MONUMENT PARK MANOR

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. Licensee did not report to the Department the incident that occurred on 06-25-25 involving staff member being arresting at the facility

Official plan of correction

Licensee will conduct staff training on the reporting requirements and provide proof of training and training material to LPA by the plan of correction date.

Deadline recorded: Aug 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above by leaving disinfectants and cleaning solutions unsecured and accessible, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/30/2023 Plan of Correction Facility agreed to conduct staff training regarding maintaining disinfectants, cleaning solutions and poisons, secured and locked, to ensure they are stored inaccessible to residents in care. Proof of correction will be submitted to CCLD by close of business on 6/30/2023.

Official classification

Type B

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in by having a broken magnetic lock on the kitchen drawer that is used to store knives, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/30/2023 Plan of Correction Facility agreed to repair/replace magnetic lock and properly secure knives to make them inaccessible to residents in care. Proof of correction to be submitted to CCLD by close of business on 6/30/2023.

Official classification

Type B

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above due to Administrator possessing the personnel records file cabinet key on their person, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/30/2023 Plan of Correction Facility agreed to maintain personnel records file cabinet key on the premises and provide proof to CCLD of the return of the key on 6/30/2023 by close of business.

Official classification

Type B

Official code

97465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care 87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. 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 by not completing Medication Administration Record, documenting assistance with self-administered medications for residents, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/30/2023 Plan of Correction Facility agreed to provide staff training regarding dispensing medication and documenting assistance with self-administered medications. Proof of correction will be submitted to CCLD by close of business on 6/30/2023.

Official classification

Type A

Official code

87355(d)

Regulation authority

CCR

What the official deficiency says

(d) All individuals subject to a criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation 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: 06/24/2022 Plan of Correction Carlos agreed the facility will submit a written statement of understanding of the regulation cited by POC due date 6/24/2022.