ESCALON SENIOR ESTATE

Official classification

Type A

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 in [1] out of [5] facility personnel did not have updated TB clearance on file which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/15/2025 Plan of Correction The facility designated staff person stated that all facility staff records will be reviewed to make sure that they are all currently TB cleared with documented proof on file at all times. A statement of correction, along with updated documents for facility staff person requiring TB clearance, will be completed and submitted into CCL by the due date.

Official classification

Type A

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 in that [3] out of [5] facility staff files did not have updated annual training hours which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/15/2025 Plan of Correction The facility designated staff person stated that all staff providing care and supervision to the residents in care will undergo training and receive the required number of hours and topics of training. A statement of correction, along with copies of updated training hours and topics, will be completed and submitted into CCL by the 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 licensee did not comply with the section cited above in that several sliding glass doors were missing proper screens while others were in need of repair/replacement to address holes, rips, and tears in them which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/21/2025 Plan of Correction The facility designated staff person stated that a review of the facility window screens and sliding glass doors, with screens, will be conducted. Any window and sliding glass door screens will be repaired/replaced in order to remove all rips, holes, and tears within them. A statement of correction, along with proof of updated window and sliding glass door screens, having been repaired will be completed and submitted into CCL by the due date.

Official classification

Type B

Official code

87507(d)

Regulation authority

CCR

What the official deficiency says

The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. 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 in that [2] out of [5] facility resident files did not contain an admission agreement which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/21/2025 Plan of Correction The facility designated staff person stated that all facility resident files will be audited to make sure that they all contain an accurate and completed admission agreement at all times. A statement of correction, along with copies of the updated Admission Agreements for the missing resident files, will be completed and submitted into CCL by the due date.

Official classification

Type A

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 in that [2] out of [4] facility staff files were not properly cleared for TB and did not contain the updated paperwork to prove TB clearance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/04/2024 Plan of Correction Facility designated Administrator stated that all facility staff persons providing direct care unto the residents will be scheduled with their responsible licensed medical professional to undergo a medical assessment and receive proper clearance for TB. A statement of correction, along with updated proof of proper TB clearance, will be completed and submitted into CCL by the due date.

Official classification

Type A

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 in that [2] out of [4] facility staff files did not contain updated First aid training which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/04/2024 Plan of Correction The facility designated Administrator stated that all facility staff persons providing care and supervision to the residents will be scheduled to receive and complete updated First aid training. A statement of correction, along with copies of completed First Aid training, will be completed and submitted into CCL by the 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 record review, the licensee did not comply with the section cited above in that [4] out of [4] facility staff files were missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/10/2024 Plan of Correction The facility designated Administrator stated that all facility staff files will be updated to contain all required forms and documents. A statement of correction, along with copies of all updated forms and documents required, will be completed and submitted into CCL by the due date.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 in that [2] out of [4] facility staff files were missing required annual training hours which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/10/2024 Plan of Correction The facility designated Administrator stated that all facility staff providing care and supervision to the residents will receive, and undergo, the required hours of annual training. A statement of correction, along with proof of updated annual staff training hours, will be completed and submitted into CCL by the due date.

Official classification

Type B

Official code

87506(b)(15)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. 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 in that [4] out of [5] facility resident files were missing the required Admissions Agreement documents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/10/2024 Plan of Correction The facility designated Administrator stated that all facility resident files will be reviewed and updated if they are missing the Admissions Agreement. A statement of correction, along with copies of the updated Admissions Agreements for the facility residents, will be completed and submitted into CCL by the due date.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that several windows were missing window screens. Window screens that were present contained holes, rips, or tears in them requiring repair/replacement which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/10/2024 Plan of Correction The facility designated Administrator stated that all window and window screens will be reviewed. Any missing window screens will be replaced while those that were observed with holes, rips, or tears in them will be repaired/replaced as necessary. A statement of correction, along with copies of the services rendered for window screen repair/replacement, will be completed and submitted into CCL by the due date.

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

The following food service requirements shall apply: All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. The facility did not meet the needs of this requirement as evidenced by the presence and continued use of food items which were expired and not of good quality at this time. This presented an immediate threat to the Health, Safety, and Personal Rights of residents in care.

Official plan of correction

The facility representative stated that an audit of all facility perishable and nonperishable quantities will be conducted. Any, and all, food items that are expired and no longer of good quality will be discarded and no longer used for the residents. A statement of correction will be completed in regards to this food audit with submission into CCL by the due date.

Deadline recorded: Feb 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

The following food service requirements shall apply: All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. The facility did not meet the needs of this requirement as evidenced by the presence and continued use of food items which were expired and not of good quality at this time. This presented an immediate threat to the Health, Safety, and Personal Rights of residents in care.

Official plan of correction

The facility representative stated that an audit of all facility perishable and nonperishable quantities will be conducted. Any, and all, food items that are expired and no longer of good quality will be discarded and no longer used for the residents. A statement of correction will be completed in regards to this food audit with submission into CCL by the due date.

Deadline recorded: Dec 22, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

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 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Jensen's check of the water temperature, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2023 Plan of Correction Licensee agrees to adjust water temperature and email a log of temperature checks conducted for 7 consecutive days by Plan of Correction due date.

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

(c) 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, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. 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 in 4 out of 5 resident records reviewed not containing updated resident appraisals and needs and service plans, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/14/2021 Plan of Correction Licensee to update reappraisals and needs and services plans for Resident2 (R2), (R3), (R4), and R5 and submit completed forms to LPA by POC due date. Licensee will read and submit a signed statement of understand regulation 87463(a) to LPA by POC due date.