Hazardous items and storageType A
- Official classification
- Type A
- Official code
- 87309(c)
- Regulation authority
- CCR
What the official deficiency says
(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in leaving medication, cigarette and lightger unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/17/2025 Plan of Correction The Licensee agreed to conduct and vendorized training to all staff including themselves and provide LPA with the training date and name of the vendor. Once the training is complete to send the certification of the training.
Staffing, personnel, and trainingType B
- 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 observation, interview and record review the licensee did not comply with the section cited above in not having health screening (TB) test results for one (1) staff which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/22/2025 Plan of Correction The Licensee agreed to submit LIC 503 (Health Screening) and TB test results for S1 by POC due date.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.696(a)
- Regulation authority
- HSC
What the official deficiency says
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review the licensee did not comply with the section cited above in not having training for the Licensee and one (1) staff which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/22/2025 Plan of Correction Licensee agreed to complete all required training for themselves and S1 and inform LPA via e-mail upon completion of the training by POC due date.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.696(a)(1)
- Regulation authority
- HSC
What the official deficiency says
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above not having required initial training for the Licensee and one (1) staff which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/22/2025 Plan of Correction Licensee agreed to completed all the training for themselves and one staff and submit proof to LPA by POC due date.
Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87506(a)
- Regulation authority
- CCR
What the official deficiency says
Resident Records/Incident Reports: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. 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 not completing/updating six (6) out of six (6) resident's Appraisal/Needs and Services Plan (LIC 625) which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/22/2025 Plan of Correction Licensee shall ensure to update and complete six (6) out of six (6) resident's Appraisal/Needs and Services Plan (LIC 625), and copy of updated forms shall be submitted to LPA by POC date.
Licensing and administrationType B
- 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. S1 has no CPR/first aid 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: 07/22/2025 Plan of Correction The Licensee will email proof of CPR by the POC