CASA DEL LAGO

Official classification

Type A

Official code

87204(a)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. 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 which facility is providing care and supervision to three hospice residents when approved for two which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2025 Plan of Correction Administrator stated that hospice waiver requesting an increase with the supporting documents as discussed during the exit interview will be suibmitted to LPA via email by POC due date.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (a) (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interviews, and record review, the licensee did not comply with the section cited above in one out of the six residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction Adminstrator stated that the full bed rail order for R5 will be obtained and submitted to LPA via email by POC due date.

Official classification

Type B

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, interviews, and record review, the licensee did not comply with the section cited above in two out of the two staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction Administrator stated that all staff will be CPR/First aid certified moving forward and will submit certifications for S1 and S2 to LPA via email by POC due date.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

1569.618 (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 requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interviews, and record review, the licensee did not comply with the section cited above for two out of the two caregivers at the time of inspection which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/12/2024 Plan of Correction Licensee to submit proof of CPR/first aid training for all staff to LPA via email by POC due date.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

All personnel (...) shall be in good health(...). Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment. This requirement is not met as evidenced by health screening forms provided by facility administrator which are dated 02/02/2023 for two of the three staff members currently employd at the facility.

Official plan of correction

Licensee scheduled health screenings for staff members S1 and S2 on the day following the initial inspection visit conducted on 02/01/23. All staff have been screened for good health at the time of the present visit, deficiency cited and cleared during the visit.

Deadline recorded: Feb 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)(6)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87411(c)(6) Personnel Requirements - General indicates that " The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2) " This requirement is not met as evidenced by the fact that licensee is unable to provide proof of some initial or annual training for staff. Based on records reviewed, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to schedule make up sessions of the missing initial and/or annual training sessions and provide documentation of completion before the Plan of Corrections due date.

Deadline recorded: Mar 7, 2023. A deadline is not proof that correction was completed.