CHANTILLY LACE MANOR IV

Official classification

Type B

Official code

87412(a)(11)

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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not ensuring that staff #1, #2 (S1, S2) do not have the health screening report available for review which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/12/2025 Plan of Correction Licensee will submit proof of doctors appointment to have the staff complete a health screening on plan of correction (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 record review, the licensee did not comply with the section cited above by not ensuring that staff #3 (S3) do not have the CPR/First Aid training by a persons qualified by such agencies as the American Red Cross. which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/12/2025 Plan of Correction Licensee will provide proof of CPR/First aid training for S3 on plan of correction (POC) due date.

Official classification

Type A

Official code

87468.2(a)

Regulation authority

CCR

What the official deficiency says

87468.2(a) 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......personal rights: This requirement is not met as evidenced by: Based on observation, the administrator did not comply with the section cited above by violating the personal rights for residents with the cameras installed in their bedrooms which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator stated that she will review regulation CCR 87468.2(a) and submit a statement of understanding to LPA via email by POC due date.

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

Official classification

Type A

Official code

87705(l)

Regulation authority

CCR

What the official deficiency says

87705(l) Care of Persons with Dementia (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: This requirement is not met as evidenced by: Based on observation, the administrator did not comply with the section cited above by restricting access to entering and exiting the main entrance door by requiring a code to be entered which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator stated that she will replace the door knob that has a code with one that doesn't have a code. Administrator stated that she will submit a statement of understanding to LPA via email by 2/8/24.

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

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, the administrator did not comply with the section cited above in having functioning carbon monoxide alarms which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/23/2023 Plan of Correction Administrator stated that she will purchase and install new carbon monoxide alarms and submit proof of receipt and picture to LPA via email by POC due date.

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, the administrator did not comply with the section cited above in maintaining knives and chemicals inaccessible to 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 Administrator locked knives and chemicals right away. Administrator stated that she will submit a statement of understanding on regulation CCR 87309(a) to LPA via email by 12/06/2023.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the administrator did not comply with the section cited above in having a transfer request of criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/23/2023 Plan of Correction Administrator stated that she will submit a transfer of criminal record clearance; associate staff to facility on Guardian and submit proof to LPA via email by POC due date.

Official classification

Type A

Official code

87705(l)

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: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the administrator did not comply with the section cited above in restricting access to exiting the main entrance door by requiring a code to be entered 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 Administrator removed code on main entrance door and now anyone inside facilty can exit at any time. Administrator stated that she will submit a statement of understanding to LPA via email by 12/06/23.

Official classification

Type B

Official code

87470(d)(6)

Regulation authority

CCR

What the official deficiency says

(d) When an emergency, as defined in Government Code section 8558, or federal emergency for a contagious disease is proclaimed or declared, the licensee shall develop an Emergency Infection Control Plan that includes infection control measures that are not already addressed in the Infection Control Plan as specified in subsection (c), to prevent, contain, and mitigate the associated contagious disease. (6) The Emergency Infection Control Plan shall be reviewed and updated as necessary or whenever new infection control measures are recommended by the federal, state, and local government public health authorities, or as determined by the Department, until the proclaimed or declared state of emergency is no longer in effect. Any updates to the plan shall be made available to staff, residents and if applicable, each resident’s representative, and submitted to the Department. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the administrator did not comply with the section cited above in providing an Infection Control Plan to LPA for inspection which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2023 Plan of Correction Administrator stated that she will submit an Infection Control Plan to LPA via email by POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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: Deficient Practice Statement Based on observation, the administrator did not comply with the section cited above in maintaining a safe and in good repair facility which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2023 Plan of Correction Administrator stated that she will have the cabinet beneath the sink and kitchen counter repaired and submit proof of picture to LPA via email by POC due date.

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, the administrator did not comply with the section cited above in providing a non-skid mat for all bathrooms which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2023 Plan of Correction Administrator stated that she will purchase a non-skid mat for the bathroom and submit proof of receipt and picture to LPA via email by POC due date.

Official classification

Type B

Official code

87412(a)

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: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the administrator did not comply with the section cited above in maintaining complete personnel records which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2023 Plan of Correction Administrator stated that she will have personnel complete their missing records and submit proof to LPA via email by POC due date.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) 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: Deficient Practice Statement Based on observation and interview the administrator did not comply with the section cited above in prohibiting access to resident records for inspection to LPA which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2023 Plan of Correction Administrator stated that she will submit a statement of understanding to LPA via email by POC due date.

Official classification

Type B

Official code

87468.2(a)

Regulation authority

CCR

What the official deficiency says

(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: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the administrator did not comply with the section cited above by violating the personal rights for residents with the cameras installed in their bedrooms which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2023 Plan of Correction Administrator stated that she will review regulation CCR 87468.2(a) and submit a statement of understanding to LPA via email by POC due date.

Official classification

Type B

Official code

87307(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building. Based on interviews and record review the licensee did not provide adequate sleeping arangements for residents, which poses a potential health and safety risk to resident(s) in care.

Official plan of correction

Licensee shall agree that prior to accepting new residents they will ensure that the residence's room is ready. Licensee shall also read regulation 87307 in its entirety. Licensee shall provide proof of correction by submitting email confirming review of the section mentioned above to LPA by 3/7/22.

Deadline recorded: Mar 1, 2022. A deadline is not proof that correction was completed.