MARY'S LOVING CARE B

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Resident in All Facilities 87468.1(a)(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as ...interfering with daily living functions such as eating, sleeping, or elimination This requirement is not met as evidenced by: Facility is locking refrigerator preventing access to residents which poses an immediate health and safety risk to persons in care.

Official plan of correction

AD stated staff will receive in-service training for keeping the refrigerator unlocked. AD to provide proof to LPA by POC due date.

Deadline recorded: Sep 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(6)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities 87468.1(a)(3) To leave... the facility at any time and to not be locked into any...building, or on facility premises by day or night. This requirement is not met as evidenced by: Facility is blocking exit doors from the outside and locking the front door with a key preventing residents from leaving which poses an immediate health and safety risk to persons in care.

Official plan of correction

Facility removed wood planks from the exit doors and unlocked front door. AD stated staff will receive in-service training for keep exits unlocked and clear. AD to provide proof to LPA by POC due date.

Deadline recorded: Sep 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on LPA observations and interviews, R1 has eloped twice in the past which poses an immediate health and safety risk to persons in care.

Official plan of correction

AD stated a second staff member from the adjacent facility will monitor R1 when other staff member is attending to other resident. AD will provide LPA with an updated LIC500 and a policy dictating procedure.

Deadline recorded: Sep 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.695(a)(2)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter... (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster... This requirement is not met as evidenced by: Based on LPA observation, the facility does not have emergency food to be self reliant for at least 72 hours which poses a potential health and safety risk to persons in care.

Official plan of correction

AD purchased 2 emergency food buckets online today. AD to email LPA pictures of food buckets and purchase receipt.

Deadline recorded: Apr 30, 2025. 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

(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on Administrator interview and record review, R3 is self administrating insulin shots which the resident is not allowed self administer under the resident's current physician's report which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 03/07/2025 Plan of Correction AD has reached out to the physician to get a new 602 that states resident can self administer insulin shots.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, a bottle of laxative and medications in a cup were found in an unlocked cabinet in the kitchen which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 03/07/2025 Plan of Correction The laxative and medications were immediately removed and stored. AD to conduct training and notify LPA of completion.

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 LPA records review 2 out 2 staff members did not meet the 20 hours training requirement for 2024 which poses a potential health and safety to persons in care.

Official plan of correction

POC Due Date: 03/27/2025 Plan of Correction AD to begin training requirement this month and will email LPA when training is complete.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the centrally stored medication list is not current nor accurate for R3 which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 03/20/2025 Plan of Correction AD has reached out the physician to provide accurate list of medications including discontinued medication order.

Official classification

Type B

Official code

1569.695(a)(2)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, the facility does not have emergency food and water to be self reliant for at least 72 hours which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 03/24/2025 Plan of Correction AD to purchase three 48 packs of bottled water and purchase emergency containers.

Official classification

Type A

Official code

87468.2(a)(1)

Regulation authority

CCR

What the official deficiency says

To have a reasonable level of personal privacy in accommodations... This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, there are 2 cameras with audio above the kitchen facing the living room and 1 camera with audio inside R2's bedroom which poses an immediate personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2025 Plan of Correction AD to remove cameras from bedroom and kitchen area immediately and replace them with no audio cameras. AD will also post signage indication recording in progress.