A1 SENIOR CARE 2

Official classification

Type B

Official code

1569.652(c)

Regulation authority

HSC

What the official deficiency says

§1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds. (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. This requirement was not met by: Administrator did not refund responsible party within 15 days of when personal belongings were removed which poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator to refund R1's responsible party for the fees from 1/16/26 to 1/31/26. Administrator to send LPA a receipt of refund by 2/13/26.

Deadline recorded: Feb 13, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met by: Incident was not reported to CCL which poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator agrees to send into CCL a death report for R1. Report to be sent into CCL by 2/13/26.

Deadline recorded: Feb 13, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by: Based on observation, the licensee had a bed in a large closet in common bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agrees to send into LPA a plan of where staff will sleep during the night shift if staff are not awake during the shift. POC to be sent into LPA by 6/30/23.

Deadline recorded: Jun 30, 2023. A deadline is not proof that correction was completed.

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 2 out of 3 persons which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/28/2023 Plan of Correction Administrator to obtain a health screening for all staff. Completed health screening to be sent into CCL by 6/28/23.

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 observation, the licensee did not comply with the section cited above for all staff records which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/31/2023 Plan of Correction Administrator brought staff records to LPA for review for annual continuation on 5/31/23.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year. 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 a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/28/2023 Plan of Correction Administrator agrees to complete a Centrally Stored Medication Record (CSMR) for each resident in care. CSMR to be sent into LPA by 6/28/23.

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: 06/28/2023 Plan of Correction Administrator agrees to complete a needs and service plan for R1 and R2. Completed needs and service plan to be submitted to LPA by 6/28/23.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. 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 in 1 out of 2 persons which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/01/2023 Plan of Correction Administrator agrees to dispense R1's medications in the way that doctor orders. In addition, Administrator to obtain physician orders for all OTC medications. Administrator to send doctor orders into CCL by 6/28/23.

Official classification

Type B

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee converted a large closet in common bathroom into a staff breakroom which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/28/2023 Plan of Correction Administrator agrees to empty closet of staff belongings, and not use closet as a staff breakroom. Administrator to send LPA a picture of the closet empty of staff belongings. Picture to be sent into LPA by 6/28/23.

Official classification

Type B

Official code

87305(b)

Regulation authority

CCR

What the official deficiency says

87305 Alterations to Existing Building or New Facilities (b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists. This requirement is not met as evidenced by: Based on observation, the Licensee converted 2 bedrooms connected the garage and did not notify CCL or update facility sketch. No permits were obtained and a fire clearance has not been complete, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Licensee shall submit an updated facility sketch which includes 2 bedrooms connected to the garage. In addition, the licensee shall submit approved permits from Roseville City Building Department. Lastly, the licensee shall submit a letter to CCL indicating the rooms connected to the garage will be for staff use or storage use only. POC shall be submitted by 06/30/22.

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

Official classification

Type A

Official code

87628(a)

Regulation authority

CCR

What the official deficiency says

Diabetes. The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement was not met as evidenced by: the caregivers, who are not licensed skilled medical professionals are giving insulin injects at the resident's request. This is an immediate safety risk to residents.

Official plan of correction

By 03/09/2022, the licensee shall submit in writing how she is going to ensure either a resident who requires injections does it by themselves or have a licensed skilled medical professional do it.

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

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: A couple of A couple of visitors were not wearing masks in the facility per the CA Public Health Mandate. This poses an immediate threat to residents in care.

Official plan of correction

By 03/09/2022, Licensee stated she posted a sign on the door, everyone is told to wear one and masks are provided upon entrance. She is going to email LPA the mask policy.

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