HENRIETTA'S HOME

Official classification

Type A

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) 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: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that R1’s Triamcinolone .1% cream, Nystop 100,000, Nystatin 100,000, and Calamine Lotion are not documented on the Centrally Stored Medication and Destruction Record and does not use Medication Administration Record (MAR), which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/26/2026 Plan of Correction Submit a copy by tomorrow of R1's updated Centrally Stored Medication and Destruction Record.

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 because R1 & R2's beds had full length bed rails and neither resident is currently enrolled in hospice services, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/26/2026 Plan of Correction Administrator shall ensure the full-size bed rails are removed from R1 & R2’s beds. Please submit a copy of the half size bed rails physician order along with a picture by tomorrow.

Official classification

Type B

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. 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 that an oxygen tank was observed in room #4 (R2 & R5'd) bedroom, but there was no " No Smoking-Oxygen in Use " posted sign in appropriate areas or in the facility physical plant, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/09/2026 Plan of Correction Administrator shall ensure that a No Smoking-Oxygen in Use sign is posted when there is an oxygen tank(s) in the facility. Submit picture proof that the signs are posted.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 that staff (S4) is not associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/26/2026 Plan of Correction Submit proof by tomorrow that S4 was associated to the facility via Guardian.

Official classification

Type A

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) 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: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that R1’s Triamcinolone .1% cream, Nystop 100,000, Nystatin 100,000, and Calamine Lotion are not documented on the Centrally Stored Medication and Destruction Record and does not use Medication Administration Record (MAR), which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/26/2026 Plan of Correction Submit a copy by tomorrow of R1's updated Centrally Stored Medication and Destruction Record.

Official classification

Type B

Official code

87412(a)(11)

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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 that Staff (S3 & S4's) health screening was not in their file or presented during the visit. Administrator did not provide documentation during the visit, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/09/2026 Plan of Correction Submit copies of S3 & S4s health screening and TB exam clearance.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(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 record review, the licensee did not comply with the section cited above in that staff (S3's) file did not have proof that 1st aid/CPR training has been completed. Administrator did not provide documentation during the visit, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/09/2026 Plan of Correction Submit a copy of S3’s 1st Aid/CPR training card.

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 section cited above in that medication pills in dispensing cups were observed in an unlocked in the kitchen drawer next to the refrigerator, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/25/2025 Plan of Correction Administrator shall submit proof that staff were trained in regulation 87465 and medication storage facility procedures.

Official classification

Type B

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 that alcohol i.e., vodka, whiskey, wine, and beer were observed unlocked in the bottom kitchen cabinet located on the right side of the refrigerator, and there are 3 residents with Dementia in which access to items poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/07/2025 Plan of Correction Administrator shall submit: 1. A written plan that addresses alcohol in the facility, storage, and storage procedures. 2. Proof of staff in-service training

Official classification

Type A

Official code

87608(a)(5)

Regulation authority

CCR

What the official deficiency says

Postural Supports. Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.” Based on photographic evidence night shift caregiver placed a laundry basket under R1's hospital bed mattress in order to limit the resident from getting up at night. Pillows and rail pads were also used. This poses an immediate health and safety risk to persons in care.

Official plan of correction

Administrator shall submit a written plan of correction by tommorrow. Submit staff in-service training by Tue. Jan. 14, 2025.

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

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care. The following requirements shall apply to medications which are centrally stored: 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 was not met evidenced by: Based on photographic evidence the findings indicate that a staff backpack that was placed on top of the kitchen counter by the toaster oven had a medication bubble pack sticking out, it is unknown which resident the medication belonged to, but medications must be locked. This poses an immediate health and safety risks to persons in care.

Official plan of correction

Licensee shall ensure all medications are locked and centrally stored, controlled subtance medications are accounted for, and MAR records are accurate. Submit by tomorrow a written POC, and proof of staff training.

Deadline recorded: Dec 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(4)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia. Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met evidenced by: Resident (R1) fell twice while sitting in the dining room chair, R4 had 2 falls; 1 in their room and iin May 2024 while sitting in the dining room chair, and as a result was hospitalized due to injuries. This poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator shall ensure that all residents in care are provided with adequate care and supervision to ensure their safety. Submit: 1. A plan on how the Dementia residents' safety will be ensured while sitting. 2. Proof of staff training.

