TOLUCA LAKE MANOR SENIOR ASSISTED LIVING II LLC

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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. Hot water temperature check conducted in rooms 4, 5, and 6 was noted at 131.9*f-136.8*f. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/17/2026 Plan of Correction Licensee/Administrator had staff adjust the hot water temperature immediately from the water heater that supplys to room 4,5, and 6. Licensee/Administrtor agreed to have staff monitor hot water temperature for rooms/bathrooms identified over required temperature. test the water temperature daily 3 times a day for 3 days and record temperature. Ensure hot water temperature is within 105-120. Submit log by 2/17/2026.

Official classification

Type B

Official code

87465(b)

Regulation authority

CCR

What the official deficiency says

(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview, the licensee did not comply with the section cited above. No PRN authorization letter on file for three out five residents. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/27/2025 Plan of Correction Administrator agreed to obtain copy of the PRN authorization letter for three out of five residents. Submit copy of the authorization letter as proof by POC date.

Official classification

Type B

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. 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. Three out four resident medications reviewed observed with no phyisian orders. This poses/posed a potential health, and safety risk to persons in care.

Official plan of correction

POC Due Date: 02/27/2025 Plan of Correction Administrator stated that she will obtained a physician orders for all OTC and vitamins and submit by POC date.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. 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. No TB results on file for resident. This poses/posed a potential health, and safety risk to persons in care.

Official plan of correction

POC Due Date: 02/27/2025 Plan of Correction Administrator contacted resident 1's doctor's office for a copy of the TB results. Administrator agreed to obtain and submit proof of TB clearance for resident #1 by POC date.

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, interview, and record review, the licensee did not comply with the section cited above in two out of two medications didnot match the LIC622, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/16/2024 Plan of Correction The Licensee has agreed to contract with a professional vendor to conduct medication training for the administrator and staff. Licensee will email the LPA all the requested training docuemnatio: Sign in sheet, agenda, professional credentials.

Official classification

Type B

Official code

87506(b)(15)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. 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 two out of two Admission Agreements were incomplete, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/23/2024 Plan of Correction Administartor will fully complete all residents admission agreements, and all required forms will be checked for completeness. LPA will conduct a case management visit to ensure completness of all files.

Official classification

Type B

Official code

1569.695(a)(2)

Regulation authority

HSC

What the official deficiency says

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as the expired food(2018-2021) was observed in the emergency food pantry, which poses a potential health, and safety risk to persons in care.

Official plan of correction

POC Due Date: 02/09/2022 Plan of Correction 1. Submit proof (picture and grocery receipt) of additional food supply purchased to feed six residents and three staff to CCLD by 2/9/2022.

Official classification

Type A

Official code

87705(e)

Regulation authority

CCR

What the official deficiency says

87705 (e)Care of pesons with Dementia. Swimming pools and other bodies of water shall be fenced and in compliance with State and local building codes. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee didnot comply with the section cited above, as the LPA observed a large fountain in the front courtyard area, containing standin/running water, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/11/2022 Plan of Correction Licensee agreed to add rocks to the fountain to ensure water depth does not pose a hazard to residents in care. Licensee will send photos to the LPA by POC due date.

Official classification

Type A

Official code

87625

Regulation authority

CCR

What the official deficiency says

87625- Incontinence Care-The licensee shall... accept or retain a resident who has a manageable ...incontinence condition: (b)The licensee shall be responsible for ...: (2) Ensuring that incontinent residents are checked, including during the night. This requirement is not met as evidence by: Based on interviews, the Licensee did not ensure residents are checked during the night for incontinence, which poses a health and safety, and personal risk to persons in care.

Official plan of correction

Licensee agrees to set up a schedule to ensure sufficient incontinent checks during the night and a way to ensure that the incontinent care has been completed. Staff will need to fill out an incontinent care log. Deficiency was corrected on todays's date 12/13/2021.

Deadline recorded: Dec 17, 2021. A deadline is not proof that correction was completed.