SANTA FE HOME CARE II

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain 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 which poses a potential health, safety and personal rights risk to persons in care.The facility's current plan of operation does not match what is on file with CCLD received on 10/12/2015. The facility did not follow its medication policy (medication refills) for R2. It indicates medications are never allowed to run out unless directed to by the physician (obtain this direction in writing).

Official plan of correction

POC Due Date: 09/03/2025 Plan of Correction The Licensee will ensure Resident #2 (R2) receives R2's medication and submit proof of correction to regina.cloyd@dss.ca.gov by the POC due date. Licensee will also submit an updated plan of operation to CCLD for approval or file the approved plan of operation at the facility by the POC due date.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review... shall prior to working... in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above for one staff which poses an immediate safety risk to persons in care. LPA did not observe staff #1 (S1) having a criminal background clearance nor association to the facility. S1 worked in the facility on 08/22/24.

Official plan of correction

The Licensee will email S1 criminal background clearance and Guardian association to the facility to ernand.dabuet@dss.ca.gov by the POC due date. The Licensee will esnure that all staff complete their background checks and are associated to the desginated facility.

Deadline recorded: Aug 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(b)(2)

Regulation authority

CCR

What the official deficiency says

87405(b)(2) Administrator - Qualifications and Duties. (b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (2)Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by: Based on interview and observation the Licensee/Administrator failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited, which poses a potential health and safety risk to residents in care.

Official plan of correction

The licensee will create a plan to ensure that the administrator performs knowledge of and conforms to applicable laws, rules and regulations. Plan of correction will be submitted by POC due date: 09/05/24 to ernand.dabuet@dss.ca.gov

Deadline recorded: Sep 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in one bathroom which poses an immediate safety risk to persons in care. LPA Cloyd measured the water temparture at 142.8 degrees F.

Official plan of correction

The staff adjusted the water heater and on 08/08/24, LPA Cloyd measured the water teamperature to be at 112 degree F. The Licensee will create a water temperature log for monthly readings and will email it to regina.cloyd@dss.ca.gov.

Deadline recorded: Aug 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review... shall prior to working... in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above for one staff which poses an immediate safety risk to persons in care. LPA did not observe staff #5 (S5) having a criminal background clearance nor association to the facility. S5 worked in the facility on 08/07/24 and 08/08/24

Official plan of correction

The Licensee will email R5's criminal background clearance and Guardian association to the facility to regina.cloyd@dss.ca.gov by the POC due date. The Licensee will esnure that all staff complete their background checks and are associated to the desginated facility.

Deadline recorded: Aug 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)(12)

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: (12) Hazardous health conditions documents 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 for one staff member which poses a potential health risk to persons in care. On 08/07/24, LPA Cloyd did not observe a health screening report (LIC 503) with TB results for Staff #5.

Official plan of correction

POC Due Date: 08/27/2024 Plan of Correction The Licensee will email R5's health screening report with TB results to regina.cloyd@dss.ca by the POC due date. The Licensee will create a licensing document checklist for staff's folders and email it with the facility's Personnel Report (LIC500) by the POC due date.

Official classification

Type B

Official code

87628(b)

Regulation authority

CCR

What the official deficiency says

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: 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 for one out of two residents which poses a potential health and safety or personal rights risk. On 08/07/24, LPA Cloyd did not observe a restricted health care plan for Resident #1 (R1) injections. LPA saw needles during medication review. Both Home Health Nurse and Staff stated that they assist with injections.

Official plan of correction

POC Due Date: 08/27/2024 Plan of Correction The Licensee will complete and maintain a current, written record of care for each resident that includes, but is not limited to, the following information listed in 87628(b)(1) - 87628(b)(3). The Licensee will email the information to regina.cloyd@dss.ca.gov by the POC due date.

Official classification

Type B

Official code

87224(f)

Regulation authority

CCR

What the official deficiency says

(f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by: Based on interview and observation, the licensee did not comply with the section cited above for Resident #1 (R1) which poses a potential personal rights risk to persons in care. Licensing did not receive notice from the facility regarding R1's permanent move.

Official plan of correction

The Licensee will provide a written report of Resident #1's eviction to regina.cloyd@dss.ca.gov by the POC due date.

Deadline recorded: Jun 10, 2024. A deadline is not proof that correction was completed.

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: Based on interview and observation, the licensee did not comply with the section cited above which poses a potential safety and personal rights risk to persons in care. LPA observed the facility being remodeled and under construction.

