HOLY SPIRIT RESIDENTIAL CARE HOME INC. II

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 7 of 7 staff files reviewed. Licensee did not have documentation of completed annual training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/15/2024 Plan of Correction Licensee to submit self certification that annual training has been completed for all staff. Self certification to be submitted to CCL by POC date of 3/15/2024.

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 in 2 of 2 resident bathrooms. Water temperature measured 130.1 degrees F at sinks accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/05/2024 Plan of Correction Licensee immediately adjusted the hot water heater. Licensee will test water twice daily for seven days to ensure water temperature is within regulation. Hot water temperature log to be submitted to CCL by POC date of 01/15/2024.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care:(a)(4)The licensee shall assist residents with self administered medications as needed. This requirement is not met as evidenced by: Based on interviews conducted, staff gave another residents medication to R1. This poses an immediate Health and Safety risk to residents in care.

Official plan of correction

Licensee will ensure all staff who deal with medication, receive refresher training. Training to be scheduled by POC date of 10/22, and evidence of completed training to be submitted to CCL by POC date of 11/18/2022.

Deadline recorded: Oct 21, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 (a)(1) Reporting Requirements: A written report shall be submitted to the licensing agency & to the person responsible for the resident within 7 days of the occurrence... This requirement is not met as evidenced by: Based on interviews conducted, Licensee did not report a 911 call for a resident to CCL within 7 days of occurrence. This poses a potential Health, Safety or personal rights risk.

Official plan of correction

Licensee to conduct training with all staff on reporting requirements. Sign in roster of completed training to be submitted to CCL by POC date of 11/18/2022.

Deadline recorded: Nov 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on LPA observation, Licensee removed the inside door handles of 2 exit doors. This poses an Immediate Safety risk to residents in care.

Official plan of correction

Licensee will develop a care plan to address exit seeking behavior, without violating regulation and what staff will do to keep residents engaged. Door handles were reinstalled during visit. Plan to be submitted to CCL by POC date of 04/15/2022.

Deadline recorded: Apr 15, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, the licensee did not comply with the section cited above in 1 out of 1 hallways. Licensee stored wheel chairs, resident lifting device and a portable generator in an exit hallway, which poses an immediate health, safety or personal rights risk to persons in care. An immediate civil penalty of $500.00 is being issued.

Official plan of correction

POC Due Date: 11/18/2021 Plan of Correction Licensee to remove items blocking the exit path. Licensee relocated the items during visit. Exit path is now clear. POC Cleared at time of visit.