CALEO BAY ALZHEIMER'S SPECIAL CARE CENTER

Official classification

Type B

Official code

87705(f)(6)

Regulation authority

CCR

What the official deficiency says

(f) Licensees that lock exterior doors or perimeter fence gates…(6) Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. This requirement was not met as evidenced by: Based on interviews and records review, R1 eloped from the facility locked perimeter. This poses a potential health, safety, or personal rights risk to residents in care.

Official plan of correction

The administrator agreed to conduct an elopment drill with staff and send proof of the training by the POC due date.

Deadline recorded: Jan 30, 2025. A deadline is not proof that correction was completed.

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 LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in employee rights for S1, S2, S3, S4, S5, S7, S8, S9, S10, criminal record statement for S1, S6, personnel record or job appliation for S3, S9 not observed in personnel files which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/07/2024 Plan of Correction Licensee will ensure staff will complete documents and maintain a copy in file and email copies to LPA by POC due date.

Official classification

Type B

Official code

87412(a)(11)

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: (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 LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in S1,S2, S3, S4, S5, S6, S7 did not have a health screening in their personnel file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/07/2024 Plan of Correction Licensee will ensure staff 1-7 obtain a health screening and maintain a copy in their personnel file and will email copies to LPA by POC due date.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review...shall prior to working...in a licensed facility:(2)Request a transfer of a criminal record clearance...This requirment was not met as evidenced by: Based on record review it was found that three staff were not associated to the facility. This poses an immediate health safety or personal rights risk to residents in care.

Official plan of correction

The administrator stated they send the LPA a self certified statement by the POC due date stating that they have reviewed their roster and understand the process to associate staff to their facility.

Deadline recorded: Sep 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

(a) In addition…all of the following personal rights:(8) To be free from neglect…physical, or sexual abuse.This requirement was not met as evidenced by: Based on interviews and records review,S1 was neglectful while changing R1, by pushing R1 and falling on top of R1’s leg resulting in a fracture. This poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

The administrator agreed to hold an all staff training on 9/21/2023, where staff will be trained on resident, changing, challenging behavior, and personal rights. The licensee agreed to send the training material to the LPA by the POC due date and notify the LPA when the training is completed on 9/21/23.

Deadline recorded: Sep 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) A plan for incidental medical...care shall be developed...(1)The licensee shall arrange, or assist in arranging, for medical...care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews and records reviews, R1 did not receive appropriate medical attention for fractured until (3) days after. This was due to S1 disseminating inaccurate statements. This poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

The administrator agreed to send the LPA training material they will use with staff for emergency scenarios and assessing residents. This will be sent to LPA by the POC due date. The Administrator agreed to send notification to the LPA when the training is completed on 9/21/23.

Deadline recorded: Sep 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87221(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish...(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...This requirment was not met as evidenced by: Based on interviews and records review it was found incident for R1 was reported past 7 days and reported inaccurate occurence to responsible party. This poses an potential health saftey or personal rights risk to residents in care.

Official plan of correction

The licensee agreed to send the LPA a self certified statement on their understanding of reporting requirments and when to report a resident fall. This is due by the POC due date the LPA.

Deadline recorded: Sep 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in having five (5) staff members associated with this facility during the time of LPA's visit which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/18/2023 Plan of Correction Licensee will ensure employees are associated before being allowed to work at this facility based on Title 22 regulations. Executive Director will associate employees by the agreed POC date so they are able to work at facility. Licensee will provide a statement of understanding of the title 22 regulations along with proof of association to LPA.

Official classification

Type A

Official code

87468.2(a)(20)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in ...Facilities: (20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents...and shall comply with all eviction and relocation protections for residents.... This requirement was not met by: Based on record review, the Licensee did not comply with the above regulation with one resident (R1). Administrator provided R1's family with an eviction notice on 9/14/22 which was effective immediately. The facility also did not conduct a reassessment of R1. This is an immediate personal rights violation of R1.

Official plan of correction

Licensee agrees to recind the eviction notice sent to the family, and provide LPA Colvin with a copy of an email sent to the family detailing the recintion of the illegal eviction. This does not prohibit the facility from issuing a 30-day eviction, should the follow the proper procedure. Additionally, Licensee agrees to have Administrator review Title 22 Reglation Section 87224 Eviction Procedures. Administrator to provide LPA Colvin with Self-Certification of completion as well as Statement of Understanding regarding proper eviction procedures. Email, self-certification, and Statement due by 9/16/22.

Deadline recorded: Sep 16, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care... shall deliver hot water. Hot water temperature controls shall be...a temperature of not less than 105 degree F... This requirement was not met by: Based on observations, the Licensee did not comply with the above regulation with at least two resident bathrooms (#46 & #36). LPA Colvin observed a maximum hot water tempurature in Room #46 of 92.6 degrees, and 86.7 degrees in Room #36. This is a potential health risk for residents in care.

Official plan of correction

Licensee agrees to adjust the settings on the water heater and re-measure the maximum hot water tempurature in 3 resident bathrooms in each wing of the facility. Licensee to provide LPA Colvin with readings for each room, confirming that the tempurature is inbewteen 105 and 120 in resident bathrooms. Readings to be provided to LPA Colvin by Plan of Correction date of 9/30/22.

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

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not being met as evidenced by: R1 was first observed at approximately 0600 with injuries to the face, eye and lip. Staff failed to call 911 for emergency medical treatment until approximately 0745. This posed an immediate health and safety risk to resident in care.

Official plan of correction

Executive Director will ensure staff are provided training of when to contact 911 and seek medical attention for residents. Proof of correction will be submitted by 10/8/21.

Deadline recorded: Oct 8, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not being met as evidenced by: Based on interviews and record reviews, between January 1, 2019 and October 26, 2019, R1 sustained multiple falls. Licensee did not ensure staff had been sufficiently informed of R1’s fall risk and/or what precautions were to be used to mitigate further falls. This posed a potential health and safety risk to resident in care.

Official plan of correction

Executive Director will ensure staff are provided training on observation of residents and ensure their needs are being met. Proof of training will be submitted by 10/8/21.

Deadline recorded: Oct 8, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not being met as evidenced by: On October 26, 2019 R1 was observed with a bloody face and injuries to eye and lip. Staff interviews could not provide evidence as to how R1 sustained the injuries. This posed an immediate health and safety risk to resident in care.

Official plan of correction

Executive Director will ensure staff are trained on expectations relating to their knowledge of residents care plan to ensure their needs are met. Proof of training will be submitted by 10/8/21.

Deadline recorded: Oct 8, 2021. A deadline is not proof that correction was completed.