C.A.L.L.-CARMELITA HOUSE

Official classification

Type B

Official code

1569.696(a)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: 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 5/5 staff did not meet annual trianing for hours or topics which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2025 Plan of Correction Administrator agreed to provide annual trianing on the required subjects and hours. Provide proof of training and an up to date LIC 500.

Official classification

Type A

Official code

87468.1(a)(16)

Regulation authority

CCR

What the official deficiency says

(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16)To receive or reject medical care or other services. This requirement was not met as evidenced by: Based on staff interviews and charting records the Licensee did not comply with the regulation above R1 was having discharge and odor in 2024 but R1 was not taken to see a doctor till 2025 which poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

Licensee agreed to, review charting notes from staff daily and make appointments immediately for residents when they need them, provide a statement of understanding to CCL as well as review and train all staff on 87468.1 and 87468.2 Personal Rights regulations and provide proof of training with an up to date LIC 500 for staffing to CCL

Deadline recorded: Jan 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.695(e)(1-4)

Regulation authority

HSC

What the official deficiency says

(e)...:(1) A resident roster with the date of birth for each resident.(2) An ANS plan for each resident.(3) A resident medication list for residents with centrally stored medications.(4) Contact information for the responsible party and physician for each resident. This requirement was not met as evidenced by: Based on interviews and record review the Licensee did not comply with the regulation above, staff were unable to locate the records for Resident to provide the EMT’s on a 911 call, which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Licensee agreed to review the facility emergency disaster plan LIC. 610E, health & safety code 1569.695, make sure facility is meeting this requirement with all records and supplies necessary and train all staff at the facility on the plan/code and provide proof of training with an up to date LIC. 500 to CCL.

Deadline recorded: Jan 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

(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 was not met as evidenced by: Based on record review the Licensee did not comply with the regulation above staff were not properly training meeting all initial and annual training requirement which poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Licensee agreed to arrange all staff to take and met the required initial and annual training requirements for CCL and provide proof of each staff meeting the training requirements as well as an updated LIC 500.

Deadline recorded: Feb 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) plan for incidental medical and dental care shall be developed by each facility. The...:(1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on staff interviews and records review the Licensee did not comply with the regulation above, R1 had immediate dental needs that were not addressed timely by the lead/supervisor based on staff charting notes and verbal notifications which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Licensee agreed to review regulation 87465 and have a full understanding of when to seek medical and dental care for residents, for lead staff to know full duty statement and sign a statement of understanding of how and when to seek medical and dental care for residents in care as well as train all facility staff on the regulation and reporting to lead staff at the facility, send proof of training and statement of understanding to CCL.

Deadline recorded: Jan 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

(a)All facilities shall have a qualified and currently certified administrator....shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility...This requirement was not met as evidenced by: Based on staff interview and record review the Licensee did not comply with the regulations above, Administrators or back up were not on the premises, to permit adequate attention to the management or administration of the facility operations which possess a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Licensee agreed to review and have a statement of understanding in Regulation 87405 and train all staff in the regulation requirements and provide proof of training and an updated LIC 500 to CCL.

Deadline recorded: Feb 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(16)

Regulation authority

CCR

What the official deficiency says

(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16)To receive or reject medical care or other services. This requirement was not met as evidenced by Based on staff interviews and charting records the Licensee did not comply with the regulation above Resident were not taken to see a doctor/dentist in a timely matter when medical/dental service were needed which poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Licensee agreed to, review charting notes from staff daily and make appointments immediately for residents when they need them, provide a statement of understanding to CCL as well as review and train all staff on 87468.1 and 87468.2 Personal Rights regulations. Provide proof of training with an up-to-date LIC 500 for staffing to CCL.

Deadline recorded: Feb 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(d)

Regulation authority

CCR

What the official deficiency says

(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying....: This requirement was not met as evidenced by: Based on record review the licensee did not comply with the regulation above, records were not provided to LPA, LPA had to look for records requested, copies of records took over 3 hours to be provided which poses a potential personal rights risk to residents in care.

Official plan of correction

Licensee agreed tol train all staff in regulation 87506, provide proof of training with an up to date LIC 500 Personnel Report for the facility.

Deadline recorded: Jan 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(1) Personal Rights. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff... This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when S1 yelled at residents in care, which posed a potential personal rights risk to residents in care.

Official plan of correction

Facility will ensure all staff attend a training focused on Resident Personal Rights. Facility will provide CCL with copy of training agenda as well as a sign in sheet for all staff who attended the training.

Deadline recorded: Nov 12, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(4) Personal Rights. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in...qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when S1 deviated from protocol and had R2 sit on their

Official plan of correction

Facility will ensure all staff attend a training focused on Resident Personal Rights. Facility will provide CCL with copy of training agenda as well as a sign in sheet for all staff who attended the training. walker, resulting in a fall, which posed an immediate safety risk to residents in care.

Deadline recorded: Oct 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(1) Personal Rights. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff,... This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when S1 yelled at residents in care, which posed a potential personal rights risk to residents in care.

Official plan of correction

Facility will ensure all staff attend a training focused on Resident Personal Rights. Facility will provide CCL with copy of training agenda as well as a sign in sheet for all staff who attended the training.

Deadline recorded: Oct 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents…shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. On 07/25/2022, staff did not follow C1’s special diet plan by giving C1 soda without Thick It powder and a non-pureed hot dog, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee will submit a plan to ensure that staff have ongoing training in following individual resident diet plans and submit the plan to CCL by 12/23/22.

Deadline recorded: Dec 23, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(8)

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:(8)To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met as evidenced by: Based on witness interviews and documentation the Licensee did not comply with the regulation above and did not notify R1’s representatives of R1’s fall which poses a potential personal rights risk to residents in care.

Official plan of correction

Administrator updated resident identification and emergency information records to include all residents contacts to notify. Administrator agreed to train staff on 87468.1 personal rights and incident reporting requirements, send copy of training with staff signatures to CCL.

Deadline recorded: May 27, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(1) Personal Rights to Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not as evidenced by: Based on interviews and record review, the licensee did not ensure the personal rights of residents in care. S1 was speaking to residents in an unsafe manner which posed a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Licensee has agreed to implement greater screening measures prior to hiring staff. Administrator will conduct training on Reg. 87468.1 Personal Rights of Residents in All Facilities with staff and send the sign-in training sheet to CCL by 4/18/22.

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