MOTHER MARY CARE HOME

Official classification

Type A

Official code

87633(d)

Regulation authority

CCR

What the official deficiency says

87633 Hospice Care of Terminally Ill Residents (d) The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client’s care needs are being met at all times. This requirement was not met as evidenced by: Based on interview and record review, Licensee did not ensure R1's oxygen was properly administered as directed on the hospice orders. This posed an immediate health and safety risk to residents in care.

Official plan of correction

Administrator will review the regulation being cited today and write a statement acknowledging that the regulation has been read and understood. POC will be emailed to LPA by POC date 06/12/2026 by end of day 5:00 PM.

Deadline recorded: Jun 12, 2026. 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

(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:Hot water temperature was measured at 122.5 degrees Fahrenheit in resident's bathroom sink, which is not within the required range of 105 to 120 degrees. This is a potential risk to residents in care

Official plan of correction

Administrator agrees to adjust the water heater immediately and ensure that the water is within regulation. Administrator will conduct a water temperature check that will include a water log for the rest of the month. The water log will be emailed to LPA by POC date 06/11/26 by end of day 5:00 PM.

Deadline recorded: Jun 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(3)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (c) ...facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided... (3) A record of each dose is maintained in the resident's record...the date and time the PRN medication was taken, the dosage taken, and the resident's response. The requirement was not met as evidenced by: interview and record review showing multiple 3+ instances of given PRN's without documentation. This constitutes an immediate health and saftey risk to persons in care

Official plan of correction

Administrator will send in a picture of documentation demonstration they understand how to document the PRN medication, by the POC.

Deadline recorded: Aug 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.626(a)(1)

Regulation authority

HSC

What the official deficiency says

California Health and Saftey code 1569.626 (a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff:(1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins independently... All 12 hours shall be devoted to the care of persons with dementia. This requirement was not met as evidinced, by record review. this constiutes a potential health and saftey risk to persons in care.

Official plan of correction

The Licensee will do a 12h inservice on dementia, then submit a progress report on as 9/18/25, The training should be started for everyone, and at least one person on each shift should be done by 9/18/25.

Deadline recorded: Sep 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

Storage Space; 87309a: 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: LPM observed toxins under the kitchen sink that were not locked to residents in care.

Official plan of correction

POC Due Date: 06/30/2025 Plan of Correction Administrator shall submit self-certification stating that she is familiar with the regulation and has reviewed this regulation with staff. Administrator will send POC to LPA by 6/30/2025.

Official classification

Type A

Official code

87355(d)(3)

Regulation authority

CCR

What the official deficiency says

87355 (d)(3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility. This was not met as evidenced by one staff member present with no fingerprint clearance. 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 one out of three persons staff S1 is not associated to the facility and finger print cleared. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/30/2025 Plan of Correction Licensee will send S1 to compleate live scan request. Licensee was advided that S1 could not enter the facility untill they were finger print cleared.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(87465(a)(4) The licensee shall assist residents with self-administered medications as needed. 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 R1'S medications we signed off which by a staff member. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/30/2025 Plan of Correction Administrator shall submit self-certification stating that she is familiar with the regulation and has reviewed this regulation with staff. Administrator will send POC to LPA by 6/30/2025. In addition Licensee will conduct medication training for all staff.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

87555 (b)(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the facility reported shopping day is tomorrow had no fresh fruit, bell perpers were the only fresh vegetable, one package of chicken for dinner this evening, no eggs, no milk and multiple packages of hot dogs and bologna.

Official plan of correction

POC Due Date: 06/30/2025 Plan of Correction Licensee will provide LPA with food shopping reciept by POC date. Kesha.Lewis@dss.ca.gov

Official classification

Type B

Official code

87511(c)

Regulation authority

CCR

What the official deficiency says

87411 (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by: Deficient Practice Statement Based on ecord review, the licensee did not comply with the section cited above there was only one training compleaed for staff. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/07/2025 Plan of Correction Licensee will provide dates for training to be complated for all staff.

Official classification

Type B

Official code

1568.618(c)(3)

Regulation authority

HSC

What the official deficiency says

1568.618(c)(3) (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, records review the licensee did not comply with the section cited above in three out of three caes. All staff had expired CPR certification. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/28/2025 Plan of Correction Licensee will provide updated training or the date of training for all staff by poc date.

Official classification

Type B

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 LPA record review, the licensee did not comply with the section cited above in staff 2-3 have fingerprint clearances for other facilities and were not transferred to current facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/29/2024 Plan of Correction Licensee agrees to have both staff fingerprint cleared today and will send documentation of clearances to LPA Wallace by Plan of Correction date of 5/29/2024. Immediate civil penalty of $500.00 issued on today's date. Licensee agrees to scan documents and submit via email: ruth.wallace@dss.ca.gov

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care ... Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidenced by: Based on LPA Jensen's observation of PRN medication for a resident that has terminated services with the facility that was stored on top of a dresser and accessible to residents in care. This poses an immediate risk to the health, safety and perosnal rights of residents in care.

