CARING HANDS RESIDENTIAL LIVING II

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 records reviewed, the licensee did not comply with the section cited above. LPA toured resident bedroom #5. LPA observed on the cabinet next to R1's bed contained a medication. LPA reviewed R1's Physician's Report dated April 22, 2021, states R1 cannot administer and/or store his/her own medications. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/09/2026 Plan of Correction Staff S1 stored the medication during LPA's visit. ADM stated he will send a letter of understanding regarding the regulation and the importance of ensuring medications are kept inaccessible to residents in care. ADM stated he will send the plan of correction to LPA by POC due date, January 9, 2026.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) 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 Based on observation and interview, the licensee did not comply with the section cited above. LPA observed a missing door frame in bedroom #4. Bedroom #2 was observed to have a hole in the wall. Bathroom #2's door frame is damaged. LPA observed numerous leaves and fruit scattered in the backyard, on the ground. LPA observed bedroom 5 was missing is sliding screen. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/15/2026 Plan of Correction ADM stated he will send a written plan of action on how he will ensure the facility will be clean, safe, sanitary and in good repair at all times. ADM stated he will send photo documentation showing the following areas have been addressed: door frames in bedroom 4 and bathroom 2, the hole in bedroom 2, the missing window screen in bedroom 5 and the scattered leaves and fruits in the backyard. ADM stated he will send to LPA by POC due date, January 15, 2026.

Official classification

Type B

Official code

87412(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above. LPA requested to review Staff S2's LIC501, LIC503 and documentation of training. LPA was not provided the following but not limited to documents regarding S2 to review/inspect : LIC501, Staff training records, LIC503. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/15/2026 Plan of Correction ADM stated he will send LPA a letter of understanding regarding the regulation. ADM stated he will send copies of S2's LIC501, LIC503 and documentation of training to LPA by POC due date, January 15, 2026.

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 and records reviewed, the licensee did not comply with the section cited above. R1's Physician's report is dated April 22, 2021. LPA requested to review documentation demonstrating the Administrator requested an updated physician's report from the resident and/or the residents representative. The Administrator also did not provide any documentation showing that R1 or R1's representative had reused to receive annual assessment for an updated physician's report. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/15/2026 Plan of Correction ADM stated he will send a copy of R1's updated physician's Report to LPA by POC due date. ADM stated he will also send a letter of understanding regarding the regulation.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) (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 records reviewed, the licensee did not comply with the section cited above. Resident R1 and R2's Centrally stored medication Record forms only has medications with start dates from the year 2024. LPA asked S1 for the most current forms for R1 and R2. S1 stated they only fill out the centrally stored medication records once a year. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/15/2026 Plan of Correction ADM stated he will send LPA a copy of R1-R2's updated Centrally stored medication record. ADM stated he will send the plan of action on how he will ensure a centrally stored record of residents prescription medications will be maintained. ADM stated he will send plan of correction to LPA by POC date, January 15, 2026

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services(d) (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by: Based on observation, facility's kitchen, sliding screen door has a stick preventing the door from opening. LPA observed the door in the living room had a Tuut door lever lock creating an obstruction to opening that door. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

ADM stated he will send a letter of understanding regarding the regulation. ADM stated he will send photo documentation showing both the Tuut door lever lock, child proofing door handle and the stick in the kitchen have been removed. ADM stated he will send the plan of corrections to LPA by POC date, March 22, 2025.

Deadline recorded: Mar 22, 2025. 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

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPA observed detergents inside the garage accessible to residents in care. LPA observed the storage shed in the backyard, contained a container of gasoline, which was accessible to residents in care. The door on the shed, does not have a locking mechanism. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/17/2025 Plan of Correction ADM stated he will send a written plan of action on how he will ensure cleaning solutions, poisonous substances, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. ADM stated his written plan will address the storage shed in the backyard and the detergents in the garage, and send to LPA by POC date, 1/17/2025.

