JUST LIKE HOME II

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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. Resident medications observed pre-set for 7-days. This poses an immediate health, and safety risk to persons in care.

Official plan of correction

POC Due Date: 12/15/2025 Plan of Correction Staff stated they will no longer pre-set medications for more than 24 hours in advance. Licensee/staff agreed to review section cited and provide a statement of understanding to CCL by 12/15/2025.

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, interview, record review, the licensee did not comply with the section cited above. Full rail observed on resident #5's bed; resident is not on hospice at this time. This poses an immediate health,safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/15/2025 Plan of Correction Staff removed the full rail during today's visit. Licensee/staff agreed to review section cited and provide a statement of understanding to CCL by 12/15/2025.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(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 cited above. Cleaning supplies observed under the sink cabinet which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/03/2024 Plan of Correction Admiistrator transfered cleaning supplies to the garage which is kept locked at all times.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above. (2) main caregivers did not have proof of required training on file. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/13/2024 Plan of Correction Administrator agreed to provide all required training to staff #2 and staff #5 and submit copy of completed training to LPA by agreed due date.

Official classification

Type B

Official code

1569.69(a)(2)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above. Staff #2 assists residents with medication and did not have record of required training on file. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/13/2024 Plan of Correction Administrator stated she will ensure staff training is provided and record is maintained on file. Administrator also stated that she will provide residents assistance with their medication until staff are provided the required training on file.

Official classification

Type B

Official code

87465(h)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: 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. Five out five resident centrally stored medication records were reviewed with administrator. Administrator confirmed that the records are not updated accordingly. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2024 Plan of Correction Administator agreed to review all five residents medication and update the centrally stored medication and destruction record by due date. Submit copy of the records to LPA by due date.

Official classification

Type B

Official code

87465(c)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: 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. PRN authoriztion letter from the physician not on file for resident #5 (PRN medication prescribed). This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2024 Plan of Correction Administrator agreed to obtain the required PRN authorization letter from resident #5's physician.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. 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. Two (2) out of five (5) residents records reviewed did not have an updated annual medical assessment. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2024 Plan of Correction Administrator agreed to obtain a current annual medical assessment for residents #3 and resident #5; submit copy of the updated medical assessment to LPA by due date.

Official classification

Type A

Official code

87465(c)(3)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. 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 as five out of five LIC622, were incorrectly filled out and had medications missing on the list of medications (Amlopidine and Duloxetine) which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/29/2023 Plan of Correction The Administrator will contract a certified/qualified presenter to train staff on the procedures on how to fill the LIC 622 correctly and to ensure all meds are correctly included and listed in the LIC622. The administartor will email the LPA all documents pertaining to the training.

Official classification

Type B

Official code

87633(b)

Regulation authority

CCR

What the official deficiency says

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: 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 one out of one resident's hospice information was not available for review at the time of the inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/15/2023 Plan of Correction Administrator will email the LPA the Hospice Documentation along with (staff training) by Hospice agency on how to assist resident on reciving hospice services.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87309(a) Knives, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as knives were accessible in an unlocked kitchen drawer, which poses an immediate health and safety risk to residents in care.

Deadline recorded: Oct 24, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87309(a)Disinfectants, cleaning solutions, knives, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as disinfectants and cleaning solutions were accessible in an unlocked kitchen cabinet, which poses an immediate health and safety risk to residents in care.

Deadline recorded: Oct 24, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87631(a)(3)(A)(B)

Regulation authority

CCR

What the official deficiency says

87631 (a)(3)(A)(B) Healing wounds: Residents with a stage one or two pressure injury must have the condition diagnosed by a physician… (A) The resident shall receive care for the pressure injury from a physician or an appropriately skilled professional; (B) All aspects of care by... facility staff shall be documented in the resident's file. This requirement is not met as evidenced by: Based on the interviews, staff provided care for pressure injuries, which can only be cared by a skilled professional, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Schedule a training regarding the care provided by staff; and, documentation in resident’s file. Verification of scheduled training with the trainer’s credentials will need to be submitted by 9/23/22, and completion of training must be submitted no later than 09/30/2022.

Deadline recorded: Sep 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

87615(a)(1) Prohibited Health Conditions. (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained...: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on the information obtained, record review and interviews, the licensee did not comply with the section cited above, as the Resident sustained pressure injuries while in care, and developed a stage four (4) sacral wound, and was retained in the facility with a prohibited health condition, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: Schedule a training for all staff regarding prohibited health conditions. Verification of scheduled training with the trainer’s credentials will need to be submitted by 9/23/22, and completion of training must be submitted no later than 9/30/22.

Deadline recorded: Sep 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466-The licensee shall ensure that residents are regularly observed for changes in physical...When changes such as …a physical health condition are observed, the licensee shall ensure that such changes are... brought to the attention of the resident's physician and ... This requirement was not met as evidenced by: Based on the investigation, staff failed to timely observe R1s change in physical health condition, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Schedule a training regarding the observation of changes in resident health and conditions; and, who to contact when those changes are observed. Verification of scheduled training with the trainer’s credentials will need to be submitted by 9/23/22, and completion of training must be submitted no later than 9/30/22.

Deadline recorded: Sep 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(2) 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: (2) To be accorded safe, healthful and comfortable accommodations... This requirement is not met as evidenced by: Based on observation, and interviews conducted, the Licensee did not comply with the section cited above, staff did not conduct initial screening for COVID-19 symptoms of individuals entering facility, while providing care and supervision to residents in care, which poses a potential health and safety risk to residents in care.

Official plan of correction

Submit staff training sign in sheet and supporting documentation on Infection Control Practices- PIN 21-38-ASC regarding masks wearing in the facility to LPA by 09/02/2022.

Deadline recorded: Sep 9, 2022. A deadline is not proof that correction was completed.