GOLDEN VALLEY RESIDENTIAL CARE FACILITY

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 [1] out of [4] facility personnel records did not have updated first aid training certification which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/17/2026 Plan of Correction The facility representative stated that all facility staff will be updated and certified for first aid training at all times. A statement of correction, along with proof of updated first aid certification, will be completed and submitted into CCL for review by this LPA by the due date.

Official classification

Type A

Official code

87412(c)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. 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 [2] out of [4] facility staff files were missing required hours for Initial/Annual training which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/17/2026 Plan of Correction The facility representative stated that all personnel files will be audited to make sure that all staff are properly obtaining the required hours for initial and annual training. A statement of correction, along with proof of updated initial/annual training, will be completed and submitted into CCL for review by this LPA by the due date.

Official classification

Type A

Official code

87202(a)(1)

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: (1) Nonambulatory persons. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above by having 4 residents who were non-ambulatory. This facility has a fire clearance for 3 non-ambulatory residents only. This poses an immediate health, safety, personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/29/2024 Plan of Correction Licensee agrees to provide a statement of correction and create a plan in place to ensure that they only obtain 3 non-ambulatory residents at a time. Licensee stated she will have the 4 resident reassessed to ensure that they are an ambulatory resident.

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: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the cited above by the fire extinguisher located in the kitchen was expired on 1/05/2022, which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/30/2023 Plan of Correction The Licensee has agreed to purchase a new fire extinguisher today after the LPAs visit. The Licensee will provide a picture and proof of purchase to the LPAs email, arielle.pascua@dss.ca.gov by the POC date 1/30/2022.

Official classification

Type A

Official code

87209(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 licensee did not comply with the section cited above by not ensuring that all disinfectants are locked away and made inaccessible to the residents in care. LPA observed that there were disinfectants and bleach under the bathroom sink. This poses an immediate health, safety, or personal rights risk to the persons in care.

Official plan of correction

POC Due Date: 01/31/2023 Plan of Correction During the visit, the LPA observed a staff member take out the bleach and disinfectant located under the bathroom sink and relocate them into a locked cabinet. POC will be cleared during this visit.

Official classification

Type A

Official code

87355(d)(3)

Regulation authority

CCR

What the official deficiency says

(d) All individuals subject to a criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. (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 requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation an individual visiting the facility on a regular basis is not fingerprint cleared, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/05/2022 Plan of Correction Licensee agrees to submit a plan to LPA via email by POC date of 2/5/2022 stating all individuals in the facility will be fingerprint cleared prior to the individual's employment, residence, or intial presence in the facility. ruth.wallace@dss.ca.gov

Official classification

Type B

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 LPA observation, staff (S1) is missing current first aid and cardiopulmonary resuscitation (CPR), 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: 02/09/2022 Plan of Correction Licensee agrees to submit to LPA via email S1's current copy of first aid and CPR by POC date of 2/09/22. ruth.wallace@dss.ca.gov

Official classification

Type B

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 LPA observation Staff (S3) is missing a current health screen and TB test, 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: 02/09/2022 Plan of Correction Licensee agrees to submit to LPA via email S3's new health screen and TB results by POC date of 2/09/2022. ruth.wallace@dss.ca.gov

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87705(f)(1) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on observation, the licensee did not ensure sharp tools and toxins. LPA observed an unlocked knife in top drawer next to sink. Lock under sink where there were toxins in kitchen not latched. Lock in kitchen where the sharps were kept not locking properly. This poses an immediate health and safety risk to residents in care.

Deadline recorded: Dec 3, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

80023(d)(2) Disaster and Mass Casualty Plan - Disaster drills shall be conducted at least every six months. The drills shall be documented and the documentation maintained in the facility for at least one year. This requirement was not met as evidenced by records reviewed, care home last conducted a fire drills on 2/3/2020. This poses a potential safety risk to the residents in care.

Deadline recorded: Dec 13, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87464 (f)(1) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This regulation was not met by evidence by: A sign-in policy upon entry was not enacted with all visitors to ensure compliance with central entry point for symptom screening and to record contact information (for reporting requirements to public health officer and contact tracing).

Deadline recorded: Dec 13, 2021. A deadline is not proof that correction was completed.