GOOD HANDS LOVING CARE-YORBA LINDA

Official classification

Type B

Official code

87506(e)

Regulation authority

CCR

What the official deficiency says

(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and AD interview, the licensee did not comply with the section cited above in five of five resident files which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/20/2026 Plan of Correction AD stated records for all current and past residents will be retained for a minimum of three years following termination of service to the resident and a written plan of action to ensure record retention will be submitted to LPA via email.

Official classification

Type A

Official code

87705(c)(1)

Regulation authority

CCR

What the official deficiency says

Per CCR 87705(c)(1): (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (1) The facility has a nonambulatory fire clearance for each room that will be used to accommodate a resident with dementia(...) " This requirement is not met as evidenced by: Based on observation and records reviewed, all four current resident are non-ambulatory even though the facility is only cleared for 3 ambulatory and 3 non-ambulatory. This constitutes an immediate risk to the health, safety and personal rights of residents in care.

Official plan of correction

Licensee to immediately request an update of its current fire clearance to extend to six non-ambulatory.

Deadline recorded: Nov 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87632(a)(1)

Regulation authority

CCR

What the official deficiency says

Per CCR 87632(a)(1): " In order to (...) retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. [which include] Specification of the maximum number of terminally ill [residents] " . This requirement is not met as evidenced by: Based on records reviewed and facility visit, there are four residents currently receiving hospice care even though the facility's waiver is only for three residents. This consitutes an immediate risk to the health, safety and personal rights of individuals in care.

Official plan of correction

Licensee to immediately communicate their plan to return to compliance either by limiting the number of hospice residents admitted or by submitting an update request for a hospice waiver with sufficient capacity.

Deadline recorded: Nov 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(2)

Regulation authority

CCR

What the official deficiency says

Per CCR87615(a)(2): " Persons who require health services for or have a health condition including (,...) those specified below shall not be admitted or retained in a residential care facility for the elderly: (2) Gastrostomy tubes " . This requirement is not met as evidenced by: Based on staff statements and records reviewed, resident R1 was admitted and stayed at the facility while being treated from dysphagia with a G-tube. This deficiency constitutes an immediate risk to the health, safety and personal rights of residents in care.

Official plan of correction

Licensee to review applicable regulations to Prohibited Health Conditions and update training to all staff members accordingly. Proof of training to be provided to LPA. R1 is no longer admitted to the facility.

Deadline recorded: Nov 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87616(a)

Regulation authority

CCR

What the official deficiency says

Per CCR 87616(a) " As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited (...) health condition but believes that the intent of the law can be met through alternative means " . This requirement is not met as (...) evidenced by: Licensee did not submit and/or obtain a written exception request prior to admitting resident R1.

Official plan of correction

Resident R1 was discharged at the time of the visit. Deficiency cleared.

Deadline recorded: Nov 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

Per CCR 87608(a)(5)(B): " Under no circumstances shall postural supports include (...) limiting the use of a resident's hands or feet. (...)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care " . This requirement is not met as evidenced by: Based on evidence submitted and records reviewed, it was determined that R1's bed had been equipped with full rails in the absence of hospice placement and appropriate physician orders. This constitutes an immediate risk to the health, safety and personal rights of residents in care

Official plan of correction

Licensee to update training on postural supports for all staff. Documentation of training to be provided to LPA.

Deadline recorded: Nov 27, 2024. 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

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above. LPA observed R1, R2, R3, and R4 are diagnosed with Dementia and did not have their current medical assessment. R1, R2, and R3 did not have a current Appraisal Needs and service plan. R6 did not have a medical assessment at the time of visit. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/19/2024 Plan of Correction Licensee states they will provide a current Physican's Report for R1, R2, R3, R4, and R6, and a current Appraisal Needs and Service Plan for R1, R2, and R3 with proof of corrected POC to CCLD via email to edward.kim@dss.ca.gov by July 19, 2024.

Official classification

Type B

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish...reports as the Department may require, including, but not limited to... (2) Occurrences, such as epidemic outbreaks... which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours… to the local health officer when appropriate. This requirement is not being met as evidenced by the facility failing to properly report to the Regional Office a COVID outbreak that started October 4, 2023. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator Daniel Yoo will review regulation section 87211 Reporting Requirements and sign a statement of acknowledgement and understanding of the Reporting Requirements. Licensee/Administrator Daniel Yoo will send a detailed plan that outlines the steps that will be taken to ensure all serious incidents and outbreaks are reported. The detailed plan will include the following: • Who will be responsible for sending incident reports • A backup staff member responsible for reporting serious incident reports if Licensee/Administrator Daniel Yoo is unavailable. The Plan of Correction will be emailed to LPA Haley by Friday, February 2, 2024 at 1PM.

Deadline recorded: Feb 2, 2024. A deadline is not proof that correction was completed.