CASA DE ESTRELLA

Official classification

Type B

Official code

87458(b)(5)

Regulation authority

CCR

What the official deficiency says

(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, 1 of the resident records review, indicated on the physicians record, the resident is bedridden. Based on LPA observation and other records reviewed, resident does not appear to be bedridden. This poses as a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/30/2024 Plan of Correction The administrator shall clarify residence ambulatory status to determine if the residence are bedridden or non-ambulatory. The facility will submit proof of updated physician report by POC due date via email at zina.brown@dss.ca.gov

Official classification

Type B

Official code

87705(l)(1)

Regulation authority

CCR

What the official deficiency says

(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the section cited above. LPAs observed two exterior front gates had padlocks in which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/26/2024 Plan of Correction Licensee will adhere to Title 22 Regulation 87705(l)(1) and remove padlocks from front gate exterior or notify licensing agency for an exemption to maintain gate locks. Proof of correction must be sent to zina.brown@dss.ca.gov within 24 hours of POC due date.

Official classification

Type A

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Based on the indivdual'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 is not met as evidenced by: Deficient Practice Statement Based on interview, records review and observation, Resident #1-#3 and Resident #5 have half bed rails but no physician order on file which poses as a personal rights risk to residents in care.

Official plan of correction

POC Due Date: 12/16/2024 Plan of Correction The licensee/administrator will obtain physician order and submit a copy to the department by POC date.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. ...The administrator shall ... shall be on the premises a sufficient number of hours to permit adequate attention...section. This requirement is not met as evidenced by: Based on observation, interview and record review, the Administrator Certificate has expired on 6/19/2021. The facility does not have a designee based on review of facility’s file with CCLD. This poses potential health, safety or personal rights risk to persons in care.

Official plan of correction

The administrator shall submit a proof of submission of administrative renewal packet to CCLD, via email, to mario.leon@dss.ca.gov by the POC due date.

Deadline recorded: Dec 30, 2022. 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 observation and interview, the licensee did not comply with the section cited above. LPA Montoya observed the water temperature next to resident bedroom #A is measured 36.2 degree F. and the water temperature in the bathroom next to resident bedroom #B is measured 36.9 degree F. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/13/2022 Plan of Correction The House Manager will adjust the water temperature to attain a temperature of not less than 105 degree F and not more that 120 degree F. Water temperature will be checked and recorded every 2 hours for 24 hours. 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

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: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above. LPA observed and took photos of the garage door with a broken window. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/26/2022 Plan of Correction The House Manager agreed to repair the broken window of the garage door. 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

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. 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. LPA observed and took photos of an unrolled water hose on the right side of the backyard. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/19/2022 Plan of Correction The House Manager will roll up the water house and ensure it does not obstruct any passageways. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

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 observation, the licensee did not comply with the section cited above. Water in bedroom D bathroom measured 136.8 F at 10:39am and 140.9 F in the kitchen at 10:42am which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/03/2021 Plan of Correction Staff immediately lowered the water temperature and the water meausred 108.8 F in the bedroom D bathroom and 111.2 in the kitchen sink.

Official classification

Type A

Official code

87309(a)

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. 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 observed unlocked drawer in kitchen with knives and scissors accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/03/2021 Plan of Correction Staff immediately locked the drawer with the knives and scissors with a key.