AGAPE OF CARMEL

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 observation, staff interview and record review, the licensee did not comply with the section cited above in three out of three staff records reviewed missing annual education / training, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/17/2026 Plan of Correction Licensee agrees to provide completed records of staff traiing by POC due date to LPA by email

Official classification

Type B

Official code

87506(b)(10)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (10) Reports of the medical assessment specified in Section 87458 Medical Assessment, and of any special problems or precautions. 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 in one out of three resident records missing medical assessment, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/17/2026 Plan of Correction Licensee agrees to provide updated resident medical assessment records by POC due date to LPA by email

Official classification

Type A

Official code

87355(a)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment....This requirement was not observed as evidenced by: The facility Administrator failed to follow regulations requirements by ensuring 1 out of 2 staff members is cleared and associated to the facility roster. This poses immediate health and safety risk to persons in care.

Official plan of correction

The facility administrator ensure to follow Licensing requirements and staff that is not cleared to be present at the facility is no longer there.

Deadline recorded: Dec 27, 2024. 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 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited.... This requirement was not observed as evidenced by: The facility administrator failed to follow Licensing regulation by providing written report for incident hat occurred on 08/16/24 to Licensing Agency, which poses potential health and safety risk to persons in care

Official plan of correction

The facility administrator will review Licensing regulation and ensure all incident reports to be provided to Fresno Licensing Office by fax or email.

Deadline recorded: Dec 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

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:(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by: Based on records review, Resident 1 physician's report is dated 5/25/2021. Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above for one out of five residents, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/20/2023 Plan of Correction Licensee agreed to have Resident 1 reassessed and provide CCLD with a new physician's report (LIC 602A) by POC due date. Licensee will establish a system to track residents' physicians reports and assessments if they are diagnosed with dementia or mild cognitive impairment.

Official classification

Type A

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

87555(a) General Food Service Requirements- The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents ...All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by Based upon observationthe Licensee failed to ensure the quality of food at the facility. Expired non-perishable food was located ouside in storage and expired perishable food was located in the kitchen fridge accessible to residents in care. This poses an immediate Health, Safety and/or Personal Rights risk to residents in care.

Official plan of correction

LIcensee agrees to audit food once a month. Licensee will provide LPA Avila with a scheduled day each month and provide the schedule via e-mail on 3/22/22

Deadline recorded: Mar 22, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

87307(d)(6)-Personal Accommodations and Services-All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to ensure all outdoor and indoor passageways are free from obstruction This poses an immediate Health, Safety and/or Personal Rights risk to clients in care.

Official plan of correction

Licensee agrees to keep passageways free of obstructions. Licensee will review regulation 87307, 87303 and 87705 and familiarize staff. Licensee will submit a letter of understanding to LPA via e-mail on 3/22/22

Deadline recorded: Mar 22, 2022. A deadline is not proof that correction was completed.