaccessible to residents at all times, will provided an in-service training to staff, and submit a copy of sign-in sheet to the department by 3/29/2022.

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication...... 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 in 3 out of 6 residents. R3 and R4 had PRN medications that did not have a label on them and R5 did not have a physician written request for the PRN medication which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/29/2022 Plan of Correction Administrator will obtain a label and written request from the residents physicians and submit the proof to the LPA by 03/29/2022.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. 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 in 3 out of 6 residents. R1, R2, and R3 all have dementia and the physician report in their files are older than 1 year which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/18/2022 Plan of Correction Administrator will obtain a current physician report for the 3 residents and submit to LPA by 04/18/2022.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 in 6 out of 6 staff. S1 - S6 do not have a valid First Aid/CPR certificate in there file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/18/2022 Plan of Correction Administrator will obtain a current First Aid/CPR certificate for the 6 staff and submit to LPA by 04/18/2022.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins,... cleaning supplies and disinfectants. This requirement is not met as evidence by: Based on observation licensee did not ensure that PRN medications for Resident #2 in bedroom #4 were not in nightstand, bleach solution and ajax were not kept under kitchen sink, and lysol, cleaning solutions in hallyway withou lock which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will ensure that all cleaning, disinfecting supplies, and PRN medication are stored inaccessible at all times, will provided in-service training to staff, and submit a copy of sign-in sheet, agenda to the department by 2/18/22

Deadline recorded: Feb 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained...: (2) Faucets used by residents for personal care... Hot water temperature ... of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidence by: Based on observation licensee did not ensure water temperature was within the required temperature in bathroom #1 which tested at 123.1 degrees which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Administrator will ensure that water temperature is withing the required 105 - 120 degrees F at all times by certifying in LIC 9098 will submit form to the department by 2/18/22.

Deadline recorded: Feb 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in all Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidence by: Based on observation administrator did not ensure residents were treated with dignity and the residents rights to privacy by keeping a video survellaince monitor in each resident's rooms and monitor through an app in administrator's cellphone which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator removed all camera monitors from each room during the visit. Deficiency cleared 2/17/22.

Deadline recorded: Feb 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirements is not met as evidence by: Based on observation licenseee did not ensure large scissors were not kept in drawer by stove which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Administrator will ensure that all sharps, tools, are kept locked at all times and will provide in-service training to staff, will submit copy of sign-in sheet, and agenda by 2/18/22.

Deadline recorded: Feb 18, 2022. A deadline is not proof that correction was completed.