BRANDON MANOR

Official classification

Type A

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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, when the LPA arrived at the facility the only staff present (Staff 3) did not have any CPR or First Aid training, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/20/2024 Plan of Correction Licensee agrees to Staff 3 trained in CPR and First-Aid. Licensee to forward proof of CPR and First-Aid training to LPA when completed.

Official classification

Type B

Official code

1569.69(a)(2)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. 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 1 out of 3 staff training files which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/29/2024 Plan of Correction Licensee agrees to ensure all staff have the required training as stated in HSC 1569.69(a)(2) and to document all training completed by staff. Licensee to forward proof to LPA by POC due date.

Official classification

Type B

Official code

87507(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. 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 1 out of 3 resident files which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/29/2024 Plan of Correction Licensee agrees to have Resident 3's responsible party sign and date Resident 3's admission agreement. Licensee to submit proof to LPA by POC due date.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person... 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. The Administrator's certificate expired on 12/29/2023. The facility has no currently certified administrator which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/02/2024 Plan of Correction Licensee agrees to forward proof to LPA that all required training has been completed, fees paid and all documents for renewal of the Administrator's Certificate have been submitted to Community Care Licensing Division Administrator Certification Bureau (ACB) by the POC due date.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

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 being met as evidenced by, LPA observed medications for residents stored in the master bedroom closet unsecured. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agrees to store all medications in compliance with CCR 87465. Licensee agrees to dispose of discontinued medications in compliance with Title 22. Licensee will conduct training with all staff regarding CCR 87465 and to provide proof of training to LPA by POC due date.

Deadline recorded: Jul 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building. This requirement is not being met as evidenced by, LPA observed the master bedroom closet has a bed and is being used as a bedroom. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee agrees to move the bed and all items not belonging to the residents out of the master bedroom closet. Licensee agrees not to use any room, other than it's commonly used purpose as stated in CCR 87307.

Deadline recorded: Jul 20, 2023. A deadline is not proof that correction was completed.