MAMA ANGELINA COCONOCHO

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

HSC

What the official deficiency says

87412(a)(11) Personnel Records(a) The licensee shall ensure that personnel records are maintained on…each employee. Each personnel record shall contain…(11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview, the licensee did not comply with the section cited above in one out of four staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/10/2025 Plan of Correction Administrator will send out Staff for the Health Screening and TB test and email LPA by POC date.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

FIRE SAFETY: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met, as evidenced by: Based on observation, the Licensee did not ensure the facility was maintained in conformity with the regulations adopted by the State Fire Marshal. The LPA observed a lock on the exterior gate. No secondary exit was available. This posed an immediate threat to the health and safety of the residents in care.

Official plan of correction

Staff removed the lock from the gate prior to the conclusion of the LPA's visit.

Deadline recorded: Feb 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

FIRE CLEARANCE: (a) All facilities shall maintain a fire clearance approved by... the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the...licensee shall...obtain an appropriate fire clearance approved by...the State Fire Marshal. (2) Bedridden persons. This requirement was not met, as evidenced by: Based on records, the Licensee didn't ensure an appropriate fire clearance was obtained prior to accepting a bedridden person into care. R3's Physician's Report noted R3 is non-ambulatory & bedridden. R3 was unable to reposition themself in bed.

Official plan of correction

The Administrator stated a copy of a 3-day eviction notice will be submitted to the Department by the POC due date.

Deadline recorded: Feb 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

INCIDENTAL MEDICAL AND DENTAL CARE: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe & locked place that isn't accessible to persons other than employees responsible for the supervision of the medication. This requirement was not met, as evidenced by: Based on observation, the Licensee did not ensure refrigerated medications were kept in a safe & locked place. LPA observed medications in the facility's refrigerator. The medications were not maintained secured from any unauthorized individuals.

Official plan of correction

The Administrator stated a lockbox will be purchased for the medications and a receipt will be submitted to the Department.

Deadline recorded: Feb 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by: Based on observations, the Licensee did not comply with the above regulation with at least one area of the facility. LPA Colvin observed that the front door was locked with a deadbolt that is only able to be unlocked with a key. This is an immediate safety risk to residents in care.

Official plan of correction

Licensee agrees to have the deadbolt removed and to provide LPA Colvin with photographic proof of removal. The Licensee may choose to replace the deadbolt with one which can be unlatched from the inside without a key. Photos to be provided to LPA Colvin by Plan of Correction date of 7/25/22.

Deadline recorded: Jul 25, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by: Based on observation, the Licensee did not comply with the above regulation with two exit doors. LPA Colvin observed both the front door and back door of the facility to have their auditory alarms turned off. LPA Colvin also tested the doors to confirm. This is an immediate safety risk to Dementia residents.

Official plan of correction

Licensee agrees to obtain additional alarms (Licensee has one which is used at night which residents do not notice and remove) which Licensee and LPA agree are suitable to meet Regulation Requirements. Licensee to provide LPA Colvin with photos of where alarms are placed. Photos due by 7/25/22.

Deadline recorded: Jul 25, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements: (a) Each licensee shall furnish...reports...including... the following: (1) A written report shall be submitted ...within seven days of...(D) Any incident which threatens the welfare, safety or health of any resident, such as... unexplained absence of any resident. This was not met by: Based on record review, the Licensee did not comply with the above regulation with at least one occurance. LPA Colvin confirmed that no report was submitted for R1's elopment from the facility on 7/4/22. This is an immediate safety risk of all residents, as the facility has never submitted a report to Licensing.

Official plan of correction

Licensee agrees to submit an incident report regarding R1's elopment from the facility and subsequent hospitaliztion. Licensee additionally agrees to review Title 22 Regulation section 87211 regarding Reporting Requirements. Licensee may self-certify to LPA Colvin once complete along with a Statement of Understanding regarding what types of incidents must be reported to Community Care Licensing. Incident Report for R1, self-certitifcaiton of Regulation Section 87211 review, and Statement of Understandin due by Plan of Correction date of 7/25/22.

Deadline recorded: Jul 25, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(11)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities: (a) Residents...have all of the following personal rights: (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours... This requirement was not met as evidenced by: Based on observations, the Licensee did not comply with the above regulation. LPA Colvin observed Visitor Hours posted outside the facility which were unreasonably restrictive. Additionally, the posted hours are not what is reflected in the facility's Admissions Agreement. This is a potential personal rights violation of all residents.

Official plan of correction

Licensee agrees to remove the posted visitor policy and provide LPA Colvin with photographic proof of removal. Licensee additionally agrees to send a notice to all families/recent visitors (within last 60 days) of residents regarding recention of posted visitation policy. Licensee may uphold visitation policy that is stated in Admissions Agreement, though provisions and considerations must be made with visitors if they cannot visit during regular hours. Photograph and copy of notice to be provided to LPA Colvin by Plan of Correction date of 8/5/22.

Deadline recorded: Aug 5, 2022. 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

Care of Persons with Dementia: (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...and a reappraisal done at least annually... This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with at least on resident. LPA Colvin observed that R1's most recent Physician's Report is dated 6/11/21. R1 is diagnosed with Dementia. This is a potential health and safety risk to R1.

Official plan of correction

Licensee agrees to have R1 seen by their Primary Care Physician (PCP) and have a new Physician's Report completed. Licensee additionally reccomended to conduct self-audit to ensure no other residents are overdue for a new Physician's Report. Licensee to provide LPA Colvin with a copy of R1's updated Physician's Report, or appointment date with Statement of Understanding that Physician's Report is to be updated at this time, by Plan of Correction of Date of 8/5/22.

Deadline recorded: Aug 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(3)(B)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services: (a) Living accommodations...shall be related to the facility's function...The following provisions shall apply: (3) Equipment and supplies necessary...licensee shall assure provision of: (B) Bedroom furniture, which shall include, for each resident...a lamp, or lights sufficient for reading... This requirement was not met by: Based on observation, the License did not comply with the above regulation with one resident. LPA Colvin observed no operational light source in R1's room other than the bedroom window. This is a potential personal rights violation of R1.

Official plan of correction

Licensee had staff replace the lamp in R1's bedroom during LPA Colvin's inspection. Licensee agrees to review Title 22 Regulations Section 87307 regarding what furniture and supplies are to be provided to residents in each bedroom. Licensee may self-certify once complete. Due by 8/5/22.

Deadline recorded: Aug 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: 87465(h)(2) Incidental Medical and Dental Care Services. Centrally stored medications shall be kept in a safe locked place that is not accessible to persons other than employees responsible for the supervision of the medication. Deficient Practice Statement Based on LPA Gardner's observation of unlocked medication left on the counter, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/12/2021 Plan of Correction Licensee agrees to review medication regulations with staff. Licensee will provide a statement of understanding signed by all staff that they understand the regulations and that medications must be locked at all times no later than close of business on 10/12/21.