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 record review and interview, the licensee did not comply with the section cited above. LPA requested to review staff S1's training for 2024. S1 stated she did not complete any training for 2024. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/23/2025 Plan of Correction ADM stated he will send a written plan of action on how he will ensure his staff meet the 20 hours of annual training. ADM stated he will send this written plan of action by POC date 1/23/25.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above. LPA requested to review R4's physicians report. S1 stated the facility is still working on filling out that form. S1 stated R4 has not had a medical assessment yet. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/23/2025 Plan of Correction ADM stated he will send a letter of understanding regarding the regulation. ADM stated he will send LPA a copy of resident R4's physicians report. ADM stated he will send to LPA by POC date, 1/23/25.

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 record review and interview, the licensee did not comply with the section cited above. R1 needs and Services plan form is blank. S1 stated R4's Needs and services plan has not been filled out. S1 stated the facility was in the process of filling out R1's ANS. Facility staff was unable to provided an updated copy of R3's Needs and services plan. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/23/2025 Plan of Correction ADM stated he will send LPA a letter of understanding regarding the regulation. ADM stated he will send LPA a copy of R1, R2 and R4's updated needs and services plan. ADM stated he will send the plan of correction to LPA by POC date 1/23/2025.

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 record review, the licensee did not comply with the section cited above. Facility staff was unable to produce a copy of an updated physicians report for R3 or documentation showing the administrator contacted the residents responsible party to get an updated physicians report. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/23/2025 Plan of Correction ADM stated he will send LPA an updated copy of R3's physicians report. ADM stated he will send to LPA by POC date, 1/23/2025.

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 record review and interview, the licensee did not comply with the section cited above. The facility conducted drills for the year 2024, for the following dates; August 30, 2024, May 31, 2024, and February 18, 2024. Staff was unable to produce documentation a drill had taken place in the 4th quarter of 2024. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/23/2025 Plan of Correction ADM stated he will send LPA a letter of understanding regarding the regulation. ADM stated he will conduct a drill and send LPA documentation showing a drill has taken place.

Official classification

Type B

Official code

87465(h)(3)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) (3) Each container shall carry all of the information specified in (6)(A) through (E) below plus expiration date and number of refills. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview, the licensee did not comply with the section cited above. R1,R2 & R4's Centrally stored medication log was not filled out. S1 stated they have not filled out their centrally stored medication record. R3's centrally stored medication record had several medications that were not listed and had incorrect information, such as the incorrect prescribing physician. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/23/2025 Plan of Correction ADM stated he will send LPA a letter of understanding regarding the regulation. ADM stated he will send LPA a copy of R1-R4's updated Centrally stored medication record. ADM stated he will send the plan of action to LPA by POC date, 1/23/25.

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, the licensee did not comply with the section cited above. While reviewing R1's medication's, LPA observed over 2 dozen medications, not secured in their container. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/26/2024 Plan of Correction ADM stated he will send plan of action on how the facility will ensure residents medications are stored in their original container. ADM stated he will also send letter of understanding regarding regulation. ADM stated he will send letter by POC date, 1/26/2024.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 Based on observation, the licensee did not comply with the section cited above. LPA observed The shower in the private bathroom, for resident bedroom #2 does not have an attached shower curtain. LPA observed an indentation in the hallway opening to bedroom 4 & 5. LPA also observed the living room closet, and the doors hinges on the top were not attached. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/01/2024 Plan of Correction ADM stated he will send plan of action on how the facility will keep be good repair at all times. ADM stated he will send plan of action to LPA by POC date, 2/1/2024.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations, the licensee did not comply with the section cited above. LPA observed bedroom #4 does not have a sliding screen for the door facing the patio. LPA observed bedroom #3's window screen was not attached and had an opening. LPA observed bedroom #2's sliding screen door was missing as well. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/01/2024 Plan of Correction ADM stated he will send plan of action on how the facility will keep all screens clean and in good repair. ADM stated he will send plan of action to LPA by POC date, 2/1/2024.

