OASIS FOR SENIORS AT HEAVEN'S GARDEN

Official classification

Type A

Official code

87705(l)(2)

Regulation authority

CCR

What the official deficiency says

(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by locking gate to emergency exit which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/17/2023 Plan of Correction Administrator agrees to remove the lock immediately. In addition, administrator agrees to submit a statement of understanding that all emergency exits must remain accessible.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. 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 or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 1 out of 2 persons which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/30/2023 Plan of Correction Administrator agrees to obtain a health care screening (LIC503) for caregiver 1 and a TB test. Copy of report to be sent into CCL by 8/30/23.

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 record review, the licensee did not comply with the section cited above in 1 out of 1 persons which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/30/2023 Plan of Correction Administrator agrees to obtain an updated CPR and first aide card for caregiver 2. Certificate to be sent into CCL by 8/30/23.

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 1 out of 1 persons which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/30/2023 Plan of Correction Administrator agrees to complete a training calendar for caregiver 2 to show when required training will be completed. Calendar to be submitted into CCL by 8/30/23.

Official classification

Type B

Official code

87467(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. 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 2 out of 2 persons which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/30/2023 Plan of Correction Administrator agrees to complete an updated needs and service plan for R1 and R2. Updated plans to be submitted into CCL by 8/30/23.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

Plan of Operation. Each facility shall have and maintain a current..plan of operation. ... Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. This requiremtn was not met based on records review and interview finding a admission agreement in use not approved by CCL. This posed a potential risk to personal rights

Official plan of correction

Licensee will submit the admission agreement that they wish to use, if different than on file, to CCL by the POC date of 11/9/22.

Deadline recorded: Nov 9, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.652(c)

Regulation authority

HSC

What the official deficiency says

Termination of admission agreement upon death of resident...- (c) A refund of any fees paid in advance... shall be issued to the individual... within 15 days after the personal property is removed. This requirement was not met based on documents and statements that fees were insufficient and exceeded 15 days. This posed a risk to personal rights.

Official plan of correction

Licensee will submit proof of reimbursement agreed to with R1's spouse, not to exceed $2,898, by rhe POC date of 10/27/22

Deadline recorded: Oct 27, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(g)(4)(B)

Regulation authority

CCR

What the official deficiency says

Admission Agreements.(g)(4)(B)The conditions under which a licensee may increase or change rates shall be specified in the admission agreement. Records found that level of care increases are not identified in the admission agreement yet were charged to R1. This posed a potential risk to personal rights.

Official plan of correction

Licensee will submit a statement of understanding of this requirement. The statement will contain that no other residents are currently charge level of care fees and that should the licensee develop level of care fees, it will be submitted for approval to CCL POC due 10/27/22

Deadline recorded: Oct 27, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations... This requirement is not met as evidenced by: Based on observation of (2) staff not wearing mask in the facility, Licensee did not comply with the section cited above that all staff are to wear maks regardless of vaccination status which poses/posed a potential health, safety or personal rights risk to persons in care.

Deadline recorded: Sep 30, 2022. A deadline is not proof that correction was completed.