MOAI

Official classification

Type A

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 (...) 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 interviews conducted, observations, and records reviewed, the facility did not ensure to follow doctor's orders regarding R1's medications, which poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

Facility will complete a statement of understanding regarding regulation 87465 and submit statement to LPA by POC due date of October 1, 2025.

Deadline recorded: Oct 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87224(a)

Regulation authority

CCR

What the official deficiency says

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required (...). This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure to issue a lawful eviction notice and provide 30-days notice upon issuance, which poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

Facility will rescind notice issued to R1 in writing and submit written rescission to LPA by POC due date of October 1, 2025.

Deadline recorded: Oct 1, 2025. 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

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on observations and interviews conducted, the facility did not ensure that R1 was free from intimidation when verbally informed of eviction prior to issuance of notice, informed of 3-day eviction, and issued a notice to perform or quit, which poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

Facility will complete a statement of understanding regarding regulation 87468.2 and submit statement to LPA by POC due date of October 1, 2025.

Deadline recorded: Oct 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observations, facility did not ensure that backyard of facility was in good repair with accessible empty pool, which poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Facility will either install gate surrounding pool and fix pool, or fill in pool with cement, by POC due date of November 30, 2025.

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

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. 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 two personnel file did not have initial training documents on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/27/2024 Plan of Correction Licensee is to ensure staff are completely the required trainings. Statement of compliance is to be submitted to LPA by POC due date.

Official classification

Type B

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can 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: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on medication audit, the licensee did not comply with the section cited above as the dosage for Trazodone on file does not match the dosage on perscription bottle, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/27/2024 Plan of Correction Licensee is to obtain an updated medication list for R1. Licensee is to ensure all physican orders are kept on file. Licensee will submit R1's updated medication list to LPA by POC due date,

Official classification

Type A

Official code

87204(a)

Regulation authority

CCR

What the official deficiency says

87204 Limitations - Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license... This requirement is not met as evidenced by: Based on file review, Licensee did not comply with the section cited above as R1 and R2 was accepted to the facility when facility was not licensed for non-ambulatory residents, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee has moved R2 to an approved non-ambulatory room. Licensee will submit a statement of compliance to operate based on licensure. POC due 2/24/2024.

Deadline recorded: Feb 24, 2024. A deadline is not proof that correction was completed.