Official plan of correction

The Licensee will provide evidence for meeting this regulation prior to the POC due date. Plan of correction to be emailed to regina.cloyd@dss.ca.gov

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

Official classification

Type B

Official code

87555

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident’s physician as a medical necessity shall be provided. This was not met based on: LPA reviewed physician’s orders for R1, R2, and R5, and found they required a special diet of low sodium, low carbohydrates, and low sugar and during interviews with R2 and R5 stated they are served item that do not meet the modified diet prescribed by physician. This poses a health and safety risk to residents in care.

Official plan of correction

Licensee aggrees to review Physicians Reports of residents, train staff on resident special diets. Have staff sign that they have been trained on residents special diet and fax to 424-544-1017 att LPA Gibbs by POC date.

Deadline recorded: May 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465

Regulation authority

CCR

What the official deficiency says

87465Incidental Medical and Dental Care (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 was not met based on: Record review of Resident R1s Physicians report and Centrally stored medications has 2 PNR medications and there is no documentation of R1 receiving thier PRN. This poses a health and safety risk to residents in care.

Official plan of correction

Licensee shall ensure medications are administered according to PCP orders and that staff a trained on administering medications. The facilty will conduct a training on medications with staff. Proof of correction receipt must be sent to by fax to 424-544-1016 att Gibbs by POC date.

Deadline recorded: May 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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, it was observed during file review that R1 does not have a Physicians Report on file, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/27/2023 Plan of Correction Administrator will submitt a medical assessment (Physician's Report) for Resident R1 to LPA by 12/27/23.

Official classification

Type B

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. 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, it was observed during file review that R1 does not have a recent TB test on file, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/27/2023 Plan of Correction Administrator will submitt a tuberculosis test for Resident R1 LPA by 12/26/23.

Official classification

Type B

Official code

8706(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 is not met as evidence by: Based on observation and interview, Licensee failed to provide resident records for (R1) hospice records and Medicaiton Administration Record during visits. This poses a potential health and safety risk to residents in care.

Official plan of correction

The licensee will ensure records for all residents are current and maintained for each resident in the facility and available to CCL during visits. LIcensee will obtain copies of hospice records and (MAR) for (R1). Proof of correction must be sent by due date 10/10/23.

Deadline recorded: Oct 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(1)(2)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (b) The administrator of a facility.. shall have the responsibility and authority to carry out the policies... (1) Knowledge of the requirements for providing care and supervision... (2) Knowledge of and ability to conform to the applicable laws, rules, and regulations This requirement was not met as evidenced by: Based on observation record and interviews, the Administrator failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited. This violation poses/posed a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee shall read Title 22, Section 87405 “Administrator - Qualifications and Duties” and send a written statement to CCLD that you have read and understand this section. This plan is due to CCLD/El Segundo ASC Office by POC date of 10/10/23.

Deadline recorded: Oct 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(e)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked. This requirement is not met as evidence by: Based on observation and interview, Licensee failed to provide personnel report LIC 500 during visits. Uncertain of adequate staff coverage. This poses a potential health and safety risk to residents in care.

Official plan of correction

The licensee will ensure records for all residents are current and maintained for each resident in the facility and available to CCL during visits. LIcensee will obtain copies LIC 500. Proof of correction must be sent by due date 10/10/23. This citation was correction during visit. A copy of LIC 500 provided.

Deadline recorded: Oct 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

98465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need .. medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist...(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by: Based on interviews, the licensee did not comply with this section. Licensee did not have evidence to show proof that prescribed medications or PRN for (R1,R3 & R4) were administered PCP orders. This poses an immediate health, safety or personal rights risks to persons in care.

Official plan of correction

Licensee shall ensure medications are administered according to PCP orders with proof of documentation. Licensee will obtain a copy of documentation noting medications were disbursed properly per PCP orders. Proof of correction receipt must be sent to by fax to 323-981-1782 attn: LPA Dabuet by 09/29/23. This was corrected during Case Management visit on 09/29/30.

Deadline recorded: Sep 29, 2023. 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 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, furnishings and equipment. This requirement is not met as evidence by: Based on interviews, the licensee did not comply with this section. Staff assisted with medications for residents without knowledge of documenting PRN or prescribed medications. Residents are not provided a safe environment. This a potential health, safety or personal rights risks to persons in care.

Official plan of correction

Licensee shall ensure medications are administered according to PCP orders and that staff a trained on administering medications. The facilty will conduct a training on medications with staff. Proof of correction receipt must be sent to by fax to 323-981-1782 attn: LPA Dabuet by 10/10/23.

Deadline recorded: Nov 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (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 evidence by: Based on observation, the licensee did not comply with this section. LPA observed ants, pest droppings, dead pest inside the refrigerator and the outside perimeter of the appliance. This poses a potentieal health, safety or personal rights risks to persons in care.

