WESTHILLS VILLA GARDENS

Official classification

Type B

Official code

87506(e)

Regulation authority

CCR

What the official deficiency says

87506(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: The licensee did not comply with the section cited above by not retaining former resident's record file at the facility for review for a minimum of three years after services, which poses a potentional health, safety, and personal rights risk to persons in care.

Official plan of correction

The licensee/Administrator has agreed to provide resident records by POC due date.

Deadline recorded: Jul 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87470(a)(2)(D)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (D) Facility items that cannot be disinfected shall be discarded immediately in an appropriate waste receptacle with a tight-fitting cover or otherwise made inaccessible to human contact or transmission. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations, the licensee did not comply with the section cited above by having uncovered trash containers with tissue in residents bathrooms; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/25/2024 Plan of Correction Licensee/Administrator shall submit to the Licensing Agency proof of covered trash containers 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 LPA file review, the licensee did not comply with the section cited above by the facility did not have a current emergency drill conducted with staff on file.which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/25/2024 Plan of Correction Licensee/Administrator shall submit to the Licensing Agency proof of drill conducted by POC due date

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 based on evidence by interview and document review. The licensee did not comply with the section cited above by not reporting an incident with a resident to state licensing within the required seven (7) day timeframe which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to read regulation 87211 entirely and send LPA self-certify letter that the regulation was read and understood. The licensee has agreed send licensing a special incident report for this incident. The licensee has agreed that moving forward all special incidents will be reported to licensing within the required time frame.

Deadline recorded: Jul 6, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

87705.Care of Persons with Dementia. (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement was not met based on evidence by interview, observation, and document review. The licensee did not comply with the section cited above by not having safety measures in place to keep dementia resident with wandering behaviors safe which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to read regulation 87705 entirely and send LPA self-certify letter that the regulation was read and understood. The licensee has agreed to put a plan in place to ensure the resident’s wandering behaviors are addressed and the resident is safe. The plan needs to be written in a letter and sent to LPA.

Deadline recorded: Jul 6, 2022. A deadline is not proof that correction was completed.