CASA FRANCESCA

Official classification

Type A

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPA observed R5's bottle of Mirtazapine 7.5 mg has been altered to change the order which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/22/2026 Plan of Correction Licensee to obtain a new label from pharmacy and forward proof to LPA.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. R5 has full bed rails on the bed and is not on hospice which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/22/2026 Plan of Correction Licensee to remove rails and forward proof to LPA by POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPA observed a hole in the screen door in R1's room which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/05/2026 Plan of Correction Licensee to repair/ replace screen door and forward proof to LPA.

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 record review, the licensee did not comply with the section cited above in two out of three staff without required annual training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/05/2026 Plan of Correction Licensee to conduct training and forward proof to LPA by POC due date.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons 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. Resident 2 is bedridden and is not residing in the designated bedridden room which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/09/2025 Plan of Correction Licensee to either move resident to bedridden room or obtain additional medical assessment determining resident to be non-ambulatory and forward proof to LPA by POC due date.

Official classification

Type A

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. 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. Facility is not documenting PRN usage which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/09/2025 Plan of Correction Licensee to conduct an in-service on PRN administration and forward proof to LPA by POC due date.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: 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. Staff 3 does not have a personnel file on-site which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/22/2025 Plan of Correction Licensee to maintain a file for all staff and forward proof to LPA by POC due date.

Official classification

Type B

Official code

1569.696(a)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: 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. Facility has not conducted required hospice training for staff which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/22/2025 Plan of Correction Licensee to conduct training and forward proof to LPA by POC due date.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. 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. Resident 5 does not have a pre-appraisal in the file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/22/2025 Plan of Correction Please obtain pre-appraisal and forward proof to LPA by POC due date.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. 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. Resident 5 does not have a medical assessment in the file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/22/2025 Plan of Correction Licensee to obtain a medical assessment and forward proof to LPA by POC due date.

Official classification

Type A

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. This req is not being met as evidenced by: Based on interview conducted, Licensee failed to ensure staff are mentally capable of performing work tasks. S1 is smoking marijuana at the facility. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee to provide an in-service regarding marijuana smoking at the facility and forward proof to LPA by POC due date.

Deadline recorded: Oct 11, 2024. A deadline is not proof that correction was completed.

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 records review the licensee did not comply with the section cited above in 3 of 3 staff (S1, S2, S3) which poses posed a potential health risk to persons in care.

Official plan of correction

POC Due Date: 08/02/2024 Plan of Correction Licensee agrees to have S1, S2 or S3 completed CRP training by due date and provide LPA proof via email.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review the licensee did not comply with the section cited above in 3 of 3 staff (S1, S2, S3) which poses posed a potential health risk to persons in care.

Official plan of correction

POC Due Date: 08/02/2024 Plan of Correction Licensee agrees to have S1, S2 AND S3 completed first aid training by due date and provide LPA proof via email.