GOLDEN CARE LIVING IV

Official classification

Type B

Official code

87458(b)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (b) The licensee shall obtain an updated medical assessment when required by the Department. This has not been met as evidenced by: R2's physican report has diagnosed (Dx) R2 with Dementia, last dated 01/23/24. Residents Dx with Dementia requires the facility to obtain a yearly, updated, LIC624a.

Official plan of correction

Licensee and LPA have agreed that this facility will obtain an updated physician's report (LIC624a) on, or prior to, the POC due date which is 07/18/25. Licensee will forward this updated physican's report to LPA at MARIO.LEON@DSS.CA.GOV

Deadline recorded: Jul 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair. This has not been met as evidenced by: based on LPA's observations; the screen, located in room #3, in disrepair. LPA also observed debris located in two (2) backyard exit doorsills and also in doorsill of room #3, which may pose a potential health and safety risk to residents in care.

Official plan of correction

Licensee and LPA have agreed that the facility will make sure to clean window/doorsills as well as screening throughout the facility. Licensee will provide video/photo evidence of the area(s) in question to LPA at Mario.Leon@DSS,CA.GOV on or prior to POC due date, 06/30/25.

Deadline recorded: Jun 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.44(a)

Regulation authority

HSC

What the official deficiency says

1569.44(a) Unlicensed residential care facility for the elderly; definition; operation without license prohibited; procedure upon discovery (a) A facility shall be deemed to be an " unlicensed residential care facility for the elderly " and " maintained and operated to provide residential care " if it is unlicensed and not exempt from the licensee, and any one of the following conditions is satisfied: This requirement is not met as evidence by: Based on interviews conducted and observation the operator is providing unlicensed care to R1-R6 who require elements of care and supervision. The facility is not licensed by CCLD. This poses a potential Health and safety risk to residents in care.

Official plan of correction

The unlicensed operator shall either cease operation of the unlicensed facility or operations ceased or submit an application to the licensing agency within 15 calendar days by 10/23/24. Failure to comply will result in civil penalties of $200 per day until a completed application is submitted.

Deadline recorded: Oct 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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. LPA identified resident #6 not in hospice care with full bed rails. R6 had no prescription from PCP stating R6 requires full bed rails. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2024 Plan of Correction LIcensee will adhere to Title 22 Reg 87608 and either remove the full bed rails or request a written prescription from PCP for approval. Proof of correction must be sent to LPA Dabuet by POC date at ernand.dabuet@dss.ca.gov

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

(c) All window screens shall be clean and maintained in good repair. 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 identified resident activity room sliding door and room #2 with no screens did not have a window screen. Hallway sliding door screen and kitchen screen had rips. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/08/2024 Plan of Correction Licensee will ensure that all windows have screens are maintained in good repair. Proof of correction is for licensee to purchase screens or make repairs must be sent by due date. Proof of correction with photos must be sent to ernand.dabuet@dss.ca.gov

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, the facility furniture end tables obstructing exit passageways in room #3. This citation poses an immediate health and safety risk to residents in care.

Official plan of correction

POC Due Date: 10/09/2024 Plan of Correction Licensee will adhere to Title 22 regulations to ensure that no exit and passageway are obstructed at all times. The licensee will remove these items and submit correction by POC due date: 10/09/24.

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, 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. LPA observed refilled medications for resident #3 dianosed with dementia accessible to resident in care. The medications were store in a closet not in locked cabinet. This violation which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/09/2024 Plan of Correction Licensee will adhere to Title 22 Reg 87705 and to ensure that all residents medications are stored in locked storage and not accessible to residents in care at all times. Proof of correction must be sent to LPA Dabuet by POC due date at ernand.dabuet@dss.ca.gov

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 ©(1 ) Personnel Requirements - General 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. 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: staff #2 has expired CPR. Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above as staff (M.E.) has an expired CPR card which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/27/2023 Plan of Correction Administrator will require staff to complete CPR training and submit proof of completion to LPA by POC due date.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

87465(a)(6) Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Mar has gaps in documentation Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above as medication administration records are not being documented properly which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/27/2023 Plan of Correction Administrator to train staff on medication documentation and will provide proof to LPA by POC due date.

Official classification

Type B

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

87303(a)(1) Maintenance and operation The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Crumbs and trash observed. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as kitchen and dinning room were observed to have crumbs and paper and the floor. Pile of laundry were observed on the floor which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/20/2023 Plan of Correction Administrator to conducted inservice with staff about maintaining a clean and safe environment to all residnts in care. Administrator to submit proof to LPA by POC due date.

Official classification

Type B

Official code

87555(b)(25)

Regulation authority

CCR

What the official deficiency says

87555(b)(25) General Food Service Requirements (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by: Detergent left on top of washer Deficient Practice Statement Based on observation the licensee did not comply with the section cited above as toxin were observed not locked and accessible to residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/20/2023 Plan of Correction Administrator will conduct inservice with staff regarding the safety of toxins and submitt proof to LPA by POC due date.

Official classification

Type B

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705(f)(1) care of persons with dementias (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 requirement is not met as evidenced by: 8 inch silver scissors observed on kitchen counter Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as scissors were lobserved accessible to residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/20/2023 Plan of Correction Administrator to conduct in service on care for persons with demential and will send proof to LPA by POC due date.

Official classification

Type A

Official code

80019(e)(3)(4)

Regulation authority

CCR

What the official deficiency says

all individuals subject to a criminal record review pursuant to health and safety code secition 1522 shall prior to working, residing or volunteering in a licensed facility: requesr a trasfer of a criminal record clearance as specified in section 80019(f) or request and be approved for a transfer ofa criminal record exemption, as specified in section 80019.1(r), unless , uponrequest for the tranfer, the Department permits the individual to be employed, reside or be present at the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, nterview, record review, the licensee did not comply with the section cited above in having a care staff not associated at the facility with pending background clearance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/14/2023 Plan of Correction Licensee will ensure all staff working at the facility is associated, as part of POC licensee will ensure staff is not working at the facility until staff is associated and without pending background clearance.

Official classification

Type B

Official code

87465(a)(8)(A-F)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. (B) Sterile first aid dressings. (C) Bandages or roller bandages. (D) Scissors. (E) Tweezers. (F) Thermometers. This requirement is not met as evidenced by: no first aide observed Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above as there is no first aide kit in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/20/2023 Plan of Correction Administrator to purchase first aide kit and manual and submit proof to LPA by POC due date.