MARY'S HOUSE #2

Official classification

Type A

Official code

87355(e)(3)

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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement was not met as evidenced by: Licensee did not ensure that staff S5 was associated to the facility during visit, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agrees to associate S5 to the facility and submit an updated LIC500 Personnel Report to the department by 08/27/2026.

Deadline recorded: Aug 21, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement was not met as evidenced by: Licensee did not ensure that R1's Centrally Stored Medication and Destruction Record (CSMDR) was not missing four medications, R2's CSMDR was not missing one medication, R3's CSMDR not missing six medications, R4's CSMDR was not missing one medication, R5 did have a CSMDR on file, and R6's CSMDR was not missing six medications, which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee agrees to submit completed and accurate copies of R1-R6’s current Centrally Stored Medication and Destruction Records by 08/27/2026.

Deadline recorded: Aug 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

Resident Records 87506(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by: Licensee did not ensure that R1's, R3's, R4's, R5's, and R6's resident records were not missing an Appraisal/Needs and Services Plan, and R5's resident record was not missing a Consent for Medical Treatment Form and LIC613C Personal Rights Form, which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee agrees to submit the Appraisal/Needs and Services Plans for residents R1, R3, R4’s, R5’s, and R6’s and R5’s Consent for Medical Treatment Form and LIC613C Personal Rights Form to the department by 08/27/2026.

Deadline recorded: Aug 27, 2026. 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

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, … Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) 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 requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above wherein 1 resident who is not under hospice care is utilizing full bed rails which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/20/2025 Plan of Correction Administrator states to reach out to the resident's doctor to see if the doctor will approve of the full bed rails. Administrator states in the meantime, he will remove one of the rails to create a half rail on the resident's bed and train staff on the resident's care plan on increased monitoring to prevent falls. Administrator will submit a photo of the bed and training record to LPA Kabariti via email by POC due date of 08/20/2025.

Official classification

Type A

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: 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 2 staff members are residing in the garage and 1 staff is residing the living room which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/20/2025 Plan of Correction Administrator states 1 of the vacant bedrooms will be used as a staff living quarters for the live-in staff. Administrator will submit an updated facility sketch to show which room will be used a staff bedroom to LPA Kabariti via email by POC due date on 08/20/2025.

Official classification

Type B

Official code

87463(h)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above wherein 1 resident does not have a medical assessment prior to admission and 2 residents medical assessment has not been updated annually which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/26/2025 Plan of Correction Administrator states he will update all residents physician's reports. Administrator states he will submit the updated physician's report for 3 residents to the Department's general email by POC due date of 08/26/2025.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above wherein 2 resident's did not have a reappraisal and 1 resident's reappraisal was not signed by the resident/responsible party which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/26/2025 Plan of Correction Administrator states he will update the 3 residents reappraisals. Administrator states he will submit the 3 resident's updated and signed reappraisal to the Department's general email by POC due date of 08/26/2026.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above wherein there was a total of 16 residents medications that was not written in the centrally stored medication record which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/26/2025 Plan of Correction Administrator states he will provide training with staff on medications. Administrator will submit the training record to the Department's general email by POC due date of 08/26/2025.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above wherein 4 staff members do not have a CPR and first aid training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/26/2025 Plan of Correction Administrator states to submit the 4 staff members 1st aid certification to the Department's email box by POC due date 08/26/2025.

Official classification

Type B

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

(b) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above in wherein 4 staff members are not provided initial and annual training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/26/2025 Plan of Correction Administrator states he will enroll all the staff in training. Administrator will submit a scheduled plan for the 4 staff to complete training to the general email box by POC due date of 08/26/2025.

Official classification

Type A

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. … This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above wherein 3 staff members does not have a TB result which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/20/2025 Plan of Correction Administrator states the 3 staff members will complete the TB test by 08/20/2025. Administrator will submit proof that the TB test was completed by POC due date of 08/20/2025.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

CCR

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 comply with the section cited above in wherein the facility is not completing emergency drills quarterly which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/26/2025 Plan of Correction Administrator will conduct an emergency drill with the staff, ASAP. Administrator will create a schedule for the emergency drills for the staff going foward. Administrator will submit proof that the emergency drill was completed and the schedule for going forward to the Department general email by POC due date of 08/26/2025.

Official classification

Type B

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication. This requirement was not met as evidenced by: Licensee did not ensure that 4 out of 4 reviewed resident Centrally Stored Medication and Destruction Records did not have centrally stored medications that were not recorded. R1 had 2 unrecorded medications, R2 had 2 unrecorded medications, R3 had 5 unrecorded medications, and R4 had 2 unrecorded medications, which poses a potential health risk to residents in care.

Deadline recorded: Aug 21, 2024. 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

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement was not met as evidenced by: Licensee did not ensure that resident R3 did not have two medications that did not have a prescription label, which poses a potential safety risk to residents in care.

Deadline recorded: Aug 21, 2024. 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

(b) Personnel records shall be maintained for all volunteers and shall contain the following: (1) A health statement as specified in Section 87411(f). (2) Health screening documents as specified in Section 87411(f). This requirement was not met as evidenced by: Licensee did not ensure that Volunteer V1 had a health statement and health screening on record, which poses a potential health risk to residents in care.

Deadline recorded: Aug 21, 2024. 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

(b) Each resident’s record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables. This requirement was not met as evidenced by: Licensee did not ensure that residents R1-R4 had Safeguard for Property and Valuables Forms in their resident records, which poses a potential personal rights risk to residents in care.

Deadline recorded: Aug 21, 2024. 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

(b) Each resident’s record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal; This requirement was not met as evidenced by: Licensee did not ensure that residents R4 and R5 had Pre-Admission Appraisal forms in their resident records, which poses an potential safety risk to residents in care.

Deadline recorded: Aug 21, 2024. A deadline is not proof that correction was completed.