VILLA AMOR

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(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 responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above wherein LPA observed 2 prescription medications that were accessible in the refrigerator and resident's bedroom which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2025 Plan of Correction Licensee immediately secured the medications. Licensee will submit a written statement and plan to ensure compliance with the section cited above to LPA Kabariti via email by POC due date.

Official classification

Type A

Official code

87628(b)(3)

Regulation authority

CCR

What the official deficiency says

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that syringes and needles are disposed of as specified in Section 87303(f)(2). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above wherein the facility is not disposing of a resident's needles appropriately after each use which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2025 Plan of Correction Licensee will order a sharps container. Licensee will send a proof of purchase of the sharps container to LPA Kabariti via email by POC due date.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

(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. … This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not ensure to submit a written incident report to the Department regarding the incident that occurred with resident (R1) which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee will submit a written plan of the section cited to LPA Dolores via email by POC due date.

Deadline recorded: Aug 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87415(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, ... and shall be available as indicated below to assist in caring for residents in the event of an emergency. (1) In facilities caring for less than sixteen (16) residents, there shall be a qualified person on call on the premises. This requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not ensure the on-call staff on the premises was available to assist in caring for R1 timely when R1 was outside of the facility yelling for help which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee will submit a written plan regarding the section cited to LPA Dolores via email by POC due date.

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

Official classification

Type B

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, and record review the licensee did not ensure emergency drills are being conducted quarterly in which the last emergency drill conducted was in April 2023 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/02/2024 Plan of Correction Licensee will conduct the emergency drill, ASAP. Licensee will send the emergency drill to LPA Dolores via email by POC due date.