Deadline recorded: Dec 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: cA written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events ... date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met evidenced by: Between Dec. 2023- June 2024 there were suspected scabies cases, that resulted in prophylaxis Permethrin treatment of residents, but none of the responsible parties had knowledge of treatment and CCLD did not receive any incident reports. This poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator shall ensure all incidents involving residents are reported to CCLD via fax and responsible parties. Submit written statement and proof of staff training.

Deadline recorded: Dec 24, 2024. A deadline is not proof that correction was completed.

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 section cited above in that a total of 3 prescribed ointment creams were observed in an unlocked bathroom drawer, 2 of the creams belonged to 2 former residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/21/2024 Plan of Correction Submit a written plan by tomorrow and completed staff in-service training on Title 22 87465 by Friday 8/23/2024/

Official classification

Type B

Official code

87705(c)(6)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. 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 that hospice/dementia residents (R1-R3) only have pre-placement and/or resident appraisals completed upon admission, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/03/2024 Plan of Correction Administrator shall submit copies of resident (R1-R3's) Appraisal Needs and Services Plans and/or updated care plans.

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 that resident (R1) is not enrolled in hospice and their bed has full bed rails; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2023 Plan of Correction Administrator shall remove the full bed rails from R1's bed, and obtain a physician order for half rails. Submit pictures of resident's bed and a copy of the physician orders for half bed rails by tomorrow.

Official classification

Type A

Official code

1569.72(c)(1)

Regulation authority

HSC

What the official deficiency says

Residents requiring skilled nursing or intermediate care; bedridden residents Notwithstanding paragraph (2) of subdivision (a), bedridden persons may be admitted to, and remain in, residential care facilities for the elderly that secure and maintain an appropriate fire clearance. (1) The fire safety requirements are met. 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 that per Physician's Report resident (R1) is bedridden presently located in room #2; which is not designated by the Fire department clearance as a bedridden room. Bedridden room is only room #4; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2023 Plan of Correction Administrator shall submit a written statement of what was done to correct the POC and if applicable picture proof evidence that resident (R1) was moved to the bedridden room.

Official classification

Type B

Official code

87411(d)

Regulation authority

CCR

What the official deficiency says

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: 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 that staff (3) began working at the facility on 5/16/2023 and no staff training has been completed/documented; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/01/2023 Plan of Correction Administrator shall submit proof of staff training for staff (S3).

Official classification

Type A

Official code

1569.605

Regulation authority

CCR

What the official deficiency says

Liability insurance… all residential care facilities for the elderly … shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement was not met as evidenced by: Based on liability insurance records reviewed, interviews conducted with Administrator and relevant witnesses, it was determined that the licensee did not have required liability insurance coverage for 08/26/2022 to present which poses an immediate safety risk to residents in care.

Official plan of correction

Licensee stated they will obtain liability insurance that complies with Health & Safety Code section 1569.605 and submit proof to LPA by POC due date (05/24/23).

Deadline recorded: May 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.605

Regulation authority

CCR

What the official deficiency says

CONTINUATION OF ABOVE Based on interviews and records review, the licensee did not maintain liability insurance covering injury to residents and guests in the amounts specified which posed a potential Health, Safety, or Personal Rights risk to 4 persons in care.

Deadline recorded: May 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87109(a)

Regulation authority

CCR

What the official deficiency says

Transferability of License (a) The license shall not be transferable. 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 that the previous licensee's facility license was posted and filed at the facility; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/13/2022 Plan of Correction Director of Assisted Living Operations emailed staff a copy of the correct licensee's license. Staff printed the copy and posted it at the facility. CLEARED during the visit.

Official classification

Type B

Official code

87507(e)

Regulation authority

CCR

What the official deficiency says

Admission Agreements The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. The licensee shall provide additional copies to the resident or resident’s representative upon request. 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 that 3 out of 4 residents (R1-R3) did not have current admission agreements issued by the new licensee; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/03/2023 Plan of Correction Administration staff agreed to submit proof that residents (R1-R3) were issued updated Admission Agreements from new licensee.