Official plan of correction

Licensee shall ensure all spaces in the residential facilty clean, sanitary and safe free from pest at all time. Licensee will obtain for pest control to spray interior and exterior of the facility. Proof of correction receipt must be sent to by fax to 323-981-1782 attn: LPA Dabuet by 10/10/23 *Civil Penalty - Repeat Violation*

Deadline recorded: Sep 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidence by: Based on observation, the licensee did not comply with this section. LPA observed (10) food items that had expired dates. This poses a potentieal health, safety or personal rights risks to persons in care.

Official plan of correction

Licensee shall discard all expired food and shall ensure the facility does not serve expired food to residnents. Licensee shall read Section 87555 and shall provide an in-service training to all staff. Proof of correciton must be faxt to 323-981-1781 attn: LPA Dabuet by 10/10/23. *Civil Penalty - Repeat Violation*

Deadline recorded: Sep 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(9)(28)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. (28) All food shall be protected against contamination... This requirement is not met as evidence: Based on observation, LPA identified unsafe practices of food items not stored properly in refridgerator and pantry free from contamination, harmful bacteria, viruses, parasites, or chemical substances. This poses a potential health, safety and/or personal rights risks to persons in care.

Official plan of correction

LIcensee will adhere to Section 87555 and ensure that all food items are handled safely, and stored in food storage containers for preparation and service. Licensee will read provide an in-serice training to all staff. Proof of correction must be sent by fax to 323-981-1781 attn: LPA Dabuet by 10/10/23.

Deadline recorded: Sep 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(c)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (c) All information and records obtained from or regarding residents shall be confidential. During the complaint visit on 5/3/2023 at 9:52 am, LPA observed residents’ confidential files including R1’s file were not locked and accessible. LPA advised S2 to keep and lock all confidential files. At 10:38 am, LPA observed R1’s confidential file folder was still accessible and not moved to a locked storage. This poses a potential health, safety and/or personal rights risk to residents in care.

Official plan of correction

Administrator locked all residents' confidential information. Administrator shall give an in-service training to staff on Section 87506 of Title 22. POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date. CIVIL PENALTY ASSESSED FOR REPEAT VIOLATION (SEE 4/21/2023 for prior citation)

Deadline recorded: May 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

8755(b)(9)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requireme (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. During LPA’s complaint visit on 5/3/2023 at 10:06 am, LPA checked and observed several bags of bread and chips were open and not sealed. LPA observed a bowl of meat, a glass container of gelatin and a soy sauce with sliced onions in the refrigerator uncovered. LPA also observed uncovered bowl of rice soup, chips and salsa near the stove oven. This poses a potential health, safety and/or personal rights risk to residents in care.

Official plan of correction

S2 covered all food and snacks during the visit. Administrator shall give an in-service training to staff on Section 87555 of Title 22. POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

Deadline recorded: May 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)(2)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). (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 was not met as evidenced by: Based on record review, observation and interviews, the licensee failed to ensure items that could constitute a danger to residents with dementia are inaccessible. Around 10:02 am, LPA observed two pairs of scissors and a knife on a dish drying rack in the kitchen and the drawer for sharp items was kept open and accessible. LPA observed a shovel in the backyard next to a storage shed; Around 10:20 am, LPA observed the cabinet for storing cleaning suppplies (Cloralen, etc ) was open and accessible. Around 10:25 am, LPA observed a trowel and a large black rake in the backyard next to the sliding door. Around 11:45 am, LPA observed lysol, laundry soap and fabric softener in the laundry room were accessible. This poses an immediate health, safety and/or personal rights risk to residents in care with dementia.

Official plan of correction

Staff (#2) moved the sharp and toxic items in a locked storage inaccessible to resident with dementia. Administrator shall read Section 87705 and shall self-certify understanding of the regulations and shall conduct an in-service training to all staff. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov by the POC due date. CIVIL PENALTY ASSESSED.

Deadline recorded: May 4, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(6)

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: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This was not met as evidenced by: At around 10:23 am, LPA Montoya observed the right side gate is locked with a padlock. This poses a potential health, safety, and/or personal rights risk to residents in care.

Official plan of correction

Administrator removed the padlock and will ensure the side gate is always unlocked. Administrator shall read Section 87468.1and shall self-certify understanding of the regulations and shall conduct an in-service training to all staff. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov by the POC due date.

Deadline recorded: May 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. Based on observation and interview, there is no sufficient lighting in bedrooms #2 and #3.

