BLESSED HOMECARE 3

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 ... (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. This was not met by evidenced by: R1 eloped from the facility on 07/25/2026 but it was not reported to the Department

Official plan of correction

Licensee will conduct a training on reporting requirements and submit materials to CCL by POC due date.

Deadline recorded: Aug 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468(b)(1)(A)

Regulation authority

CCR

What the official deficiency says

(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on review of records, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/10/2026 Plan of Correction Licensee will submit all signed personal rights forms to LPA by POC due date.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

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: Based on medication audit, Licensee did not comply as LPA observed R1 medication order for Vitamin D3 25mcg daily but S1 has been administering 50mcg, which poses a potential risk.

Official plan of correction

Licensee is to conduct a medictaion training on ensuring the correct dose is given. Proof of training is due June 13, 2025.

Deadline recorded: Jun 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87755(c)

Regulation authority

CCR

What the official deficiency says

87755 Inspection Authority of the Licensing Agency (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b). This requirement is not met as evidenced by: Based on observation, Licensee did not comply as LPA arrived to conduct a medication audit but the medication administration record was not available at the facility which poses a potential risk.

Official plan of correction

Licensee is to submit a statement of understanding that the medication administration record should not leave the facility. POC is due June 13, 2025.

Deadline recorded: Jun 13, 2025. A deadline is not proof that correction was completed.

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 file review, the licensee did not comply with the section cited above as fire and earthquake drills has not been conducted quarterly which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/04/2025 Plan of Correction Licensee will create a drill schedule to be in compliance and provide a copy to LPA Yang by April 4, 2025.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on file review, the licensee did not comply with the section cited above as LPA osberved two staff files that did not have first aid certification which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/04/2025 Plan of Correction Licensee is to conduct an audit of staff files to ensure all caregivers have a first aid certification. Licensee is to provide proof of S1 and S2's first aid by April 4, 2025.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as LPA observed gardening tools and recycling boxes located on the exterior pathway which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/04/2025 Plan of Correction Items were removed immediately. Licensee is to provide LPA a statement of compliance of the following regulation.

Official classification

Type A

Official code

87355(c)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: This requirement is not met as evidenced by: Based on observation, file review and interview, the licensee did not comply with the section cited above as S1 was observed to be working but are not associated to the facility roster which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee is to submit paperwork required for criminal clearance transfer for the facility and/or associate S1 on Guardian immediately or S1 is to vacate the facility. Proof of association is due to LPA on 11/6/2024. Failure to provide POC by due date may result to civil penalty of $100 per day until received. Civil penalty and repeated violation civil penalty assessed.

Deadline recorded: Nov 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Based on file review, Licensee did not comply as R1 did not have a LIC 602 / Medical Assessment present on file which poses a potential risk for residents in care.

Official plan of correction

Licensee is to obtained an updated LIC 602 / Medical Assessment for R1. Licensee is to notify LPA once completed - POC is due by December 5, 2024.

Deadline recorded: Dec 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(d)(3)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (3) Ability to maintain or supervise the maintenance of financial and other records. This requirement is not met as evidenced by: Based on file review and interview, Licensee did not comply as R1's skilled nursing facility discharge paperwork was mistaken for LIC 602 which R1 has no current LIC 602 on file, which poses a potential risk for residents in care.

Official plan of correction

Licensee and Administrator are have a training of 87458 Medical Assessment and 87506 Resident Records . Notification of completion is to be submitted to LPA by November 15, 2024. Failure ot correct in a timely manner may assessed to civil penalty of $100 per day.

Deadline recorded: Nov 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.312(e)

Regulation authority

HSC

What the official deficiency says

§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement is not met as evidenced by: Based on file review of the incident report and interview, Licensee did not comply as R1 left the facility through the front door without staff seeing which poses an immediate health and saftey risk.

Official plan of correction

Licensee shall provide a plan to LPA of hoe facility will ensure residents in care will not be absent without leave. Plan is to be provided to LPA by 11/6/2024. Failure to correct may result to $100 per day until received and/or corrected.

Deadline recorded: Nov 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555a

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Based on LPA and S1's food inspection, Licensee did not comply as there was a jar of instant coffee in the pantry with expiration date of August 31, 2024, which poses a potential risk for residents in care.

Official plan of correction

Coffee was disposed. Licensee is to conduct an audit of food pantry and refrigerator with documentation of expiration dates. Licensee is to submit the proof of the audit to LPA by Tuesday November 12, 2024. Failure to correct in a timely manner may result to $100 civil penalty until corrected.

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

Official classification

Type A

Official code

87355(c)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above as one staff was observed to be working and one staff was residing at the facility but are not associated to the facility roster which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

S1 and S2 is to leave the facility until cleared and associated to the facility roster. Informal meeting will be held to discuss this matter. Failure to provide POC by due date may result to civil penalty of $100 per day until received.

Deadline recorded: Aug 21, 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

87203 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 is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as LPA observed facility fire door to be hooked open and smoke alarm to be removed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee unhooked fire door immediately. Licensee will input fire alarm up immediately and provide proof to LPA. Licensee wil fix fire door to ensure it can self-latch. Licensee will install a magnetic door opener as facility has the tendency to keep fire door opened. Failure to provide POC by due date may result to civil penalty of $100 per day until received.

Deadline recorded: Aug 21, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(c)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: 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 as two staff were observed to be working at the facility since licensure but are not associated to the facility roster which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/19/2024 Plan of Correction Licensee is to submit the required documents to CCLD to transfer clearance to facility roster. Licensee is to submit a statement of understanding that all staff are to be fingerprint cleared and associated to facility prior to employment. Failure to provide POC by due date may result to civil penalty of $100 per day until received.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 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 is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as LPA observed facility fire door to be hooked open which poses an immediate health, safety or personal rights risk to persons in care. Failure to provide POC by due date may result to civil penalty of $100 per day until received.

Official plan of correction

POC Due Date: 07/19/2024 Plan of Correction Licensee unhooked fire door immediately. Licensee is to submit statement of understanding to obey fire safety law where fire doors are to be kept closed at all times. Failure to provide POC by due date may result to civil penalty of $100 per day until received.