CHLOIE'S COTTAGE

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 1 out of 3 staff did not have a health screening with TB testing available for LPA to review which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/21/2026 Plan of Correction Administrator agreed to submit proof of health screening and TB clearance for S3.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (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 was not met as evidence by: During review of resident medications and MAR records it was revealed that staff are not properly documenting the MAR as signatures were missing for 4 out of 14 medications for R1.

Official plan of correction

Licensee/Administrator to provide a training for all staff that assist with medication, training should include proper safe keeping of medication, procedures on how to administer medication and proper record keeping of medications. Training must be completed by POC due date and a copy of the training materials and participant signatures shall be emailed to LPA by POC due date. tena.herrera@dss.ca.gov

Deadline recorded: Sep 1, 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

87465 Incidental Medical and Dental Care (a) 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: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by: During medication review LPA observed 1 medication within R1's prescribed medications to not have a doctors order documented for it, additionally R5 was missing 1 routine medication and 1 PRN from their prescribed medications these medications were listed on R5’s current physician report dated 5/6/2025.

Official plan of correction

Licensee/Administrator to obtain current medication lists for each resident and must have all medications that are listed in their prescribed medication boxes and submit photos of proof to LPA via email by POC due date. tena.herrera@dss.ca.gov

Deadline recorded: Aug 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(14)

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: (14) To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls. This requirement was not met as evidence by: LPA observed facility phone to not be reasonably accessible to residents as it has been moved from the kitchen to the locked staff office. R1s calls are being monitored, per staff R1 allegedly calls 911 for non emergency matters but there was no documentaion or poof porvided to LPA of these alleged calls and continuous behaviors.

Official plan of correction

Licensee/Administrator to make phone accessible to all residnets and a training on all residnet personal rights must be conducted with all staff that include the right to make and receive confidential phone calls. The training must be completed by POC due date and a copy of the training materials and participant sigatures must be emailed to LPA by POC due date.

Deadline recorded: Sep 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in a pair of large scissors, and knives/sharps were observed accessibel to the residents in unlock kitchen drawers which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2025 Plan of Correction Administrator will provide in-service training to staff and will submit a copy of trainig log, that includes training topic, date, time, and signatures by POC due date 8/19/25.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 4 out of 6 residents' beds were observed with full bed rails (2 were made full with half bed rails combine) which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2025 Plan of Correction Administrator will change full bed rails to 3/4 bed rails and submit a picture to the department by POC due date 8/19/25.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) 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. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in shower floors in both bathrooms were observed with soap buildup and mold, clutter of old furniture was observed in the back porch and side porch, and a ripped cushion was observed in a chair in the back porch which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/25/2025 Plan of Correction Administrator will submit pictures to the department of clean showers, and remove the clutter to the deparment by POC due date 8/25/25.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 6 out of 6 residents were observed with bed rails (4 with full bed rails and 2 with 3/4 bed rails) which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/25/2025 Plan of Correction Administrator will obtain a physician's order for resident #1-6 and submit a copy to the department or remove bed rails by 8/25/25.

Official classification

Type A

Official code

87705(d)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 2 out of 3 exit doors do not have a working auditory device which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2025 Plan of Correction Administrator will ensure each auditory device is in working condition and will submit a picture/video of working auditory devices to the department by POC due date 8/19/25.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355. Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department This was not met as evidenced by: S5 working 1 day at the facility prior to fingerprint clearance being verified or obtained. This poses an immediate health and safety risk to residents in care.

Official plan of correction

S5 no longer works in the faciltiy. POC cleared at the time of this visit.

Deadline recorded: Feb 4, 2025. 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

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in two (2) out of two (2) bathrooms. Bathroom #1 water temperature was 128.6 and bathroom #2 129.7 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2024 Plan of Correction Assistant Administrator will adjust water temperature and provide proof via email to LPA. Administartor will also log water temperature to insure water is at required temperature.

Official classification

Type A

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above facility did not have two days of perishable food for the six residents in care which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2024 Plan of Correction Assistant Administrator will go shopping and provide receipts and pictures via email as proof to LPA.