Official plan of correction

Administrator shall provide more lightings for room #2 and room #3. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

Deadline recorded: May 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(c)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (c) All information and records obtained from or regarding residents shall be confidential. During LPA's visit on 4/11/2023 AND 4/14/2023, LPA observed all five residents' records (folders) are stored in an unlocked cabinet. This poses a potential personal rights, health or safety risk to residents in care.

Official plan of correction

Administrator shall ensure all residents records are kept confidential in a locked storage. Administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

Deadline recorded: Apr 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This was not met as evidenced by: Based on LPA Montoya’s observations during a tour of the inside and outside grounds of the facility on 4/11/2023, kitchen floor is dirty, the bottom of the dishwasher had molded water and smelled malodorous, the laundry floor was covered with water leak, the ground of the right side of the facility is covered with molded water and white powder across the walkway. This poses a potential health, safety and/or personal rights risk to residents in care.

Official plan of correction

Administrator shall clean all the mentioned spaces in the home that are unsanitary. Administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

Deadline recorded: Apr 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This was not met as evidenced by: Based on LPA Montoya’s observations during a tour of the inside and outside grounds of the facility on 4/11/2023, facility has expired food. LPA observed the following expired food: Chicken Bolgna – expired on 2/7/2023; a bag of wheat bread – expired on March 1, 2023; a bag of white bread – expired on March 18, 2023; a bag of garden salad – expired on April 7, 2023, and lettuce looks saggy. This poses a potential health, safety and/or personal rights risk to residents in care.

Official plan of correction

Administrator shall discard all expired food and shall ensure the facility does not serve expired food to residents. Administrator shall read Section 87555 and shall provide an in-service training to all staff. Administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

Deadline recorded: Apr 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(30)(31)(B)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b) The following food service requirements shall apply:(30) All utensils used for eating and drinking and in preparation of food and drink, shall be cleaned and sanitized after each usage. (31) Dishes and utensils shall be disinfected: (B) In facilities not using mechanical means, by an alternative comparable method approved by the licensing agency or by the local health department, such as the addition of a sanitation agent to the final rinse water. LPA observed about five white plates stored in the cabinet are still wet and one of them has food residue on the edges of the plate. LPA observed the dishwasher is not in good repair. R4 stated sometimes plates, cups and utensils are left overnight in the sink unwashed. This poses a potential health, safety and/or personal rights risk to residents in care.

Official plan of correction

Administrator shall ensure all utensil for eating and drinking are always cleans and sanitizes. Administrator shall give staff an in-service training about this section. Administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

Deadline recorded: Apr 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87413(a)(1)

Regulation authority

CCR

What the official deficiency says

87413 Personnel - Operations (a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This was not met as evidenced by: Based on LPA’ review of staff’s timesheets and interviews conducted, there is a lack of staffing in the facility. Since January 2023 to April 2023, there were days that facility had only one staff duringd day and night. There are currently five residents in the home of which three are diagnosed with dementia. One out three residents with dementia is ambulatory, two are non-ambulatory. R3 and R5 observed only one staff (S2) is present in the facility every day and some days, another staff comes to help S2. This poses a potential health, safety and/or personal rights risk to residents in care.

Official plan of correction

Administrator shall ensure the facility has sufficient staffing all the time. Administrator shall submit an updated LIC 500 CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

Deadline recorded: Apr 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

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: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This was not met as evidenced by: Based on record review, observation and interviews, the licensee failed to ensure S1 is fingerprint clear prior to working. S1 started working as a caregiver in this facility on 4/4/2023. This poses an immediate health, safety and/or personal rights risk to residents in care.

Official plan of correction

Administrator shall read Section 87355(e)(1) and shall self-certify understanding of the regulations and shall commit to comply. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov by the POC due date.

Deadline recorded: Apr 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

HSC

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This was not met as evidenced by: Based on record review, observation and interviews, the licensee failed to ensure items that could constitute a danger to residents with dementia are stored inaccessible. LPA observed R1 who has dementia sitting at the back patio and a couple of shovels and a rake are accessible at the patio. LPA observed the cabinet under the sink where cleaning supplies such as bleaches, glass cleaner, etc. are stored is unlocked and accessible to residents with dementia.

Official plan of correction

Administrator shall read Section 87705(f)(1) and shall self-certify understanding of the regulations and shall conduct an in-service training to all staff. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov by the POC due date.

Deadline recorded: Apr 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (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 was not met as evidenced by: Based on observations and interviews, the facility is in disrepair. The diswasher is broken and has malodorous smell, the back door is rotted, the floor in the laundry room is covered with water due to a leak, the outdoor patio is covered with dried leaves, the lock of the right side gate is not working properly and the kitchen floor and oven are dirty.

