EPIC ASSISTANCE CARE HOME

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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 of the hot water temperature in the resident bathrooms, the licensee did not comply with the section cited above in eight of eight bathrooms which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2026 Plan of Correction Admin Silvana stated that they will forward proof of the hot water temperature reading in a video format of all eight resident bathrooms to LPA via email by POC due date.

Official classification

Type B

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and measurements conducted during the visit, the licensee did not comply with the section cited above as one faucet was found to deliver water at 138F which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/02/2025 Plan of Correction Facility is equipped with two water heaters, one of which required to be adjusted. Temperature lowered during the visit.

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 staff interviews and records reviewed, the licensee did not comply with the section cited above as two staff members on duty during the visit did not possess a current CPR/First Aid certificate which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/09/2025 Plan of Correction Licensee to schedule adequate CPR/First Aid training to ensure the presence of at least one trained staff member per shift at all times. Proof of training to be provided before the plan of corrections due date.

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. 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 spite of a Technical Violation Advisory Note issued in May 2024. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/09/2025 Plan of Correction Licensee to obtain an adequately sized poster and replace the small version on display before the plan of corrections due date.

Official classification

Type B

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87211(a)(2) on Reporting Requirements states that: " Occurrences, such as epidemic outbreaks (...) shall be reported within 24 hours (...) to the licensing agency " . This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, multiple staff members and resident contracted COVID in November 2022 and were not reported to the Department. This constitutes a potential risk to the health, welfare and personal rights of the residents in care.

Official plan of correction

Licensee to review applicable regulations and conduct staff training on Reporting Requirements.

Deadline recorded: Jul 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87470(b)(3)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87470(b)(3) on Infection Control Requirements states that: “There shall be separation and care of residents whose illness requires separation, including quarantine or isolation, from others.” This requirement was not met as evidenced by: Interviews and licensee admission that staff members with confirmed COVID-19 diagnosis kept on providing care and supervision without the facility having reported a Critical Staffing Shortage.

Official plan of correction

Licensee to update the Infection Control Plan and provide staff members with training on the recommendations in place to avoid the transmission of respiratory infections.

Deadline recorded: Jul 28, 2023. 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

The California Code or Regulations Section 87705(c)(5) on the Care of Persons with Dementia states that: " Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, (...) This requirement is not met as evidenced by: Deficient Practice Statement Based on record reviewed, the licensee did not comply with the section cited above in that three out of six Physician's Reports indicated a confirmed Dementia diagnosis yet were dated by up to two years prior, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/14/2023 Plan of Correction Licensee is to schedule appointments with Primary Care physicians of residents with a confirmed Dementia diagnosis and submit the updated Physician's Reports to LPA on or before POC due date of 4/14/2023. Civil Penalty - Repeat Violation is being assessed.

Official classification

Type B

Official code

87412(c)

Regulation authority

CCR

What the official deficiency says

Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not being met as evidenced by: Deficient Practice Statement Based on record review, Licensee failed to ensure verification of staff training is maintained. Two out of two staff do not have documentation of required training. This poses a potential health and safety risk to residents in care.

Official plan of correction

POC Due Date: 04/14/2023 Plan of Correction Licensee to ensure all staff training is up to date and verification is maintained in staff file. Licensee to forward proof to LPA by POC due date OF 04/14/2023

Official classification

Type B

Official code

6151(e)(3)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Title 7 Section 6151(e)(3) indicates that: " Portable fire extinguishers shall be subjected to an annual maintenance check. " This requirement is not met as evidenced by: Based on observation and record review, fire extinguisher maintenance is out of date since August 2022 which poses a potential Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Licensee will contract a licensed vendor to performed the required annual maintenance on the fire extinguishers present within the physical plant and provide documentation thereof to Licensing Program Analyst before the Plan of Corrections due date.

Deadline recorded: Mar 22, 2023. 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

The California Code or Regulations Section 87705(c)(5) on the Care of Persons with Dementia states that: " Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, (...) This requirement is not met as evidenced by: Based on review, the four resident records observed to include an outdated physician report for residents with confirmed dementia diagnoses, which poses a potential Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Licensee is to schedule appointments with the primary care physician of all residents with a confirmed dementia diagnosis and submit the updated physician reports resulting from the visits to LPA before the plan of correction's due date.

Deadline recorded: Mar 22, 2023. A deadline is not proof that correction was completed.