COMFORTS OF HOME RESIDENTIAL CARE, LLC

Official classification

Type B

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, record review, the licensee did not comply with the section cited above in 2 out of 2 MAR Resident records which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/13/2026 Plan of Correction Administrator will conduct in house training with staff on proper medication dispensing and documentation by POC date.

Official classification

Type B

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. 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 four out of four MAR records which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/31/2025 Plan of Correction Licensee stated they have staff who are certified to dispense medication and will be training them to begin documenting and administering medication at the facility. Licensee will email proof of the training and the effective date.

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 interview and record review, the licensee did not comply with the section cited above with S1 who was cleared but did not have a transfer for the fcility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/24/2024 Plan of Correction The administrator provided a transfer to the LPA during the time of the visit. The administrtor agreed to send the LPA LIC500 showing that sufficent staff coverage exist for staff that are fingerprint cleared.

Official classification

Type B

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above with MARS log that was not initaled for C1, and PRN medication that did not have a physican's order for C1 which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/30/2024 Plan of Correction The administrtor agreed to send the LPA the orders for the PRN medication by the POC due date for C1.

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 interview and record review, the licensee did not comply with the section cited above with drill that was due december and has not been yet conducted. Documentation was unable to be provided for last drill in October 2023 which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/31/2024 Plan of Correction The administrtor stated theywould conduct a drill by the end of the month and send the documentation to the LPA by the POC due date.

Official classification

Type B

Official code

87507

Regulation authority

CCR

What the official deficiency says

87507 Admission Agreements (g) Admission agreements shall specify the following: (5) Refund conditions. (E) Preadmission fees shall be refunded... 1. A 100 percent refund of a preadmission fee shall be provided to an applicant... b. The licensee fails to provide full written disclosure of preadmission fee charges and refund conditions. This requirement was not being met as evidenced by: Through interviews obtained, this poses a potential risk to residents in care.

Official plan of correction

Licensee will draft a new admissions agreement to comply with Title 22 and review the regulation, and agrees to provide the applicable refund amount of the preadmission fee to W1. Licensee to provide LPA Gardner with self-certification of the reviewed regulation. Proof requested is due by Plan of Correction date of 12/28/21.

Deadline recorded: Dec 28, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507

Regulation authority

CCR

What the official deficiency says

87507 Admission Agreements (g) Admission agreements shall specify the following: (5) Refund conditions. (E) Preadmission fees shall be refunded (1) A 100 percent refund of a preadmission.. (b) The licensee fails to provide full written disclosure of preadmission fee... b. The licensee fails to provide full written disclosure of preadmission fee charges and refund conditions. This requirement was not being met as evidenced by: Through interviews obtained, this poses a potential risk to residents in care.

Official plan of correction

Licensee to provide LPA Gardner with self-certification of the reviewed regulation. Proof requested is due by Plan of Correction date of 12/28/21.

Deadline recorded: Dec 28, 2021. A deadline is not proof that correction was completed.