ELDER CREEK VILLA III

Official classification

Type A

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

Personnel Records Personnel records: (a)Th e 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 was not met, evidenced by, based on, staff Allen, did not have a current health screening during today's visit, which is a health and safety risk to residents and staff in care.

Official plan of correction

Staff Allen Rapisura will submit to LPA a current health screening report, showing negative or positve test results. Allen was informed to not return to the facility until he has negative test results and it is submitted to LPA.

Deadline recorded: May 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87407(k)

Regulation authority

CCR

What the official deficiency says

Administrator Recertification Requirements: (k) Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days, to: This requirement was not met, evidenced by, during today's annual inspection, LPA observed the current Administrator's certificate expired 01/16/2025. LPA was informed the son will be taking over as Administrator for the facility.

Official plan of correction

Allen Rapisura will submit the required documents needed to change the current Administrator to the new one, who will be the son.

Deadline recorded: May 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87204(a)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by: Deficient Practice Statement Based on today's observations and recored review, the facility has a hospice waiver for (2); but has accepted an additonal (2) residents without requesting for an exception or hospice waiver increase; which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/12/2025 Plan of Correction Administrator Allen will first submit a hospice exception for the other (2) residents that are not approved to be on hospice at this time.

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 observations and record review (2) residents incomplete Licensing documents in files; which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/19/2025 Plan of Correction Administrator will submit Licensing records for resident 1 # 2 by POC date: admission agreement, physician report, TB results, weight, needs and service plan, client personal property document, physician report

Official classification

Type B

Official code

87633(h)(1)

Regulation authority

CCR

What the official deficiency says

(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident's record: (1) A written request for acceptance or admittance to or retention in the facility while receiving hospice services, along with any advance directive and/or request regarding resuscitative measures form executed by the resident or (in certain instances) the resident's Health Care Surrogate Decision Maker. This requirement is not met as evidenced by: Deficient Practice Statement Based on today's observations and recored review, the facility has a hospice waiver for (2); but has accepted an additonal (2) residents without requesting for an exception or hospice waiver increase; which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/09/2025 Plan of Correction Administrator Allen will first submit a hospice exception for the other (2) residents that are not approved to be on hospice at this time.

Official classification

Type A

Official code

87208(d)

Regulation authority

CCR

What the official deficiency says

(d) A licensee who accepts or retains bedridden persons shall include additional information in the plan of operation as specified in Section 87606(f). This requirement is not met as evidenced by: Deficient Practice Statement Based on today's annual inspection and observation and record review for resident # 1 and 4, both are bedridden, and the facility does not have a fire clearance for bedridden clients. This poses an immediate health and safety risk to resident in care.

Official plan of correction

POC Due Date: 07/10/2024 Plan of Correction Caregiver Allen Rispura will submit LIC200 application and possible fee submitted to Licensing to obtain approval and fire clearance for facility due to have bedridden clients.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Deficient Practice Statement Based on today's annual inspection and observation and record review for resident # 1 and 4, both are bedridden, and the facility did not have a fire clearance for bedridden clients. This poses an immediate health, safety or personal rights risk to persons in care. An immediate civil penalty in the amount of $500 will be fined.

Official plan of correction

POC Due Date: 07/10/2024 Plan of Correction Caregiver Allen Rispura will submit LIC200 application, possible fee, and new facility sketch submitted to Licensing to obtain approval and fire clearance for facility due to have bedridden clients and the room built in the garage for staff, used a a break room.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by: Deficient Practice Statement Based on today's annual inspection and observation and record review for resident # 1 and 4, both are bedridden, and the facility did not have a fire clearance for bedridden clients. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/10/2024 Plan of Correction POC

Official classification

Type A

Official code

87412(a)(13)

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: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: This requirement is not met as evidenced by: Deficient Practice Statement Based on annual inspection, the Administrator's son's family, wife visited the facility, and according to the personnel summary, the wife did not have a fingerprint clearance or was associated to the facility. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/10/2024 Plan of Correction POC

Official classification

Type A

Official code

87555(b)(23)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by: Deficient Practice Statement Based on today's annual inspection for the facility's food supply, LPA observed food to be not properly wrapped, opened, old and freezer burned. This is a immediate health and safety risk to residents in care. POC cleared, food was discarded.

