STERLING SENIOR COMMUNITY V

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 record review, the licensee did not comply with the section cited above for one out of three residents which poses a potential safety risk to persons in care. The facility has an approved waiver for two (2) hospice residents but the facility is currently caring for three (3) residents on hospice (Resident #1, #2, and #3). The office staff immediately emailed a letter requesting for a hospice increase to regina.cloyd@dss.ca.gov

Official plan of correction

POC Due Date: 04/16/2024 Plan of Correction The Licensee will request for an increase prior to accepting or retaining any hospice resident that exceeds beyond the approved hospice amount. The Licensee will ensure that its request for a hospice increase meets the Title 22 regulations and emailed regina.cloyd@dss.ca.gov prior to the POC due date.

Official classification

Type B

Official code

87405(d)(1)(2)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (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. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by: On 12/12/2023, LPA Lourdes Montoya observed during records review that R1's Appraisal/Needs and Services Plan dated 7/1/2021 is identical to R1's Appraisal/Needs and Services Plan dated 1/21/2023. LPA observed the typed written date (7/1/2021) was erased with a white out and the date was changed with a hand written date (1/21/2023). Two staff (S1-S2) acknowledged that the appraisal dated 7/21/2021 is a photo copy of the appraisal dated 1/21/2023. S3 on the other hand argued that since R1 did not have any medical change, a photo copy of R1's 2021 appraisal is acceptable to make R1's appraisal current. This poses a potential health, safety and/or personal right risk to persons in care.

Official plan of correction

The administrator shall self-certify understanding of the section cited herein and shall always comply. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

Deadline recorded: Dec 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(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 was not met as evidenced by: On 12/12/2023, LPA interviewed two staff (S1-S2). Interviews with S1 and S2 revealed they assumed the resident records are maintained completely and accurately. LPA reviewed records of five out of five residents (R1-R5). LPA’s records review revealed resident records are not maintained completely and accurately. This poses a potential health, safety, and/or personal rights risk to persons in care.

Official plan of correction

Licensee shall ensure all resident records are complete and accurate. House Manager agreed to obtain all missing resident records and shall submit copies to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 12/29/23.

Deadline recorded: Dec 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(4)(A)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement was not met as evidenced by: On 12/12/2023, LPA interviewed two staff (S1-S2). Interviews with S1 and S2 revealed there are two caregivers providing care and supervision to five residents during day shift from 7:00 AM through 7:00 PM. S1 and S2 stated an awake staff is placed to work overtime at nght from 7:00 PM - 7:00 AM when any residents pose a restless behavior. Based on interview with S1 and S2 and LPA's records review, it was revealed that four residents (R1, R2, R4 & R5) need close supervision due to their medical conditions, however S1 and S2 stated there are no on-duty awake staff during night shift unless needed. This poses a potential health, safety, and/or personal rights risk to persons in care.

Official plan of correction

Licensee shall ensure there's always one aware staff during night shift to provide care and supervision to residents with dementia. Licensee shall self-certify understanding of the section cited herein and shall comply. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 12/29/23.

Deadline recorded: Dec 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608(a)(3) (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement was not met as evidenced by: On 12/12/2023 during an unrelated complaint visit, LPA observed two residents (R2 & R4) use full bedrails and two residents (R3 & R5) use half bedrails. Upon review of these residents’ records, LPA did no find prescriptions. S1 confirmed none of them have prescriptions for bedrails. This poses a potential health, safety and/or personal rights risk to residents in care.

Official plan of correction

Licensee shall ensure residents have prescriptions for postural supports. House manager agreed to consult with the residents’ family and their medical providers for the need of postural support. House Manager Mendoza shall remove the postural supports of the residents who do not have prescriptions. Proof of correction shall be submitted to CCLD via email to LPA Montoya at lourdes.montoya@dss.ca.gov by the POC due date, 12/29/2023.

Deadline recorded: Dec 29, 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(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: LPA observed one loose interior door casing in resident bedroom #2; toilet bowl not properly working and inoperable door bell. This poses a potential health, safety and/or personal rights risk to residents in care.

Official plan of correction

Licensee shall ensure the facility is maintained in good repair at all times. House Manager agreed to reinstall the interior door casing, fix the toilet bowl and the door bell. Proof of correction shall be submitted to CCLD via email to LPA Montoya at lourdes.montoya@dss.ca.gov by the POC due date, 12/29/2023.

Deadline recorded: Dec 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) 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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not secure sharp items or toxins in locked area, LPA Cifuentes found a pair of scissors in an unlocked drawer in facility bathroom and cleaning products and detergents outside and in an unlocked cabinet. This poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 04/20/2022 Plan of Correction Facility staff secured scissors immediatly and moved cleaning products and detergents to garage. Licensee will get a lock for cabinet in laundry room to secure toxins. POC will be sent to LPA via fax by POC due date.