ALWAYS TLC

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above S1's CPR expired in 2024 and S2's personnel file was not available for review which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2025 Plan of Correction The administrator will schedule S1 to complete the CPR training by 8/29/2025 and submit proof of completion to CCL by 8/29/2025.

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2025 Plan of Correction The administrator stated that S1's training was completed and will submit a copy of S1's annual training records to CCL by 8/29/2025.

Official classification

Type B

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed there was non slip- resistant mats in both bathrooms which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/05/2025 Plan of Correction The Administrator/licensee will provide photos to proof that the non-slip resistant mats are placed in bathrooms by 9/5/2025.

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed the same illegal storage room in the garage that was observed during the annual inspection in 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/08/2025 Plan of Correction During the annual visit, the administrator stated that since he is not getting any clear instructions from the Local Fire Marshal after many attempts, he has decided to demolish the storage room in one week. The administrator will provide photos to CCL by 9/8/2025 of the garage after the storage room is demolished.

Official classification

Type A

Official code

87755(c)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: 87755 Inspection Authority of the Licensing Agency (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as S2 and R4's files were not at the facility for review which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2025 Plan of Correction The administrator/licensee will provide a plan of correction indicating that files are available for inspection by 8/29/2025.

Official classification

Type B

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by:87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as S1 and S2 reported that they reside at the facility and they sleep on the living room couches as well as another female staff who is currently on vacation which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/05/2025 Plan of Correction The administrator/licensee will submit a plan of correction to CCL by 9/5/2025 indicating the sleeping arrangement for facility staff members.

Official classification

Type A

Official code

87470(b)(2)

Regulation authority

CCR

What the official deficiency says

(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed that there was no gowns available at the facility while caring for a resident who has a contagious disease which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/07/2024 Plan of Correction The administrator/licensee will develop a plan to ensure appropriate PPE is available at all times to ensure the safety of staff, residents and visitors.The administrator/licensee will provide a copy of the plan to CCL by 8/7/2024.

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed a unit was built in the garage and according to the San Mateo Consolidated Fire Department and Foster City Building permit, there was no records of a building permit was obtained which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/07/2024 Plan of Correction The administrator/licensee will develop a plan to indicate the steps that the facility will take to be in compliance with the unit in the garage. The administrator/licensee will provide a copy of the plan to CCL by 8/7/2024.

Official classification

Type A

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed a unit was built in the garage and according to the San Mateo Consolidated Fire Department and Foster City Building permit, there was no records of a building permit was obtained which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/07/2024 Plan of Correction The administrator/licensee will develop a plan to indicate the steps that the facility will take to be in compliance with the unit that was built in the garage without a building permit. The administrator/licensee will provide a copy of the plan to CCL by 8/7/2024.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above LPA observed outdoor passageway was blocked by the wooden fence and stored many medical devices and other objects which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/07/2024 Plan of Correction The administrator/licensee will develop a plan to ensure passageways are free of obstruction. The administrator/licensee will provide a copy of the plan to CCL by 8/7/2024.

Official classification

Type A

Official code

87456(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 4 out of 6 residents did not have a pre-admission appraisal which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/08/2024 Plan of Correction The administrator/licensee will develop a plan to ensure pre-admission appraisal is obtained prior to resident's admission. The administrator/licensee will provide a copy of the plan to CCL by 8/7/2024.

Official classification

Type A

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 1 out of 6 resident did not have a completed medical assessment/LIC602 on file which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/07/2024 Plan of Correction The administrator/licensee will develop a plan to ensure all the residents have a documentation of a medical assessment, signed by a physician on file. The administrator/licensee will provide a copy of the plan to CCL by 8/7/2024.

Official classification

Type A

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility was not able to provide any documents that emergency drills were completed accordingly which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/07/2024 Plan of Correction The administrator/licensee will develop a plan to indicate when a drill will be conducted and how often it will be performed moving forward. The administrator/licensee will provide a copy of the plan to CCL by 8/7/2024.

Official classification

Type A

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 2 out of 6 residents with bed rails by the head of the bed without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/07/2024 Plan of Correction The administrator will develop a plan to indicate when a physician's order will be obtained for the device that is being used and will provide a copy of the physician's orders when obtained. The administrator/licensee will provide a copy of the plan to CCL by 8/7/2024.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 4 out of 6 residents have bed rails by the head and foot of the bed and according to the staff, these residents are not on hospice which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/07/2024 Plan of Correction The administrator/licensee will develop a plan to ensure compliance. The administrator/licensee will provide a copy of the plan to CCL by 8/7/2024.

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 1 staff did not have any training records for 2023 and 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/13/2024 Plan of Correction The administrator/licensee will develop a plan to indicate when training will be completed for this staff and on the plan, it shall indicate what steps the facility will take to prevent this from happening again. The administrator/licensee will provide a copy of the plan to CCL by 8/13/2024.

Official classification

Type B

Official code

87506(b)(17)(E)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (E) Section 87463, Reappraisals; and This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 6 out of 6 residents did not have a copy of the reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/13/2024 Plan of Correction The administrator/licensee will develop a plan to indicate when the reappraisals will be completed for all the residents and will provide a copy of the completed reappraisals. The administrator/licensee will provide a copy of the plan to CCL by 8/13/2024.

Official classification

Type B

Official code

87456(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed resident with diagnosis of dementia did not have a recent medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/13/2024 Plan of Correction The administrator will develop a plan to indicate when an updated medical assessment will be completed for the residents who are diagnosed with Dementia. The administrator/licensee will provide a copy of the plan to CCL by 8/13/2024.

Official classification

Type B

Official code

87705(c)(3)(A)(B)(C)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(3) In addition to the on-the-job training requirements..staff who provide direct care to residents with dementia shall receive the following training... A) Dementia care including,..(B) Recognizing symptoms..(C) Recognizing the effects of medications...this requirement is not met as the facility was not able to provide documents that facility staff has received this training while providing care to resident with Dementia which poses a potential health risk to residents in care.

Official plan of correction

The administrator will review the regulation and submit a statement to CCL stating that it was reviewed. In addition, the administrator will provide in-services to staff pertaining to this regulation. The administrator will provide a copy of the statement and a copy of the in-service sign-in record to CCL by the plan of correction due date of 11/18/2022

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