Official plan of correction

POC Due Date: 07/09/2024 Plan of Correction POC cleared, food was discarded

Official classification

Type A

Official code

87555(b)(28)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by: Deficient Practice Statement Based on today's annual inspection for the facility's food supply, LPA observed food to be not properly wrapped, opened, old and freezer burned. This is a immediate health and safety risk to residents in care. POC cleared, food was discarded

Official plan of correction

POC Due Date: 07/09/2024 Plan of Correction POC cleared during visit. Food was discarded

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Deficient Practice Statement Based on today's annual inspection and record review, all residents 1-5, per LIC858, were missing important and required licensing documents, such as physician reports, re and pre-appraisal, needs and service plan, functional capabilities documents. This is a potential health and safety risk to residents in care.

Official plan of correction

POC Due Date: 07/23/2024 Plan of Correction Caregiver will review all resident files, and will make sure all Licensing requirement documents are in the files. POC wil be emailed to LPA.

Official classification

Type B

Official code

87457(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors. This requirement is not met as evidenced by: Deficient Practice Statement Based on today's annual inspection and record review, all residents 1-5, per LIC858, were missing important and required licensing documents, such as physician reports, re and pre-appraisal, needs and service plan, functional capabilities documents. This is a potential health and safety risk to residents in care.

Official plan of correction

POC Due Date: 07/23/2024 Plan of Correction Caregiver will review all resident files, and will make sure all Licensing requirement documents are in the files. POC wil be emailed to LPA.

Official classification

Type A

Official code

87455(c)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Deficient Practice Statement (c) No resident shall be accepted or retained if any of the following apply: This requirement was not met, evidenced by, during today's annual inspection, LPA observed the facility retained (2) residents that were bedridden and one had a prohibited health condition (colostomy) bag, resident#1. This is an immediate health and safety risk to residents in care and an immediate civil penalty will be assessed and an immediate $500.00 civil penalty will be assessed.

Official plan of correction

POC Due Date: 07/10/2024 Plan of Correction Caregiver Allen AGREED to submit to LPA training will be provided by nurse Rebecca and staff inservice documents will be submitted to LPA.

Official classification

Type B

Official code

87305(b)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Deficient Practice Statement This requirement is not met as evidenced by: Based on today's physical plant inspection, LPA observed the facility built an additional sleeping room in the garage for staff. LPA reviewed the original facility sketch, and the additional room was not included when the application was submitted. This is a potential health and safety risk to residents in care.

Official plan of correction

POC Due Date: 07/23/2024 Plan of Correction The Administrator AGREED to contact the City of Santa Clarita by the POC date and will submit documentation of the scheduled visit and contact to inspect the building and issue an approval or denial of the building.

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Based on today's physical plant inspection, LPA observed the facility built an additional sleeping room in the garage for staff. LPA reviewed the original facility sketch, and the additonal room was not included when the application was submitted. This is a potential health and safey risk to residents in care. Deficient Practice Statement Based on today's physical plant inspection, LPA observed the facility built an additional sleeping room in the garage for staff. LPA reviewed the original facility sketch, and the additonal room was not included when the application was submitted. This is a potential health and safey risk to residents in care. This poses as a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/01/2023 Plan of Correction The Administrator AGREED to contact the City of Santa Clarita by the POC date and will submit documentation of the scheduled visit and contact to inspect the building and issue an approval or denial of the building.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Based on resident record review, LPA observed resident #1 (R1) not having a current physician report, who is diagnosed with dementia. The last report observed was date 07/2019. Deficient Practice Statement Based on resident record review, LPA observed resident #1 (R1) not having a current physician report, who is diagnosed with dementia. The last report observed was date 07/2019. This poses as a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/01/2023 Plan of Correction The Administrator AGREED to submit an updated physician report for R1 by POC date.

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, LPA observed staff #1 (S1) not to have current first aid or CPR training. Certifcate had expired 2/2021. This poses as a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/25/2023 Plan of Correction Administrtator has AGREED to submit current CPR/First Aid certifcate for staff # 1.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

Storage Space: Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement has not been met as evidenced by a report (S223) received stating that during a visit on 3/17/21 the reporting party observed Clorox, glass cleaner, dishwasher pod and sharp kitchen tools acceessible to the residents. This posses an immediate health and safety risk to the residents in care.

Official plan of correction

In conjunction with this complaint investigation, LPA conducted an annual insection. At the time of the inspection, disinfectantans, cleaning solutions and other items which can pose a danger if readily available were observed locked and inaccessible to the residents in care. No further correction needed at this time.

Deadline recorded: May 28, 2022. A deadline is not proof that correction was completed.