Facility condition and maintenanceType A
- Official classification
- Type A
- Official code
- 87311
- Regulation authority
- CCR
What the official deficiency says
All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation and manager interview, Licensee did not ensure that the facility's telephone service was working. This posed an immediate health, safety, and personal rights risk to 3 of 3 residents (R1, R2, and R3) in care.
Official plan of correction
POC Due Date: 09/03/2025 Plan of Correction During today's visit, Licensee contacted their telephone service provider and made an appointment for 09/04/2025 for the facility's phone line to be reactivated. This action resolved the immediate risk. LPA recored the cell phone numbers of multiple live-in staff, in the interim.
Fire safety and emergency preparednessType A
- 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 was not met, as evidenced by: Deficient Practice Statement Based on LPA observation and manager interview, Licensee did not maintain the facility in continuous conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire. This posed an immediate safety risk to 3 of 3 residents [R1, R2, and R3] in care.
Official plan of correction
POC Due Date: 09/03/2025 Plan of Correction Licensee agreed to either have the facility’s fire extinguisher professionally-serviced or to purchase a new extinguisher, and to send a photo of either the updated service tag or the purchase receipt to LPA, by the POC due date.
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87470(b)(2)(C)
- Regulation authority
- CCR
What the official deficiency says
(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around residents and annually thereafter. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review and manager interview, Licensee did not ensure that 6 of 6 staff (S1 through S6) received training on the proper use of all required PPE within the last year. This posed a potential health risk to 3 of 3 residents (R1, R2, and R3) in care.
Official plan of correction
POC Due Date: 10/02/2025 Plan of Correction Licensee agreed to train all current staff on PPE. The training will include hands-on practice and will cover: a) handwashing, b) how and how often to disinfect commonly touched surfaces, c) how to correctly don and doff surgical masks, N-95 respirators, face shields, gowns, and gloves, d) how perform an N-95 seal check, and e) how to correctly set up a COVID-19 isolation bedroom. Licensee agreed to E-mail the training sign-in sheet to LPA, by the POC due date. Going forward, Licensee agreed to repeat this training at least annually.
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(e)(2)
- Regulation authority
- CCR
What the official deficiency says
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA measurement via thermometer, Licensee did not maintain hot water temperature controls to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degrees F and not more than 120 degrees F. This posed a potential health and personal rights risk to 3 of 3 residents (R1, R2, and R3) in care.
Official plan of correction
POC Due Date: 09/02/2025 Plan of Correction During today’s inspection, adjustments were made to the facility’s water heater settings, which brought said water taps back into the complaint temperature range. The Plan of Correction is Satisfied.
Resident rightsType B
- Official classification
- Type B
- Official code
- 87467(a)(3)
- Regulation authority
- CCR
What the official deficiency says
(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review and manager interview, for 3 of 3 residents (R1, R2, and R3), Licensee did not within the last 12 months arrange a meeting with the resident and required individuals to review and revise the written record of care. This posed a potential health risk to persons in care.
Official plan of correction
POC Due Date: 10/02/2025 Plan of Correction For R1, R2, and R3 each, Licensee agreed to conduct a care conference with their responsible person (and home health/hospice personnel, as applicable) to review the resident's facility Plan of Care, updating it as needed. All parties to the meeting will sign. Licensee agreed to E-mail proof of care conference completion to LPA, by the POC due date. Going forward, Licensee agreed to faciliate such care conferences at least once every 12 months for each resident.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(a)
- Regulation authority
- HSC
What the official deficiency says
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on records review and manager interview, Licensee did not have a written emergency and disaster plan that included all of the required elements. This posed a potential safety risk to 3 of 3 residents (R1, R2, and R3) in care.
Official plan of correction
POC Due Date: 10/02/2025 Plan of Correction During today's visit, LPA provided Licensee with a copy of form LIC610E. Licensee agreed to develop a written LIC610E Emergency Disaster Plan which meets all the elements required by HSC 1569.695, and to E-mail it to LPA, by the POC due date.
Fire safety and emergency preparednessType B
- 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 records review and manager interview, Licensee did not conduct a disaster drill at least quarterly for each shift, and did not vary the type of emergency covered from quarter to quarter, taking into account different emergency scenarios. This posed a potential safety risk to 3 of 3 residents (R1, R2, and R3) in care.
Official plan of correction
POC Due Date: 10/02/2025 Plan of Correction Licensee agreed to conduct three (3) disaster drills (one on AM shift, one on PM shift, and one on NOC shift), and to E-mail proof of drill completion to LPA, by the POC due date. Going forward, Licensee agreed to drill each shift at least once per quarter, and to vary the type of disaster covered from one quarter to the next, and to keep written records of all drills.