SANDHILL ASSISTED LIVING LLC

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This was not met as evidenced by: Based on interviews, R1 was not provided timely medical care due to Licensee took two days after UTI home test before R1 was able to talk to a physician, which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee to submit a plan addressing how residents medical needs will be addressed in a timely manner. Licensee to submit plan by POC due date.

Deadline recorded: Feb 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents... This requirement was not met as evidenced by: Based on interviews, observations and records review, there was not enough staff member scheduled to cater to the resident’s care which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

On 4/10/25 LPA delivered a copy of amended LIC9099D. Deficiency is cleared and corrected.

Deadline recorded: Feb 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(g)(5)(A)(1)

Regulation authority

CCR

What the official deficiency says

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 due R1, R2, R3s admission agreements have a clause regarding not providing refund of fees upon death, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/11/2024 Plan of Correction Facility administrator to submit a plan of action to licensing by 11/11/2024 to describe how facility plans to provide the refund per regulations or as required to family member and refund policy moving forward. In additional facility to submit a revised admission agreement to meet CCR 87507(g)(5)(A) by 11/11/2024.

Official classification

Type A

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b) The following food service requirements shall apply: (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: Based on observation, there was not enough supply of canned good and 7-day non-perishable foods, which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee to submit a plan to address the food supply in the facility. Licensee to submit photos of food supply. LIcensee to submit by POC deadline.

Deadline recorded: Feb 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211(a) Each licensee shall furnish... such reports... including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency...(D)Any incident which threatens the welfare...or unexplained absence of any resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on record reviews and interviews, the licensee did not comply with the section cited above due incident not being reported to CCLD which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/19/2023 Plan of Correction Licensee to submit a plan in order to address reporting requirements to CCLD. Licensee to submit plan by POC due date.

Official classification

Type A

Official code

87705(c)(5)(A)

Regulation authority

CCR

What the official deficiency says

87705 (c)Licensees who accept and retain residents with dementia...(5)Each resident with dementia shall have an annual medical assessment... (A) When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed... This requirement was not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above due to R1 not being reassesed after the elopement which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit a plan of action and submit the reassessment report (whenever available) to LPA by POC deadline.

Deadline recorded: Sep 2, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(c)(4)(A)

Regulation authority

CCR

What the official deficiency says

87705(c) Licensees who accept and retain residents with dementia...(4)There is an adequate number of direct care staff...(A)In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents... This requirement was not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above due to R1 having wandering behaviors but Licensee did not schedule nigh supervision which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit an updated LIC500 which states that there would be a night shift scheduled. Licensee to submit by POC due date.

Deadline recorded: Sep 2, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(h)

Regulation authority

CCR

What the official deficiency says

Amended 87705(h)Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.This requirement was not met as evidenced by: Based on ord reviews and interviews, the licensee did not comply with the section cited above due resident with dementia being able to leave facility unassited which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit a plan and in-service training for staff about Dementia plan of operation of the facility. Licensee to submit to LPA by 8/9/23.

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

Official classification

Type A

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

Amended to Type A 87211(a) Each licensee shall furnish... such reports... including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency...(D)Any incident which threatens the welfare...or unexplained absence of any resident. This requirement was not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above due incidents not being reported to CCLD which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit a plan of action regarding timely submission of incident reports. Licensee to submit to LPA by 8/15/23.

Deadline recorded: Aug 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(8)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility...8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available.... This requirment is not met as evicenced by: the facility did not have a first aid kit for LPA to inspect during the pre-licensing inpsection which poses a potential health risk to residents in care.

Official plan of correction

The administrator will review this requirement and obtain a complete set of first aid kit for the facility. The administrator will provide in-service to staff on the importance of having a first aid kit in the facility, to ensure it contains the required items and the location of the first aid kit. The administrator will submit proof that the first aid kit is obtained, properly stored and provide a copy of the in-service record to CCL by 11/1/2022.

Deadline recorded: Nov 1, 2022. A deadline is not proof that correction was completed.