BRASWELL'S CHATEAU VILLA

Official classification

Type A

Official code

1569.311

Regulation authority

HSC

What the official deficiency says

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. 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 carbon monoxide alarms throughout the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/24/2025 Plan of Correction Staff went to purchase carbon monoxide alarms for every bedroom in the facility, Administrator has agreed to provide proof to LPA by POC due date.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. 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 sharps locked in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/24/2025 Plan of Correction Administrator has agreed to purchase a lock box for the sharps and provide proof of purchase to LPA by POC due date.

Official classification

Type A

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations, the licensee did not comply with the section cited above by medications for resident #3 (R3) were observed to be in a zip lock bag without a prescription label, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/20/2023 Plan of Correction Licensee/administrator shall submit to the Licensing Agency a statement of understanding on regulation cited by POC due date.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) 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 LPA observations, the licensee did not comply with the section cited above by Medications for resident #1 (R1) were not administered as prescribed as medications for days past were observed still in the bubble packet with no documentation to why medication was not given. Medications for resident #2 (R2) were not administered as prescribed as medications for days past were observed still in the bubble packet with no documentation to why medication was not given. Medications for resident #4 (R4) were not administered as prescribed as medications for days past were observed still in the bubble packet with no documentation as to why medication was not given, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/20/2023 Plan of Correction Licensee/Administrator shall conduct an inservice training with Medtechs on medication management and submit proof of training to the Licensing Agency by POC due date.

Official classification

Type B

Official code

87412(c)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited above by not maintaining verification of food service training for staff #1(S1) on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/30/2023 Plan of Correction Licensee/Administrator shall submit to the Licensing Agency proof of training by POC due date.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(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 LPA records review, the licensee did not comply with the section cited above by not maintaining verification of staff #2 (S2) CPR/first aid training on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/30/2023 Plan of Correction Licensee/Administrator shall submit to the Licensing Agency proof of training by POC due date.

Official classification

Type B

Official code

87457(c)

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. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited above by not maintaining record of R3's pre-admission appraisal on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/30/2023 Plan of Correction Licensee/Administrator shall submit to the Licensing Agency documentation of resident appraisal by POC due date.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355Criminal Record Clearance(e) All inviduals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal...exemption as required...This requirement is not met by: Staff 1 (S1) stated that they have been working at the facility for 3 months and Staff 2 (S2) stated that they have been working at the facility for 6 weeks. Which poses an immediate health, safety, and personal rights concern to all residents in care.

Official plan of correction

Administrator immediately had both staff leave the facility. Administrator read and submit a self-ceritified statement of understanding by POC due date.

Deadline recorded: Jul 29, 2023. 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

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 was not met as evidenced by: The Licensee did not ensure the facility was in good repair. Based on LPA observation, the door exiting to the smoking area was found to be misaligned preventing it's proper closure. This poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Administrator reported the door with be realigned and properly functioning by POC due date. Video proof of the door working properly will be submitted to LPA by POC due date.

Deadline recorded: May 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355.Criminal Record Clearance. (e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above by allowing S1 to work at the facility for eight (8) months without a criminal background exemption which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/17/2022 Plan of Correction The licensee has agreed to read regulation 87355 entirely and send LPA self-certify letter that the regulation was read and understood. The license has agreed to remove S1 from the facility and not allow S1 to work at the facility until S1 has a criminal background exemption.