AHAU BOARDING CARE HOME

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 storage unit in the back yard that is being used as a living space for one of the caregivers which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/20/2024 Plan of Correction The administrator will develop a plan in writing to address the storage unit in the backyard that is being used as a living space and the plan shall indicate the steps that the administrator will take if the storage unit is deemed to be inhabitable by the Fire Marshal. The administrator will provide a copy of the plan to CCL 11/20/2024.

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 administrator was not able to provide any documents to proof that emergency drills were conducted accordingly which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/20/2024 Plan of Correction The administrator will develop a plan to ensure emergency drills are conducted accordingly and will provide a copy of the plan to CCL by 11/20/2024. The plan shall include staff education and a schedule of the emergency drills.

Official classification

Type A

Official code

87705(c)(4)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current 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 during the inspection, the administrator was the only staff on-site and she was giving a shower to R1, the other 3 residents were left unattended in the dining room and R2 called out serveral times for assistance before he/she was attended to which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/20/2024 Plan of Correction The administrator will develop a plan in writing to ensure there is an adequate number of direct care staff to support each resident's needs and they are being supervised at all times. The administrator will submit a copy of the LIC500 and a copy of the plan to CCL by 11/20/2024.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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 the administrator stated that the liability insurance has not been renewed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/26/2024 Plan of Correction The administrator will provide a copy of the current Liability Insurance to CCL by 11/26/2024.

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 the administrator was not able to provide proof that the training was completed for Staff #1(S1) which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/26/2024 Plan of Correction The administrator will provide a copy of the required training records for S1 to CCL by 11/26/2024.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. 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 R3 has a diagnosis of dementia and the LIC 602 was not completed annually which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/26/2024 Plan of Correction The administrator will provide a copy of updated LIC602 for R3 and provide a copy to CCL by 11/26/2024.

Official classification

Type A

Official code

87309(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 as the chemical storage room was unlocked during the facility tour which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/13/2023 Plan of Correction The administrator will develop a plan to ensure the chemicals will be locked and inaccessible to residents at all time. The administrator will submit a copy of the plan to CCL by 12/13/2023.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, record review and interview the licensee did not comply with the section cited above as expired medications for 2 out of 3 residents were observed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/13/2023 Plan of Correction The administrator will review medication for all residents and discard all the expired medication. The administrator will provide a written statement to CCL by 12/13/2023 indicating this has been completed.

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, record review and interview the licensee did not comply with the section cited above as the facility was not able to provide documents that drills were performed accordingly which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/13/2023 Plan of Correction The administrator will provide a plan to ensure compliance. The plan shall include when the drills will be completed. The administrator will provide a copy of the plan to CCL by 12/13/2023.

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 5 out of 5 residents did not have an preadmission which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/13/2023 Plan of Correction The administrator will provide a statement to ensure all preadmission appraisal is completed prior to admission. The administrator will provide a copy of the statement to CCL by 12/13/2023.

Official classification

Type A

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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 5 residents have half bed rails, however, none of them have a physician's order indicating the need for the postural support which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/13/2023 Plan of Correction The administrator will provide a plan to obtain a written order from the physician for the postural support and the plan shall indicate when the order will be obtained. The administrator will submit a copy of the plan to CCL by 12/13/2023 and will provide a copy of the written physician order to CCL when obtained,

Official classification

Type B

Official code

87113

Regulation authority

CCR

What the official deficiency says

The license shall be posted in a prominent location in the licensed facility accessible to public view. 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 did not observed any required posters during the facility tour including by not limiting to resident's rights, CCL complaint poster, non-discrimination, etc. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/19/2023 Plan of Correction The administrator will post the required posters and provide a photo of the posters to CCL by 12/19/2023

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 the administrator was not able to provide training records for staff #1 (S1) which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/19/2023 Plan of Correction The administrator will provide a copy of the training records for S1 to CCL by 12/19/2023.

Official classification

Type B

Official code

87457(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors. 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 5 out of 5 residents did have a completed appraisal and service plan which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/19/2023 Plan of Correction The administrator will complete an appraisal and service plan for all the residents and will provide a copy of the appraisal and service plan to CCL by 12/19/2023.

Official classification

Type A

Official code

1569.0822(c)(3)

Regulation authority

CCR

What the official deficiency says

§1569.49 Civil penalties; regulations setting forth appeal procedures for deficiencies..(c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for any of the following serious violations:.. (3) Absence of supervision as required by statute or regulation. This requirement is not met as evidenced by there was absence of supervision when LPA arrived at the facility as the only staff (administrator) was taking a shower which poses an immediate health risks for residents in care.

Official plan of correction

The administrator/licensee will develop a plan to ensure residents are being supervised at all times. Administrator/licensee will provide a copy of the plan to CCL by 11/2/2023. Immediate Civil Penalty is being assessed today (11/1/2023) for absence of supervision.

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

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space..(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 evidence by LPA observed a knife on the counter next to the stove which poses an immediate health risks to residents in care.

Official plan of correction

The administrator/licensee will develop a plan to ensure all items that could pose a danger is inaccessible to residents at all times. The administrator/licensee will submit a copy of this plan to CCL by 11/2/2023.

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

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation..(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by LPA observed dirty dishes in the sink, big pile of soiled clothes on the laundry room floor, fruits were stored on the counter with piles of paper, the unused towel paper dispenser in the bathroom was covered a white layer of dust etc. which poses an immediate health risk to residents in care.

Official plan of correction

The administrator/licensee will provide proof that facility is clean, safe, sanitary and submit a copy of the proof (photos) to CCL by 11/2/2023. Administrator/Licensee will submit a plan on how the facility will maintain and sustain a clean, safe, and sanitary environment for resident. Administrator/Licensee will submit a copy of the plan to CCL by 11/2/2023.

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