HAZEL HOME FOR SENIORS

Official classification

Type A

Official code

87202(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (1) Nonambulatory persons. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations and records reviewed, the facility did not ensure that two (2) of five (5) non-ambulatory residents were residing in bedrooms approved for non-ambulatory residents, which poses an immediate health, safety, or personal rights risk to the residents in care.

Official plan of correction

POC Due Date: 03/21/2025 Plan of Correction Facility is in the process of obtaining a fire clearance to accept and retain a non-ambulatory resident for room 2, room 6, and/or manager bedroom. LPA will follow up with facility regarding status of fire clearance.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(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 LPA's observations and records reviewed, the facility did not ensure to complete initial training for newly hired staff in accordance with the Health and Safety code and maintain documentation for initial training at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/11/2025 Plan of Correction Facility will ensure that newly hired staff obtain initial training per Health and Safety code regulation 1569.625. Facility will obtain missing training for staff member (S1) by POC due date. Facility will submit documentation for S1's training to LPA by POC due date.

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 LPA's observations and records reviewed, the facility did not ensure to complete quarterly drills and maintain documentation for quarterly drills at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/11/2025 Plan of Correction Facility will ensure to complete and document quarterly drills and maintain documentation for drills at the facility at all times. Facility will complete a statement of understanding regarding regulation 1569.695 and submit statement to LPA by POC due date.

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 LPA's observation, the facility did not ensure that fire extinguisher was serviced, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/14/2024 Plan of Correction Facility will service fire extinguisher and provide LPA proof of service by POC due date of 3/14/2024.

Official classification

Type B

Official code

1569.657(a)

Regulation authority

HSC

What the official deficiency says

§1569.657 Rate increase due to change in level of resident care; notice (a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure to send a written notice to R1's authorized representative regarding a rate increase due to a change in the level of R1's care, which poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Facility will send a written notice to R1's authorized representative indicating additional services provided. Facility will provide a copy of the written notice to LPA by POC due date of 12/27/2022.

Deadline recorded: Dec 27, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(f)

Regulation authority

CCR

What the official deficiency says

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure to send an invoice for R1's rent every month to R1's authorized representative in agreement with R1's Admission Agreement, which poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Facility will send any missing invoices to R1's authorized representative. Facility will provide proof that the invoices were sent to R1's authorized representative to LPA by POC due date of 12/27/2022.

Deadline recorded: Dec 27, 2022. 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 the licensee did not comply with the section cited above in chemicals unsecured in the kitchen and bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/30/2022 Plan of Correction Disinfectants secured while LPAs present Licensee will submit a plan to ensure monitoring of facility safety

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in two of three caregvers which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/06/2022 Plan of Correction Licensee will submit proof of S2 and S3 initial 20 hours, 1st and and restricted conditions training by 5/6/22

Official classification

Type B

Official code

1569.69(a)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in 3 out of 3 staff files S1 S2 and S3 did not have proof of medication training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/06/2022 Plan of Correction Licensee will provide proof of required medication training by the plan of correction (POC) date of 5/6/22

Official classification

Type B

Official code

87457(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in 3 of 4 resuidents R2 R3 and R4 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/30/2022 Plan of Correction Licnese will update appraisal/ needs and services plans for all residents who have significant changes of condition and establish review meeting dates by the POC date of 5/30/22.

Official classification

Type B

Official code

87465(d)

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: This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in 3 of 3 residents who receive PRN medications do not have PRN authorization letters on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/30/2022 Plan of Correction Licensee will submit proof of letters signed by physician for residents receiving PRN medication by the POC date of 5/30/22

Official classification

Type B

Official code

87212(b)(1)

Regulation authority

CCR

What the official deficiency says

(b) The plan shall be subject to review by the Department and shall include: (1) Designation of administrative authority and staff assignments. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in 2 of 3 caregivers do not have documented knowledge of nor designation to be a responsible party in the Administrator's absence which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/16/2022 Plan of Correction Licensee will submit LIC 308s for those staff to be responsible and are trained to CCL by the POC date of 5/16/22

Official classification

Type B

Official code

87618(b)(5)

Regulation authority

CCR

What the official deficiency says

(5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observatioj and records review the licensee did not comply with the section cited above in1 of 1 residents with Oxygen does not have a plan and staff training in place to assist R1 as needed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/16/2022 Plan of Correction Licensee will submit proof of training and the restricted health condition plan to CCL by the POC date of 5/16/22

Official classification

Type B

Official code

87705(c)(3)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in 2 of 3 staff, S2 S3 do not have record of dementia training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/06/2022 Plan of Correction Licensee will sumit proof of training to CCL by the POC date of 5/6/22.