DEVEREUX FOUNDATION - WEISMAN CENTER (RCFE)

Official classification

Type B

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465(c)(2) Incidental and Medical Care: ....Once ordered by the physician the medication is given according to the physician's directions. This requirement has not been met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above when the facility self-reported two medication errors which occurred on 1/16/2026 and 3/26/2026 which poses a potential health and safety risk to residents in care.

Official plan of correction

POC Due Date: 07/21/2026 Plan of Correction Program Manager stated S1 & S2 were counseled and conducted re-training; S1 & S2 are no longer employed by the facility. POC cleared at the time of the inspection.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement LPA observed hallways and door jams throughout the facility in need of patching and painting which poses a potential safety and well-being of clients in care.

Official plan of correction

POC Due Date: 07/31/2026 Plan of Correction Licensee agrees to conduct thorough patching and painting as needed throughout the facility including but not limited to hallways, doorways, and other maintenance no later than due date. Licensee agrees to send photos directly to LPA of the finished work no later than POC due date.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(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 record review, the Licensee did not comply with the section cited above when staff left a client alone and unsupervised in the facility vehicle which poses an immediate personal rights risk to residents in care.

Official plan of correction

Program Director agrees to provide written disciplinary action for S1 and will conduct a Personal Rights re-training for S1. Written discplinary action and proof of re-training will be sent via email to LPA no later than due date. Proof of re-training will include date of training, description, S1's signature, and who conducted the training.

Deadline recorded: Feb 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(c)(1)

Regulation authority

CCR

What the official deficiency says

87506(c)(1) Resident Records…The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above when R1’s RP was not provided records, which posed a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Program Manager agrees to provid a resident's records upon request to residents' responsible parties. Program Manager agrees to provide written statement to CCLD acknowledging CCR87506. Administrator agrees to submit written statement directly to LPA via email no later than POC due date.

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

Official classification

Type A

Official code

1569.625(b)(2)

Regulation authority

CCR

What the official deficiency says

Type A: 1569.625(b)(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…and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care... 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 record review, the licensee did not comply with the section cited above in seventeen of the seventeen employee training files reviewed, which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/26/2024 Plan of Correction Program Manager agrees to conduct 20 hours of training to all staff including but not limited to dementia, postural supports, restricted health conditions, and hospice care. Training to include first and last names of all trainees, description of trainings, outside agency training vendor within due date of POC (7/26/2024).

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465(c)(2) Incidental Medical and Dental Care: Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above when staff did not follow physician’s orders for medications, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Program Administrator agrees to schedule medication training for all staff by POC due date. Program Administrator agrees to conduct medication training from an outside source for all staff. Proof of training will include first and last name of trainees, name of trainer description of training. Training sign-in sheet to be provided to LPA via email. CIVIL PENALTTY ASSESSED

Deadline recorded: Feb 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465(c)(2) Incidental Medical and Dental Care: Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above when staff did not follow physician’s orders for medications, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Program Director agrees to schedule medication training for all staff by POC due date. Program Director agrees to conduct medication training from an outside source for all staff. Proof of training will include first and last name of trainees, name of trainer trainer, description of training. Training sign-in sheet to be provided to LPA via email. CIVIL PENALTTY ASSESSED

Deadline recorded: May 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(c)(1)

Regulation authority

CCR

What the official deficiency says

87506(c)(1) Resident Records The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above cited section when they failed to provide R1’s responsible party’s attorney all of R1’s records as requested in a subpoena, which posed a potential personal rights risk to clients in care.

Official plan of correction

Program Director agreed to provide R1’s responsible party’s attorney all of R1’s records by 3/6/2023, and copy LPA on the email to confirm the documents were provided to R1’s responsible party and Attorney on record.

Deadline recorded: Mar 6, 2023. 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(a)(2) Personal Rights of Residents in All Facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on LPA observation, Licensee failed to ensure all staff wore face coverings properly at all times while in the facilities. Staff 1, Staff 2, and Staff, 3 were not properly wearing a mask at the time LPA entered into the facility which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator agrees to notify all staff to wear masks at all times in the facility. Administrator agrees to conduct an infectious control training, review and train staff on all recent PIN’s released for 2022 and 2023, including mask-wearing mandates, and provide copy of training and staff signatures to CCL by 1/26/2023. List of attendees with signatures to include first and last name of each attendee shall be provided to LPA via email.

Deadline recorded: Jan 26, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465(c)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above when staff did not follow physician’s orders for medications, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Staff who committed the medication errors received retraining. POC cleared during visit.

Deadline recorded: Nov 17, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355(e)(1) Criminal Record Clearance. All individuals…shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not ensure that HCS 2 had a fingerprint clearance prior to working, which posed an immediate health and safety risk to residents in care

Official plan of correction

POC Due Date: 07/27/2022 Plan of Correction Program Director agrees to submit association paperwork for HCS 2 by 7/27/2022. Program Director agrees to not allow staff to work again until associated

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with regulation above when HCS 1 was present in the facility without wearing the mask properly, which poses an immediate personal rights risk to residents in care.

Official plan of correction

POC Due Date: 07/27/2022 Plan of Correction Program Administrator agrees to schedule infection control training, including mask requirements, for all staff by 7/27/2022. Training will be completed and provide proof of training with staff signatures by 8/2/2022

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405(a) Administrator Qualifications and Duties. All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not ensure the facility currently has a certified Administrator, which poses a potential health and safety risk to residents in care.

Official plan of correction

POC Due Date: 08/05/2022 Plan of Correction Program Administrator agrees to provide all required documents to CCL to designate a qualified/certified Administrator by 8/5/2022.