FAMILY AFFAIR CARE HOME

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 hot water temperature in the bathrooms was measured at 91- 151 degrees F which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/05/2026 Plan of Correction The administrator will develop a plan to indicating action that was taken to ensure hot water temperature is within range and provide a copy of the plan to CCL by 3/5/2026. In addition, the administrator will take daily temperature of the kitchen and all the bathroom/shower rooms for 7 days and provide a copy of results to CCL by 3/13/2026.

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 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: 03/27/2025 Plan of Correction The administrator will develop a plan to ensure drills are completed accordingly and will provide a copy of the signed and dated plan to CCL by 3/26/2025.

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 10 out of 10 residents with bed rails with a written order from a physician which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/27/2025 Plan of Correction The administrator will develop a plan to ensure a physician's order is obtained for all resident with bed rails and the plan shall indicate the date that a physician's order will be obtained and the date shall be no later than 4/4/2025. The administrator will provide a copy of the signed and dated plan to CCL by 3/26/2025 and provide a copy of all the physician's order to CCL by 4/7/2025.

Official classification

Type A

Official code

87618(b)(3)(A)

Regulation authority

CCR

What the official deficiency says

(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility. 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 R1 and R7 have oxygen and the administrator did not make a report to the local fire jurisdiction which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/27/2025 Plan of Correction The administrator will develop a plan to ensure a report for R1 and R7 is provided to the local fire jurisdiction and provide a copy to CCL by 3/27/2025.

Official classification

Type A

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. 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 observe any " No Smoking- Oxygen in Use " signs at the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/27/2025 Plan of Correction The administrator will provide photos to CCL to ensure signs are posted in the appropriate areas by 3/27/2025.

Official classification

Type B

Official code

87219(a)

Regulation authority

CCR

What the official deficiency says

(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include: 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 annual visit on 3/18/2025 and the continuation visit on 3/26/2025, LPA did not observe any activities were provided to the residents. LPA observed majority of the residents were watching TV and others were in bed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2025 Plan of Correction The administrator will review the Regulation and after the review, the administrator will develop a plan to ensure the facility is providing meaningful activities to all the residents and the plan shall indicate the different types of activities that will be provided. The administrator will submit a copy of the plan of correction to CCL by 4/3/2025.

Official classification

Type B

Official code

87618(b)(5)

Regulation authority

CCR

What the official deficiency says

(5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment. 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 was not able to provide training records for S1 and S2 to ensure they are knowledgeable and has the ability to operate oxygen equipment which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2025 Plan of Correction The administrator will provide a copy of the training records for S1 and S2 to CCL by 4/3/2025.

Official classification

Type A

Official code

87412(a)(4)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (4) Written verification that the employee is at least 18 years of age, including, but not necessarily limited to, a copy of his/her birth certificate or driver's license. 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 S3 and S4 did not have any documents in their files to verify this information which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction The administrator will develop a plan in writing to ensure compliance and the plan shall indicate the compliance date no later than 3/25/2025. The administrator will provide a copy of the plan of correction to CCL by 3/19/2024.

Official classification

Type A

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 4 staff did not have proof that their health screen was completed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction The administrator will develop a plan in writing to ensure compliance and the plan shall indicate the compliance date no later than 3/25/2025. The administrator will provide a copy of the plan of correction to CCL by 3/19/2024.

Official classification

Type A

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: 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 S1 and S2 have missing documents from the personnel records and S3 and S4 did not have a personnel file which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction The administrator will develop a plan in writing to ensure compliance and the plan shall indicate the compliance date no later than 3/25/2025. The administrator will provide a copy of the plan of correction to CCL by 3/19/2024.

Official classification

Type A

Official code

87355(e)(4)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. 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 S3 and S4 did not have proof that background/fingerprint clearance process were completed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction The administrator will develop a plan in writing to ensure compliance and the plan shall indicate the compliance date no later than 3/25/2025. The administrator will provide a copy of the plan of correction to CCL by 3/19/2024.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: 87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility converted a private room (bedroom 3) into a 2 bedroom without a fire clearance was which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction The administrator will develop a plan to ensure compliance and the compliance date should be no later than 3/25/2025. The administrator will submit a copy of the plan to CCL by 3/19/2025.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: 87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed garage was cluttered, uncleaned cat food all over the ground, files, dirty plastic bags on the floor, table, unknown brown liquid bottle on the table, lighter, cigarettes on top of the laundry, and soiled linens on the floor which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction The administrator will develop a plan to ensure the facility is clean and safe at all times and will submit a copy of the plan of correction to CCL by 3/19/2025.