Official classification

Type B

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, the licensee did not comply with the section cited above. LPA observed the private bathroom for Resident bedroom #2 does not have a non-skid mat which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/01/2024 Plan of Correction ADM stated he will send plan of action on how the facility will ensure non-skid mats or strips shall be used in all bathtubs and showers. ADM stated he will send plan of action to LPA by POC date, 2/1/24.

Official classification

Type B

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 LPA's observation, the licensee did not comply with the section cited above. LPA observed a bottle of Lysol all purpose cleaner in the private bathroom, in resident bedroom #2. While touring the backyard of the facility, LPA observed a can of " Henry-Wet patch, roof leak repair " , directly outside Room #3's window. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/01/2024 Plan of Correction ADM stated he will send plan of action on how the facility will ensure disinfectants, poisons and other items which could pose a danger are inaccessible to residents in care. ADM stated he will send plan of action to LPA by POC date, 2/1/24.

Official classification

Type B

Official code

87412(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above. LPA requested 3 staff files. S1 only provided 1 and stated there were no other files. S1 contacted ADM, and informed LPA the other staff documents were at another facility. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/01/2024 Plan of Correction ADM stated he will send LPA plan of action on how the facility will ensure staff records are available to inspect during normal business hours. ADM stated he will send plan of action to LPA by POC date, 2/1/24.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, R1's Needs and services plan, dated April 23, 2021, the form is blank under socialization, emotional, mental, physical, functioning needs. A review of R1's physician report, dated April 22, 2021, states R1 is non ambulatory, and " needs assistance while in bed, as needed during the day while up. " This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/01/2024 Plan of Correction ADM stated he will send plan of action on how the facility will ensure appraisals are updated as frequently as possible. ADM also stated he will update R1's needs and services plan. ADM stated he will send an updated copy to LPA by POC date, 2/1/2024.

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 record review, the licensee did not comply with the section cited above. Based on facility records the last drill conducted was on August 23, 2023. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/01/2024 Plan of Correction ADM stated he will conduct a drill by POC date and send LPA documentation that a drill has taken place. ADM stated he will send plan of corrections by POC date.

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 record review, the licensee did not comply with the section cited above. While reviewing R2's file, LPA observed R2's physicians report (PR), dated, 9/9/20. The PR states R2 has a neurocognitive disorder. LPA observed R3's PR, dated 11/29/22. R3's PR states R3 has a neurocognitive disorder. R3's Needs and services plan is dated 12/23/22. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/01/2024 Plan of Correction ADM stated he will send plan of action on how the facility will ensure Each resident with dementia shall have an annual medical assessment and a reappraisal done at least annually. ADM stated he will send plan of action by POC date, 2/1/2024.

Official classification

Type A

Official code

87506(d)

Regulation authority

CCR

What the official deficiency says

d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement was not met as evidenced by: Deficient Practice Statement Based on observation and records reivew, the licensee did not comply with the section cited above, as 4 out of 4 files were observed as incomplete and administrator was not able to provide up to date copies in a timely manner which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/23/2023 Plan of Correction Licensee to update all paper facility files with up to date information, and provide proof of completed files to LPA by POC due date.

Official classification

Type B

Official code

87468.1(a)(3)

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... (3) To be free from... other actions of a punitive nature, such as... interfering with daily living functions such as eating. This requirement was not met as evidenced by: Based on observation, the licensee did not comply with the section cited above due to refrigeration unit possessing a lock which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee is to remove locks from food refirgeration and freezer units. Licensee shall provide photo documentation of removed locks to the department by POC due date.

Deadline recorded: Nov 29, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465(h)(2) - Incidental Medical and Dental Care - ...(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 was not met as evidenced by: LPA observed resident medication visible and accesible in resident room. This poses a potential risk to the health and safety of residents in care.

Official plan of correction

Licensee to submit written plan of action and proof of correction to CCLD by POC due date.

Deadline recorded: Nov 29, 2021. A deadline is not proof that correction was completed.