Official plan of correction

Administrator shall ensure that the facility is always clean, safe, sanitary and in good repair. Administrator shall submit a POC for all the mentioned deficiencies to CCL via email to lourdes.montoya@dss.ca.gov by the POC due date.

Deadline recorded: Apr 14, 2023. 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 LPA's observations, the licensee did not comply with the section cited above. The water temperature in the common bathroom is 124.4 degree Fahrenheit and the water temperature in bedroom # 3 is 124.00 degree Fahrenheit. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/28/2022 Plan of Correction Administrator shall ensure the water temperature in resident bathrooms is in compliance. Administrator shall adjust the water temperature to not less than 105 to and not more than 120 degree Fahrenheit. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov

Official classification

Type A

Official code

87355(e)(1)

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: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Montoya’s interview with the Administrator (S1) on 9/23/22, S3 started working on 9/23/22 without a background clearance. LPA Montoya and LPA Gibb observed S3 is working in the facility in blue scrub uniform. Based on review of S3’s timesheet, she began working on 9/14/2022 to date. On 9/27/22, LPA returned to the facility and observed S3 is working again without background clearance. The administrator failed to ensure S3 obtained a California background clearance prior to working or volunteering. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/28/2022 Plan of Correction LPA Montoya and LPA Gibb observed S3 left the facility around 1:44 pm and was relieved by S4. On 9/27/22, S3 left the faciity at around 2:30 pm and was relieved by S4. This deficiency has been corrected.

Official classification

Type B

Official code

87307(d)(7)

Regulation authority

CCR

What the official deficiency says

(7) Fireplaces and open-faced heaters shall be adequately screened. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. The fireplace in the family room is not properly screened which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/10/2022 Plan of Correction Administrator shall ensure the fireplace is properly screened. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov by the POC due date.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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. Resident #1 has no Physician’s Report on file. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/10/2022 Plan of Correction Administrator shall ensure Resident #1 has a current Physician's Report (medical assessment) on file readily available for inspection by CCLD. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov by the POC due date.

Official classification

Type B

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. Medication is dispensed to another container one week prior to administration per Staff 2. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/10/2022 Plan of Correction Administrator shall ensure resident medications that are centrally stored shall be stored in its original container and shall not be transferred between containers. Administrator shall read Section 87465 and shall self-certify understanding of the regulations and shall commit to comply. Administrator shall conduct an in-service training to all staff and send a proof of the completed proof. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov by the POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, and sanitary andn in good repair at all times. Maintenance shall include provision of maintenance srevices 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. LPA Montoya and LPA Gibb observed three stove burners are not operable; the sliding door in the kitchen and the screen door are not in good repair; doorbell is broken off the wall; a missing kitchen cabinet; a fire extinguisher mounted in the laundry room was last serviced on 2/15/2018. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/10/2022 Plan of Correction Administrator shall ensure all broken items mentioned in deficient practice statement are repaired by the POC due date. POC shalle be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 10/10/2022.

Official classification

Type A

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Montoya’s interview with the Administrator (S1), S3 started working on 9/23/22 without a background clearance. LPA Montoya and LPA Gibss observed S3 is in the facility in blue scrub uniform. Based on review of S3’s timesheet, S3 worked on 9/14/22-9/18/22 and based on interview with R1 and R2, S3 continued to work on 9/19/22, 9/20/22 and 9/23/22. The administrator failed to ensure S3 obtained a California background clearance prior to working or volunteering which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/28/2022 Plan of Correction Administrator shall review Section 87405 of Title 22 and shall self-certify understanding of this regulation and shall commit to comply. Administrator shall submit a self-certification letter to CCLD via email to Lourdes.montoya@dss.ca.gov

Official classification

Type A

Official code

87405(d)(5)

Regulation authority

CCR

What the official deficiency says

(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (5) Good character and a continuing reputation of personal integrity. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, record review, the licensee did not comply with the section cited above. The administrator (S1) stated S3 just started working on 9/23/2022 when asked by LPA Montoya. Based on LPA Montoya’s interview with two residents (R1 and R2), and review of S3’s timesheet, S3 began working at the facility on 9/14/2022 and continued to work until LPA's visit day. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/28/2022 Plan of Correction Administrator shall not make false statements to CCLD and shall always display good character and a continuing reputation of personal integrity. Administrator shall review Section 87405 of Title 22 and shall self-certify understanding of the regulation and shall commit to comply. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov by the POC due date.