Official classification

Type A

Official code

87355(e)(4)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. 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 2 out of 3 staff were not associated with the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/21/2024 Plan of Correction The administrator will provide a copy of the necessary documents to CCL by 3/21/2024 to complete the association process.

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 1 out of 4 staff did not have any proof that training and orientation were completed upon hire which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/21/2024 Plan of Correction The administrator will submit a plan to ensure all staff members have completed the required training upon hire and the plan will indicate when the staff will complete the required training. The administrator will submit a copy of the plan to CCL by 3/21/2024.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: 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 1 out 4 staff files was not maintained at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/27/2024 Plan of Correction The administrator will submit a plan to CCL to ensure compliance by 3/27/2024.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. 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 3 out of 4 residents did not have a centrally stored medication in their file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/27/2024 Plan of Correction The administrator will submit a plan to ensure compliance and will submit it to CCL by 3/27/2024. The administrator will submit a copy of the centrally stored medication record for all the residents to CCL by 3/27/2024.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... Violation of this regulation is evidenced by: Based on the interviews conducted an information collected, the facility failed to submit an incident report for an incident that occurred on 2/15/23. In addition the facility adminsitrator acknowledged that she was unaware that a report had to be submitted to CCL.

Official plan of correction

Facility administrator to read CCR 87211 Reporting Requirements and submit acknowledgement of the regulation to LPA by due date.

Deadline recorded: Mar 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals: (a) ...The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to... Violation of this regulation is not met as evidenced by: Based on interviews conducted and information collection, the facility administrator acknowledged that she refused to take R1 back to the community because the hospital did not properly assess her, however instead of administrator going to assess her, the administrator called R1's responsible party to assess R1 prior to discharge. In addition, the administrator acknowledged she did not reassess R1 when R1 was in the hospital or when R1 returned back to the community.

Official plan of correction

Facility administrator to review CCR 87463 and submit acknowledgement to LPA. In addition, administrator to submit a written plan to address concerns regarding what facility can do if hospital does not properly assess resident prior to discharge.

Deadline recorded: Mar 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87355 Criminal Record Clearance:(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or... Violation of this regulation is not met as evidenced by: During the visit, LPA observed S1 cleaning the facility however he was not fingerprint cleared and/or associated. In addition, Administrator indicated that S1 has an appointment to get fingerprinted on 2/21/23.

Deadline recorded: Feb 22, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87465 Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... Violation of this regulation is not met as evidenced by: During the visit, LPA observed the medication cabinet to be unlocked and accessible which poses an immediate health and safety concern to residents in care.

Deadline recorded: Feb 22, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons...which could pose a danger if readily available to clients shall be stored where inaccessible to clients. Violation of this regulation is not met as evidenced by: During the visit, LPA observed the chemicals and toxins cabinet located in the garage to be unlocked and inaccessible to residents which poses an immediate health and safety risk to residents in care.

Deadline recorded: Feb 22, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87705 Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (1) Knives... and other items that could constitute a danger to the resident(s). Violation of this regulation is not met as evidenced by: During the visit, although LPA observed the knives locked and stored away from residents, LPA observed a knife on the kitchen counter top while a staff member was not present

Deadline recorded: Feb 22, 2023. 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

87555 General Food Service Requirements: (b) The following food service requirements shall apply: (8) All food shall be of good quality... Violation of this regulation is not met as evidenced by: During the visit, LPA observed the facility fridge to have gallons of expired milk which poses an immediate health and safety risk to residents in care.

Deadline recorded: Feb 22, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

POSTURAL SUPPORTS 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 violation exists based on observation of full bed rails on bed of client #4 in shared room beyond living room. Client is not on hospice care. Licensee failed to ensure that full bed rails are NOT used, which poses an immediate health, safety or personal rights risk for clients in care.

