A AND E LOVING SENIOR HOME CARE, INC.

Official classification

Type A

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 not locking the cleaning solutions/supplies located in the laundry room cabinet making it accessible to their residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/22/2023 Plan of Correction Licensee stated to immediately lock the cleaning solutions in the laundry room cabinet once and submit proof to LPA Brown at Plan of Correction (POC) due date. Licensee stated to submit Signed Statement of Understanding on CCR 87309(a) to LPA Brown at POC due date.

Official classification

Type A

Official code

87309(b)

Regulation authority

CCR

What the official deficiency says

(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above. 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 storing the residents whole day pre-poured medicines in the kitchen cabinet and not locked which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/22/2023 Plan of Correction Licensee removed the pre-poured medicines found in the kitchen drawer and transferred it to a locked medicine cabinet during the visit. Licensee stated to train all staff on CCR 87309(b) and submit proof of Training Log to LPA Brown at Plan of Correction (POC) due date.

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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 pre-pouring the residents whole day of medications in a small container per resident which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/22/2023 Plan of Correction Licensee stated to train all staff on CCR 87465(h)(5) and submit proof of Training Log to LPA Brown at Plan of Correction (POC) date.

Official classification

Type A

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 by not securing or locking two (2) scissors found in the kitchen drawer not locked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/22/2023 Plan of Correction Licensee stated to train all staff on CCR 87705(f)(1) and submit proof of Training Log to LPA Brown at POC due date.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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 not locking the nutritional supplements or vitamins in the kitchen cabinet making it accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/22/2023 Plan of Correction Licensee stated to train all staff on CCR 87705(f)(2) and submit proof of Training Log to LPA Brown at Plan of Correction (POC) due date.

Official classification

Type A

Official code

87705(l)(2)

Regulation authority

CCR

What the official deficiency says

(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. 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 locking/securing the side gate/perimeter fence gate with a pad lock in a manner that residents are unable to exit without assistance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/22/2023 Plan of Correction The licensee agrees to remove the lock and agree to not lock the perimeter fence gate without Licensing and Fire Marshall approval. Administrator unlocked gate during visit. Plan of Correction (POC) cleared.

Official classification

Type B

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. 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 not having non-skid mat or strip in the hall bathroom which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/27/2023 Plan of Correction Licensee stated to put/purchase a non-skid mat/strip in the hallway bathroom and submit proof to LPA Brown at Plan of Correction (POC) due date.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. 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 not having the Cleaning Supplies cabinet in good repair located in the laundry room which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/27/2023 Plan of Correction Licensee stated to repair the Cleaning Supplies cabinet in the laundry room and submit proof of repair to LPA Brown at POC due date.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(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 and interview, the licensee did not comply with the section cited above by not having the backyard/outdoor free of obstructions which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/27/2023 Plan of Correction Licensee cleared the backyard/outdoor of obstructions during the visit. Plan of Correction (POC) cleared.

Official classification

Type B

Official code

87412(a)(12)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General. 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 not having Staff #4 (S4) and Staff #5 (S5) Health Screenings Report in their staff facility file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/27/2023 Plan of Correction Licensee stated to complete S4 and S5 Health Screening Report and update S4 and S5 file and submit proof to LPA Brown at POC due date.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by having R3 with full bed rail and not having a written order from a physician indicating the need for the postural support and shall be maintained in the resident's record which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/04/2023 Plan of Correction Licensee stated to submit a written order from R3's physician indicating the need for the postural support and maintain in R3's facility file and submit proof to LPA Brown at Plan of Correction (POC) date. Also, if Physician required full bed rail, Exception Letter must be submitted for approval to CCLD with a written order from a physician indicating the need for the full bed rail.

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by not having a Hospice Care Plan that specifies the need for full bed rails for Resident #1 (R1), Resident #2 (R2), Resident #5 (R5) and Resident #6 (R6) which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/04/2023 Plan of Correction Licensee stated to submit R1, R2, R5 and R6 Hospice Care Plan that specifies the need for full bed rails and submit to LPA Brown at POC due date.

Official classification

Type A

Official code

87705(4)(A)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal... This requirement is not met as evidenced by: Based on interviews & records review, it was found that Licensee did not ensure there's a staff scheduled to work night (NOC) shift for night supervision to residents with dementia which pose immediate health, safety and personal rights risk to residents in care.

Official plan of correction

The Licensee stated to train all staff on CCR 87705(4)(A) and submit proof of Training Log to LPA Brown at Plan of Correction (POC) due date.

Deadline recorded: Oct 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (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...This requirement is not met as evidenced by: Based on interviews & records review, the Licensee did not comply with the section cited above by failing to complete the required annual medical assessment, reappraisal and reassessment done for R1's dementia care needs which pose potential health, safety and personal rights risks to resident in care.

Official plan of correction

The Licensee stated to train all staff on CCR 87705(5) and submit proof of Training Log to LPA Brown at POC due date.

Deadline recorded: Nov 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a) Additional Personal Rights of Residents in Privately Operated Facilities: ...Residents in privately operated RCFEs shall have all of the following...rights: (4)To care, supervision, & services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, & competency to meet their needs. This requirement was not met as evidenced by: Based on interviews & records review, it was found that Licensee did not ensure R1 received the care, supervision & services to meet their needs. On 09/28/2023, R1 was admitted for Home Health Service at a community care licensed facility in Laverne and R1 was diagnosed with Stage 2 Pressure Ulcer of left buttock. However, it was found that treatment and care for the injury was not being provided as needed. This violation of regulation posed an immediate health, safety and personal rights risk to R1.

Official plan of correction

The licensee stated to train all staff on CCR 87468.2(a)(4) and submit proof of Staff Training Log to LPA Brown at Plan of Correction (POC) due date.

Deadline recorded: Oct 28, 2023. A deadline is not proof that correction was completed.