TENDER HOME SENIOR CARE

Official classification

Type A

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and records review the licensee/admin did not comply with the section cited above. 5 of 5 of the resident's medications in the Medication Administration Records were not recorded and given per physician's orders according the facility's Plan of Operation which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/05/2025 Plan of Correction Licensee/Administrator will conduct daily audits of the centrally stored medications and MAR for the next 7days and weekly audits thereafter for 30 days with proof of audit logs submitted to Licensing once after the initial 7days and again after 30 days. Licensee/Admin to submit an audit plan to LPA Viarella via email by 09/05/25 at 5pm PST.

Official classification

Type A

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff This requirement is not met as evidenced by: Based on LPA observation R1's records were not made available for review during this visit. This violation poses an immediate health, and safety risk to residents in care.

Official plan of correction

Licensee shall submit by fax a statement that all records will be made readily available for review upon request.

Deadline recorded: Mar 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: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. This requirement is not met as evidenced by: Based on Licensee admittance that the reporting requirements has not been met. This violation poses an immediate health, and safety risk to residents in care.

Official plan of correction

Licensee shall submit by fax a statement that in all instances that a report is warranted they are to be submitted by fax to CCL.

Deadline recorded: Mar 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on S1 did not allow R1 to sit rather than lie on bed. This violation poses an immediate health, and safety risk to residents in care.

Official plan of correction

Licensee shall submit a plan by fax to train staff on residents rights by POC due date of 3/8/24. In addition, submit a letter by fax indicating the in-service training for staff has been completed by 3/15/24.

Deadline recorded: Mar 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from...humiliation...or other actions of a punitive nature... This requirement is not met as evidenced by: Based on R1 was demanded to lie down by S1. This violation poses an immediate health, and safety risk to residents in care.

Official plan of correction

Licensee shall submit a plan by fax to train staff on abuse by POC due date of 3/8/24. In addition, submit a letter by fax indicating the in-service training for staff has been completed by 3/15/24.

Deadline recorded: Mar 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.69(a)(5)

Regulation authority

HSC

What the official deficiency says

To complete the training requirements set forth in this subdivision, each employee shall pass an examination that tests the employee’s comprehension of, and competency in, the subjects listed in paragraph (4). This requirement was not met as evidenced by LPA review of staff file which and statements from the licensee that the staff member did not complete an examination regarding medication administration and was not aware of the requirement which poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Licensee will provide a written statement to LPA that the Licensee understand the requirement and to identify all staff that will be administering medications to residents in the future and provide LPA with a sample examination that meets the requirements in the Health and Safety code.

Deadline recorded: Sep 2, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(d)(3)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements - General: Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement was not met as evidenced by observations by LPA who observed a staff member alone at the facility who could not speak english and would not be able to communicate effectively with residents to meet their needs and communicate with emergency responders in the case of an emergency at the facilty which poses a potential health, safety and personal rights risk to residents in care. The department emphasizes that we are not prohibiting non-english speakers from working in a licensed facility, but one staff member must be present who can effectively communicate with residents to meet their needs at all times a resident is present in the facility.

Official plan of correction

Licensee will provide a written statement that they understand that the staff member cannot be at the facility alone with residents due to their inability to communicate effectively with residents. Licensee will provide LPA and update LIC 500 which shows a new staff shedule that include an addidtional staff member whenever a staff present is unable to communicate with residents.

Deadline recorded: Sep 2, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.69(b)

Regulation authority

HSC

What the official deficiency says

Employees assisting residents with self-administration of medication; training requirements: Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement was not met as evidenced by training records for S2 only contained 5 hours of annual training instead of the required 8 which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Facility will conduct the remaiining medication training for all staff who administer medications to residents. Licensee will ensure all staff members are trained on medications in accordance with regulations of the health and safety code.

Deadline recorded: Jul 15, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by the injury sustained and bruising observed by home health aid after the date of the reported fall by R1 and the injury was not reported or observed prior to Home health aid which poses an immediate health, safety and personal rights risk to reidents in care.

Official plan of correction

Facility will develope a weekly resident checklist where staff members will inspect residents during routine care and documents any observed changes for the Licensee to review and recommend changes.

Deadline recorded: Jul 15, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on review of 5 residednt records, the licensee did not comply with the section cited above in 3 out of 5 resident records which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2022 Plan of Correction Facility will contact all responsible parties for residents with a diagnosis of dementia and provide them with the LIC 602(a) to be completed by the resident's physician by the POC due date.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by, on 5/4/22 licensee did not ensure the personal rights of persons in care to safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of persons in care, in that facility staff Tamaka Holder and three visitors did not wear face coverings while in the facility, as required by the Order of the State Public Health Officer dated June 11, 2021 requiring compliance with CDPH Guidance for the Use of Face Coverings, and as required by COVID-19 Prevention Emergency Temporary Standards (ETS) at Title 8, CCR section 3205, and an individual mask exemption did not apply.

Official plan of correction

Licensee will submit daily attestations to department indicating the Administrator has been at the facility and has observed all staff and visitors wearing face coverings as required. If a staff or visitor is observed without a mask Licensee will submit what steps and discipline was enacted to correct the staff or visitors.

Deadline recorded: May 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

Plan of Operation: (a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. This requirement was not met as evidenced by LPA review of facility plan of operation which included language that all medications administered would be recorded and documented. LPA observed the facility had not been following the plan of operation and recently reinstituted documenting medication administration.

Official plan of correction

Facility will continue to document all prescribed medications and PRNs administered to residents. Licensee will email LPA with updated MARs for each resident weekly (Mondays) to verify that medications are being documented and recorded by staff. If it is noted a medication was given and not recorded, an incident report will be sent to the department.

Deadline recorded: May 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

Administrator - Qualifications and Duties: 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: (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by LPAs observations that staff continue to not wear masks when inside the facility as required by the Order of the State Public Health Officer dated June 11, 2021 requiring compliance with CDPH Guidance for the Use of Face Coverings, and as required by COVID-19 Prevention Emergency Temporary Standards (ETS) at Title 8, CCR section 3205, and an individual mask

Official plan of correction

Licensee will submit daily attestations to department indicating the Administrator has been at the facility and has observed all staff and visitors wearing face coverings as required. If a staff or visitor is observed without a mask Licensee will submit what steps and discipline was enacted to correct the staff or visitors.

Deadline recorded: May 13, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by, on 4/6/22 licensee did not ensure the personal rights of persons in care to safe and healthful accommodations and engaged in conduct inimical to the health, welfare, and safety of persons in care, in that facility staff Tamaka Holder did not wear face coverings while in the facility, as required by the Order of the State Public Health Officer dated June 11, 2021 requiring compliance with CDPH Guidance for the Use of Face Coverings, and as required by COVID-19 Prevention Emergency Temporary Standards (ETS) at Title 8, CCR section 3205, and an individual mask exemption did not apply.

Official plan of correction

Licensee will submit a written plan of correction stating that all staff are required to wear a facemask and the steps the facility will take to ensure the mask requirement is adhered to. Licensee understands that another citation will result in an immediate civil penalty.

Deadline recorded: Apr 7, 2022. A deadline is not proof that correction was completed.