STETSON COURT LIVING

Official classification

Type A

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 in [1] out of [5] staff person did not have 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: 05/23/2026 Plan of Correction The facility designated Administrator stated that all facility staff persons will be updated for proper First Aid Training at all times. A statement of correction, along with a copy of updated First Aid training for all facility staff, will be completed and submitted into CCL by the due date for review by this LPA.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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 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 window screens and sliding glass door screens were in need of repair/replacement since they had rips, holes, 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: 05/29/2026 Plan of Correction The facility designated Administrator stated that an audit of all window screens and sliding glass door screens will be repaired/replaced to remove any holes, rips, tears and be in good functioning order at all times. A statement of correction, along with proof of services rendered for the screen repairs, will be completed and submitted into CCL by the due date for review by this LPA.

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 record review, the licensee did not comply with the section cited above in [3] out of [5] facility resident 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: 05/29/2026 Plan of Correction The facility designated Administrator stated that an audit of all window screens and sliding glass door screens will be repaired/replaced to remove any holes, rips, tears and be in good functioning order at all times. A statement of correction, along with proof of services rendered for the screen repairs, will be completed and submitted into CCL by the due date for review by this LPA.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: . LPA Lund observed that there were three residents on hospice out of the six residents. All three residents are bedridden and get out of bed with out the help of staff.

Official plan of correction

Administrator shall submit a new fire clearance by 12/2/2024 or issue 30 day notices to residents to LPA Lund.

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

Official classification

Type B

Official code

80087(a)

Regulation authority

CCR

What the official deficiency says

Buildings and Grounds - The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. LPA Lund observed debris on the side of the facility and the emergency exit gate doesn’t have a latch and needs to be fixed.

Official plan of correction

Administrator shall submit pictures of debris on the side of the facility and the emergency exit gate doesn’t have a latch and needs to be fixed. The pictures shall be sent by POC 12/10/24.

Deadline recorded: Dec 10, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA interviewing staff, the licensee did not comply with the section cited above in staff have been sleeping in common areas on roll away beds. The facility sketch shows bedroom #3 as a staff room, but a resident is living in that room. 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 Licensee agrees to submit a plan of correction by 4/4/24 stating how the facility will comply with community care licensing regulations regarding fire clearance. Licensee agrees to submit via email to LPA. ruth.wallace@dss.ca.gov

Official classification

Type B

Official code

1569.69(e)(2)(B)

Regulation authority

HSC

What the official deficiency says

(e) Each person who provides employee training under this section shall meet the following education and experience requirements: (2) The person shall meet any of the following practical experience or licensure requirements: (B) Two years of full-time experience, or the equivalent, within the last four years, as an administrator for a residential care facility for the elderly, during which time the individual has acted in substantial compliance with applicable regulations. 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 have been sleeping on roll away beds in common areas and facility sketch shows bedroom #3 as a staff room. A resident in living in #3 bedroom. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2024 Plan of Correction Licensee agrees to submit letter stating how administrator will be in compliance with applicable regulations regarding the requirements for fire clearance and qualifications for administrator. Licensee agrees to submit via email to LPA. ruth.wallace@dss.ca.gov

Official classification

Type A

Official code

87202

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:Based on observation the licensee did not comply with the section cited above as the fire extinguisher were last purchased on Januaryof 2022 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The facility will arrange for a company to service the extinguishers and will provide proof to CCL that the fire extinguishers have been serviced or a new one purchased and are in compliance.

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

Official classification

Type A

Official code

87705(I)(8)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia. Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. LPA was able to determine the last disaster drill was conducted on 12/30/2021 this poses an immediate safety risk.

Official plan of correction

The facility shall develop and implement a policy regarding fire drill and earthquake drill practices and procedures that include conducting fire drills at least once every three months on each shift and shall include, at a minimum, all direct care staff. Send copy of updated policy and fire drill log by POC date

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

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia Licensees who accept and retain residents with dementia shall ensure that each resident with dementia has an annual medical assessment and a reappraisal done at least annually. LPA observed that R1 diagnosed with dementia didn't have an updated LIC 602.

Official plan of correction

All residents diagnosed with dementia will be scheduled with their responsible physician and be assessed for any changes to their needs with an updated LIC 602. Statement of correction, with copy of updated LIC 602, to be completed and submitted into CCL by the due date.

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

Official classification

Type B

Official code

80087(a)

Regulation authority

CCR

What the official deficiency says

Buildings and Grounds - The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by: LPA observed debris on the side of the house. This poses a potential safety risk to the residents in care.

Official plan of correction

Administrator shall submit pictures of the removed debris on the side of the house in the fire lane. The pictures shall be sent by POC 6/15/22.

Deadline recorded: Jun 2, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355(e)(2) Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall request a transfer of a criminal record clearance from another facility or Trustline. This requirement is not met as evidenced by: Based on LPA observation and record review licensee failed to ensure S1 obtained a criminal record clearance transfer prior to starting.

Official plan of correction

Licensee will obtain the criminal record clearance transferfor S1. Licensee has agreed to not allow said staff member or potential new hire to be present in the facility without first obtaining a criminal record clearance transfer. Licensee to review the cited regulation to ensure continued compliance. *****Immediate Civil Penalty Assessed******

Deadline recorded: Mar 29, 2022. A deadline is not proof that correction was completed.