GENTLE CARING HOME

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 one of two staff which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2026 Plan of Correction Administrator stated proof of transfer request on Guardian will be submitted to LPA via email by POC due date.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in one of two staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/30/2026 Plan of Correction Administrator stated proof of 20 hour training for S2 will be submitted to LPA via email by POC due date.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. 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 two of four residents, R1 and R3, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/04/2026 Plan of Correction Administrator stated the completed needs and services plan for R1 and R3 will be submitted to LPA via email by POC due date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record reivew, the licensee did not comply with the section cited above in one of two staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/04/2026 Plan of Correction Administrator stated proof of disaster training for S2 will be 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 staff records reviewed and interview conducted, the licensee did not comply with the section cited above as current caregivers staying overnight are not in possession of a valid CPR training at the time of the visit. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction Licensee to ensure staff is training. Proof of training to be submitted to LPA before the plan of corrections due date.

Official classification

Type B

Official code

87412(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

Per CCR 87412 (c): " Licensees shall maintain in the personnel records verification of required staff training and orientation. (1) The following staff training and orientation shall be documented: (A) For staff who assist with personal activities of daily living, there shall be documentation of at least ten hours of initial training within the first four weeks of employment(...) " This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed during the visit, the licensee did not comply with the section cited above as the two currently scheduled caregivers have received training but no training records are present for review at the time of the visit. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction Licensee will document training for the two currently scheduled caregivers and provide copies to LPA before the plan of corrections due date.

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interviews conducted, the licensee did not comply with the section cited above as medication is prepared ahead of administration for up to seven days in advance, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction Licensee will conduct an updated in-service training for staff assisting with medication self-administration and provide proof of training and attendance to LPA before the plan of corrections due date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and records reviewed, the licensee did not comply with the section cited above as no fire drills have been conducted with the present staff since September 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction A complete schedule for quarterly drills along with proof of completion of at least one fire or disaster drill to be provided to LPA before the plan of corrections due date.

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as one bottle of bleach was found in the sink of one resident bathroom and health supplements were observed in the unlocked staff bedroon. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/20/2024 Plan of Correction Licensee placed the potentially dangerous items out of reach of residents during the visit. Deficiency cleared.

Official classification

Type B

Official code

87606(c)

Regulation authority

CCR

What the official deficiency says

(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). 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 as one resident was confirmed to have been assessed as currently bedridden in spite of the fire clearance not including that level of care. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/06/2024 Plan of Correction Licensee has verbally informed the resident and their reporting party that the facility was no longer an appropriate placement due to the resident's required level of care. Licensee intends to formally notify both the resident and their responsible party so an appropriate relocation can be conducted.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

California Code of Regulations Section 87355(e)(1) indicates that: " All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working (...) in a licensed facility: Obtain a California clearance (...) as required by the Department. " This requirement is not met as evidenced by: During the visit, caregiver S1 was present shadowing caregiver S2. An inquiry in Guardian was not able to locate any background clearance obtained by caregiver.

Official plan of correction

Licensee needs to ensure that all staff members are adequately cleared and associated prior to be scheduled to work at the facility.

Deadline recorded: Aug 24, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations on Criminal Record Clearance Section 87355(e)(1) indicates that: " All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department. " This requirement is not met as evidenced by: During the visit, caregiver S1 was present shadowing caregiver S2. An inquiry in Guardian was not able to locate any background clearance obtained by caregiver. Deficient Practice Statement Based on observation and record review made during the visit, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. An immediate civil penalty is being assessed.

Official plan of correction

POC Due Date: 08/24/2022 Plan of Correction Licensee will ensure staff S1 has satisfied the requirement of CCR Section 87355(e)(1) before being added to the facility schedule and working at the facility.