DISCOVERY COMMONS WHITTIER

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation R2 had direct access to over the counter medication, the licensee did not comply with the section cited above in 1 out of 1 resident which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/17/2025 Plan of Correction Administrator will submit plan that will address when staff re-training will be completed on reg 87309(a). Training must be completed by 11/24/25 and proof must be emailed to LPA Ramirez.

Official classification

Type A

Official code

87309(b)

Regulation authority

CCR

What the official deficiency says

(b) Residents may have access to items specified in subsection (a) for personal use unless there is documentation, as specified in Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, that indicates the resident's or other residents’ safety would be at risk if allowed access. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, R5 bathroom cabinet was unlocked and R5 had direct access to personal grooming and hygiene items, the licensee did not comply with the section cited above in 1 out of 1 resident, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/17/2025 Plan of Correction Administrator will submit plan that will address when staff re-training will be completed on reg 87309(b). Training must be completed by 11/24/25 and proof must be emailed to LPA Ramirez.

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, LPA Ramirez did not observe poster in main entry or anywhere else in the facility.the licensee did not comply with the section cited above in 68 out of 68 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/28/2025 Plan of Correction Administrator will send picture of poster in main entrance.

Official classification

Type A

Official code

876615(a)(1)

Regulation authority

CCR

What the official deficiency says

(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 in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not being met as evidenced by : Resident #1 was admitted to the hospital on 1/16/23 with an unstageable pressure injury on his right hip, a deep tissue injury on his right hip, and an unstageable pressure injury on his right foot. This poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee will ensure that the facility abides by Title 22 regulations, and does not retain resident(s) with prohibited health conditions. LIcensee will ensure that an in service training with staff is provided, on Section 876615, and will provide LPA with proof of training by POC date.

Deadline recorded: Aug 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not being met as evidenced by : Resident #1 was diagnosed with a staphylococcus (staph) infection in his mouth, upon hospital admittance on 1/16/23. This poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee will ensure that the facility abides by Title 22 regulations. Licensee will ensure that an in service training is provided with staff on Section 87465, and will provide LPA with proof of training by POC due date.

Deadline recorded: Aug 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not being met as evidenced by : resident #1 was admitted to hospital on 1/16/23, and diagnosed with severe malnutrion. It is documented that resident #1 lost sixteen lbs between 12/5/22, and 1/16/23. This poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee will ensure that the facility abides by Title 22 regulations. Licensee will ensure that staff are provided with an in service training on Section 87466, and will provide LPA with proof of training by POC due date.

Deadline recorded: Aug 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: 4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs This requirement was not being met as evidenced by : resident #1 was admitted to hospital on 1/16/23, with severe sepsis with acute organ dysfunction, pneumonia, hypernatremia, severe protein calorie malnutrition. and several pressure injuries. This poses a an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee will ensure that the facility abides by Title 22 regulations. Licensee will ensure that staff are provided with an in service training on Section 87468.2, and will provide LPA with proof of training by POC due date.

Deadline recorded: Aug 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not being met as evidenced : LPA Rea learned that Resident #6 prescribed medication OLANZAPINE F/C 2.5MG TABLET which is to be administered every day at 4:00pm was not given as prescribed. This poses a health and safety risk to residents in care.

Official plan of correction

Administrator will ensure that residents receive medications as prescribed. Administrator will send LPA a written plan detailing what the facility plan is to ensure that there is sufficient staff to administer medications as prescribed.

Deadline recorded: May 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not being met as evidenced : LPA Rea learned that Resident #6 prescribed medication OLANZAPINE F/C 2.5MG TABLET which is to be administered every day at 4:00pm was not given as prescribed. This poses a health and safety risk to residents in care.

Official plan of correction

Administrator will ensure that residents receive medications as prescribed. Administrator will send LPA a written plan detailing what the facility plan is to ensure that there is sufficient staff to administer medications as prescribed.

Deadline recorded: Apr 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not being met as evidenced by: Administrator did not submit a special incident report to Community Care Licensing indicating the facility had a scabies outbreak.

Official plan of correction

Administrator will ensure that Title 22 regulations are being followed. Administrator will review Section 87211, and will send LPA a written statement indicating that the section has been read, and is understood.

Deadline recorded: Jan 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: LPA observed that staff #1-staff #4 did not have first aid cards in their files. Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff files reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/12/2024 Plan of Correction Administrator will comply with Title 22 regulations, and will ensure that all staff have current first aid cards in their employee file, and will send proof to LPA by POC due date.

Official classification

Type B

Official code

1569.657(a)

Regulation authority

HSC

What the official deficiency says

For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. This requirement is not being met as evidenced by : LPA observed that Resident #1's rate was increased on April 1, 2023, and resident #1's family member was not provided a written notification of a rate increase due to a change in resident #'1s condition.

Official plan of correction

LIcensee will provide a credit to resident #'1s May 2023 statement in the amount of $2097.29. Licensee will provide proof of credit to LPA by POC due date.

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

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Administrator failed to report 3 covid positive resident(s) to Community Care Licensing as required, which poses a health and safety risk to residents in care.

Official plan of correction

Administrator will submit Special Incident Report(s) for Residents #1 - #3 to Community Care Licensing by POC due date, and will submit proof that report has also been made to the Department of Public Health. Administrator will review Section 87211 and will send written statement stating that the section was read and is understood.

Deadline recorded: Jan 17, 2023. A deadline is not proof that correction was completed.