HOVLEY CARE LLC

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 in two (2) out of two (2) staff who do not have documentation of the training available for review during the visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2024 Plan of Correction Licensee will ensure staff have conducted the training listed above and send proof of completion for Staff One (S1) and Staff Two (S2) by the agreed plan of correction date 07/12/2024

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. 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 for Resident One (R1) who did not have a updated record of the centrally stored medication list, the most recent list is dated 03/14/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2024 Plan of Correction Licensee will ensure the facility maintains an updated centrally stored medication list for R1 and other residents in care. Licensee will send proof of a updated centrally stored medication list for R1 by the agreed plan of correction date 07/12/2024.

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, the licensee did not comply with the section cited above in conducting a quarterly disaster drills with staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2024 Plan of Correction Licensee will read the regulation cited and conduct a type of disaster drill with staff from the AM shift and PM shift. Licensee will submit proof of training and the materials covered during the training to LPA by the agreed plan of correction date 07/12/2024.

Official classification

Type B

Official code

87156(a)

Regulation authority

CCR

What the official deficiency says

(a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. 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 paying their annual licensing fee since the year 2021 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2024 Plan of Correction Licensee will ensure fees are paid and will submit proof of payment to LPA by the agreed plan of correction date 07/12/2024.

Official classification

Type B

Official code

80072(a)(3)

Regulation authority

CCR

What the official deficiency says

Personal Rights; (a) Except .... each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature.... This requirement is not met based as evidence by interview. The licensee did not comply by yelling at resident which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee stated moving forward resident will be spoken to in a respectful tone and a written statement of understanding of the regulation cited will be provided to LPA by the POC 2/12/2024.

Deadline recorded: Feb 12, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(1)

Regulation authority

CCR

What the official deficiency says

Personal Rights; To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups This requirement is not met based as evidence by interview. The licensee did not comply by barging into resident’s bedroom without knocking and not accord resident personal privacy which poses a potential health, safety, or personal rights risk to persons in care

Official plan of correction

Licensee stated a written statement of understanding of the regulation cited will be provided to LPA by the POC 2/12/2024.

Deadline recorded: Feb 12, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Facility does not have any carbon monoxide alarms in the facility. Deficient Practice Statement Based on observation the licensee did not comply with the section cited above in zero (0) carbon monoxide alarms are in the facility, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/02/2023 Plan of Correction Facility will buy a carbon monoxide and send proof to LPA.

Official classification

Type A

Official code

87211(a)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: No SIR for resident's death. Facility has not reported any SIR to CDSS. Deficient Practice Statement During annual, LPA observed and through interview and record review, the licensee did not comply with the section cited above in not reporting to CDSS any serious incident reports, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/08/2023 Plan of Correction LPA will do a case management with facility.