Official plan of correction

The Licensee immediately locked all medications and agrees to email an attestation that this regulation has been read, understood and will be complied with by Plan of Correction due date.

Deadline recorded: May 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(3)(B)

Regulation authority

CCR

What the official deficiency says

Personal Accomodations Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement was not as evidenced by: Based on LPA Jensen's observation of 3 of 3 residents missing a lamp from their bedrooms. This poses a potential risk to the health, safety and persobal rights of residents in care.

Official plan of correction

Licensee agrees to place lamps in all resident rooms and ensure that lamps are accessible to residents in care. Licensee will consider using battery operated lamps if a resident has adverse behaviors related to electrical cords.

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

Official classification

Type B

Official code

87506(b)(16)

Regulation authority

CCR

What the official deficiency says

Resident Records .... Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables. This requirement was not met as evidenced by: Based on LPA Jensen's review of a resident file, Resident 1 did not have a personal property inventory completed upon admission or upon receipt of additional proeprty sent by family members. This poses a potential risk to the health, safety and personal rights of residents in care.

Official plan of correction

The Licensee agrees to complete a personal proeprty inventory for resident 1 and email to LPA at maja.jensen@dss.ca.gov by Plan of Correction due date.

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

Official classification

Type B

Official code

87303(b)(1)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). This requirement was not met as evidenced by: This requirement was not as evidenced by LPA Jensen's observation of the facility thermostat temperature reading of 67 degrees upon arrival. This poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

The Licensee will send an attestation that the regulation has been read, understood and will bve complied with at all times by the POC due date

Deadline recorded: Feb 4, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

00000

Regulation authority

CCR

What the official deficiency says

Intentionally left blank

Deadline recorded: Feb 4, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87633(l)

Regulation authority

CCR

What the official deficiency says

...Nothing in this section [which deals with terminally ill residents and hospice care] shall be construed to relieve a licensed residential care facility for the elderly of its responsibility to notify the appropriate fire authority of the presence of a bedridden resident in the facility as required under subdivision (f) of Section 1569.72 and to obtain and maintain a fire clearance as required under Section 1569.149. This requirement was not met as evidenced by: Based on LPA's review of records including resident file, LIC 200, facility sketch and STD 850 as well as the interview with Administrator Jean Alvarez, there are two residents that are bedridden and no fire clearance for bedridden residents. This poses an immediate risk to the health , safety and personal rights of residents in care.

Official plan of correction

Licensee will complete a new LIC 200 and update the facility sketch to reflect the rooms designated for bedridden residents. Licensee will email it to maja.jensen@dss.ca.gov. LPA Jensen will assist Licensee in completing the STD 850 and sending it to the Fire Marshal by 11/10/22.

Deadline recorded: Nov 10, 2022. A deadline is not proof that correction was completed.

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 ... This requirement was not met as evidenced by: Based on LPA Jensens review of records for resident 1 which contained multiple incomplete and missing documents. This poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

The Licensee agrees to participate in the Technical Support Program offered by Community Care Licensing. LPA Jensen will forward the program information to the Licensee and the Licensee will make arrangements for engagement with the program by the Plan of Correction due date.

Deadline recorded: Nov 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(14)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (14) To have reasonable access to telephones, to both make and receive confidential calls...This requirement was not as evidenced by: LPA Jensen's observation of 67 unretreived voicemails. This poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Licensee conducted an inservice training on use of the facility answering machine in the presence of LPA Jensen. No further Plan of Correction is required

Deadline recorded: Nov 11, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

80088(e)(1)

Regulation authority

CCR

What the official deficiency says

Furniture, Fixtures, Equipment, and Supplies: (e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature shall be maintained at not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C This requirement was not met as evidenced by hot water tested at 123.5 in the client's bathrooms. This is an immediate safety hazard.

Official plan of correction

Facility shall adjusted hot water temperature to not less than 105 degrees F and not more than 120 degrees F. LPA requested hot water temperature logs over the course of the next 3 days to clear the cited deficiency. Hot water logs are to provide proof that hot water is being maintained within the regulatory requirement.

Deadline recorded: Oct 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on observation and records review, the Licensee did not ensure medications ordered for residents are given as prescribed which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator has developed a plan on how the facility will follow the Physician's orders and document correctly when medications are missed. Please send the agenda along with the sign-in sheet for the in-service. The facility will also report all incidents of medication errors, missed medication Etc.. to the resident's Primary Care Physician and to the department.

Deadline recorded: Oct 17, 2022. A deadline is not proof that correction was completed.