Official plan of correction

Full bed rail was reduced to half bed rail in LPA's presence and positione at the head of the bed. Deficiency corrected and cleared

Deadline recorded: Oct 24, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

PERSONAL RIGHTS Residents in all RCFEs shall have the following personal right: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met, as there is no COVID screening or temperature check upon arrival at facility for visitors. Visitor log does not include date, contact information, confirmation that COVID symptoms are absent, and temp check. Licensee failed to ensure that visitors are properly COVID screened, which poses a potential health, safety or personal rights risk to clients in care.

Official plan of correction

Visitor log will be revised to include date, time, contact information, confirmation that COVID symptoms are absent, and temp check. Proof of correction to be sent to CCLD BY DUE DATE

Deadline recorded: Oct 31, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87629(a)

Regulation authority

CCR

What the official deficiency says

87629 Injections..(a) The licensee shall be permitted to accept or retain a resident who requires intramuscular,..intradermal injections if the injections are administered by the resident or by an appropriately skilled professional. This requirement is not met as evidenced by: R2 was not able to administer injections and injections were administered by S1 who was not an appropriately skilled professional which posed an immediate health and safety risks to residents in care.

Official plan of correction

Administrator and/or licensee will develop a plan to be in compliance with this regulation and such plan shall be submitted to CCL by 5/12/22. In addition, the administrator and/or the licensee will review this regulation, and submit a statement of acknowledgment his/her review to CCL by 5/12/22.

Deadline recorded: May 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

87457 Pre-Admission Appraisal - General..(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal ... This requirement is not met as evidenced by: the facility did not conduct a pre-admission appraisal of R1 which resulted the facility not able to meet R1's blood sugar management needs which posed an immediate health and safety risks to residents in care.

Official plan of correction

The administrator will review this regulation and submit a written statement of compliance pertaining to the regulation to CCL by 5/12/22.

Deadline recorded: May 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 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:(2) To be accorded safe, healthful... This requirement is not met as evidenced by: during the 10-day initial complaint visit, LPA observed staff #1 was not wearing any face covering which posed an immediate health and safety risks to resident in care.

Official plan of correction

The administrator and/or designee shall provide in-services to facility staff on the importance of following the mandated mask protocol. The administrator and/or designee will provide a copy of the sign-in records to CCL by 5/12/2022.

Deadline recorded: May 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical,...When changes such as...physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: the facility failed to observe R1's blood sugar level which posed an immediate health and safety risks to resident in care.

Official plan of correction

The administrator will review this regulation and provide a copy of a signed statement acknowledging of the review and understanding to CCL by 5/12/22. The administrator will provide in-services to staff on the importance of Observation of the Resident and provide a copy of the education sign-in record to CCL by 5/12/22.

Deadline recorded: May 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care...(a)A plan for incidental medical... shall be developed by each facility..(4) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: the facility failed to assist R1's pain medication during the night upon R1's request as prescribed by R1's physician posed an immediate health and safety risks to resident in care.

Official plan of correction

The administrator/Licensee will validate all staff are trained on assisting residents with their prescribed medication. Afterwards, the administrator or the licensee will submit a statement to CCL of such validation by 5/12/22. In addition, the administrator and/or designee will provided in-service to facility staff on assisting resident's medication at all times as prescribed and provide a copy of the facility staff sign-in record to CCL by 5/12/22/

Deadline recorded: May 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services..(a)Living accommodations...The facility shall be large enough to provide comfortable living accommodations and privacy for the residents...(2)Resident bedrooms shall be provided which meet..(B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This requirement was not met as evidenced by: the facility moved 2 male residents who were sharing a room into the living room to accommodate a female resident who did not get along with her roommate which posed an immediate health and safety risks to resident in care.

Official plan of correction

The administrator or licensee should review this regulation and provide a statement of acknowledgment to CCL by 5/12/22. In addition, the administrator shall develop a plan to avoid this situation from happening again and provide a copy of the plan to CCL by 5/12/22.

Deadline recorded: May 12, 2022. A deadline is not proof that correction was completed.