MARCEL'S MEMORY CARE

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 (h) The following requirements shall apply to medications which are centrally stored:d service. (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 licensee did not comply with the section cited above by not keeping the medicines locked. LPAs observed the medicine drawer was unlocked and easily accessible to persons other than employees responsible for supervision of medication, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/01/2025 Plan of Correction On 2/20/25 LIC/ADM stated the magnetic lock will be replaced with a lock that will not easily break. LIC/ADM corrected this deficiency on 2/28/2025 by replacing the magnetic lock.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (e)Water supplies and plumbing fixtures shall be maintained ...(2)Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. .... shall be maintained to automatically regulate the temperature of hot water... of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the section cited above by not maintaining the hot water temeprature between 105 degree F to 120 degree F. LPAs measured the water temperature 2 times. Water temperature measured at 103.1 degree Farenheit in 2 bathrooms and kitchen, which pose/poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/01/2025 Plan of Correction On 2/20/2025, LIC/ADM stated that her maintenance person will need to check the water control system and will correct the deficiency and monitor the water temperature to measure between 105 degree Fahrenheit to 120 degree Fahrenheit. On 2/28/2025 - LIC/ADM have corrected this deficiency and water temperature measured at 107 degree Fahrenheit.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Physical Plant/Environmental Safety (a) Except as specified in subsection (b), the licensee shall ensure that ...knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in 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 by not locking sharps/knives inside the kitchen drawer and can be easily accessed by persons in care which pose/poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/01/2025 Plan of Correction On LIC/ADM stated that the magnetic locking mechanism of the drawers will be replaced. On 2/28/2025, LIC/ADM corrected this deficiency and placed a padlock on the drawer.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355(e)(2) - 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: (2) Reqest a transfer of a criminal record clearance specified in section 87355(c) This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview. S1 stated that he/she started working on 2/7/2025 at the facility. ADM stated S1 is new and is currently working in associating S1 to the facility. Per record review in Guardian check, S1 has a cleared criminial record. The licensee did not comply with the section cited by not timely associating S1 to the facility prior to having S1 work at the facility. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/21/2025 Plan of Correction ADM stated that she will submit the LIC 9182, Criminal Record Clearance Transfer Request Form with required supporting documents to the Department by POC due date. ADM will fax the confirmation of this request.

Official classification

Type A

Official code

87405(a)(1)

Regulation authority

CCR

What the official deficiency says

87405 - Administrator Qualification (d) The administrator shall have the qualification as specified in Section 87405(d)(1) through (7). (2) Knowledge of and the ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by. Based on interview, ADM did not exhibit understanding of the applicable laws, rules and regulations by assuming that S1s livescan automatically will be associated with the facility.

Official plan of correction

ADM stated that she will follow up with Guardian until she get the confirmation and will email LPA proof of correction and confirmation that the confusion has been resolved.

Deadline recorded: Jul 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's measurement, the licensee did not comply with the section cited above. Facility kitchen water tempreture was measured at 142 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/03/2024 Plan of Correction ADM stated she will adjust facility water temperature to within acceptable levels and provide proof of correction by POC due date. Facility to maintain water temperature maintenance log for 1 week and provide report to licensing upon completion.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. 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's observed in the front gate of the home, a locked gate. The metal gate has dead bolt lock on both sides, requiring a key to open. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/03/2024 Plan of Correction ADM stated she will remove the dead bolt lock. ADM stated she will send photo documentation the lock has been removed. ADM stated she will send documentation by POC date, 02/03/2024.

Official classification

Type A

Official code

87405(d)

Regulation authority

CCR

What the official deficiency says

(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. 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. ADM did associate S1 who has been working since October 2023. R1's MAR states R1 refused in future dates. ADM stated she locked the front gate to the facility due to residents wandering behaviors. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/03/2024 Plan of Correction ADM stated she will send letter of understanding regarding the regulation. ADM stated she will send letter by POC date 2/3/2024.

Official classification

Type A

Official code

87207

Regulation authority

CCR

What the official deficiency says

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. 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 R1's MAR, the form states R1 refused Medication #1 from Feburary 1st to Feburary 8, 2024. Today is Feburary 2, 2024. ADM stated that was a mistake. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/03/2024 Plan of Correction ADM stated she will send plan of action on how the facility will ensure resident medications are accurate, to ensure false informaton isn't disseminated. ADM stated she will send plan of action by POC date, 02/03/2024.

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 in resident bedroom #2's window sill dead flys and cobwebs. LPA observed a red container with gasoline in the backyard, located in between the garage door and kitchen window. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/09/2024 Plan of Correction ADM stated she will send plan of action on how she will ensure the facility is clean and safe. ADM stated she will send plan of action by POC date, 02/09/2024.

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 observation, the licensee did not comply with the section cited above. LPA observed a spray bottle of Lysol. in bathroom #2's cabinete, below the sink. LPA observed Miracle-Gro plant food and Insect & Fungal disease control spay was observed in the backyard, acessible to residents in care. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/09/2024 Plan of Correction ADM stated she will send plan of action on how the facility will ensure disinfectants, cleaning solutions and other items which could pose a danger to residents are stored in a secure place, inacessible to residents in care. ADM stated she will send plan of action by POC date, 02/09/2024.

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 record review and interview, the licensee did not comply with the section cited above. ADM stated she has not yet updated the staff files for herself or S1. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/09/2024 Plan of Correction ADM stated she will send plan of action on how the facility will ensure that personnel records are maintained on the licensee, administrator and each employee, for the facility. ADM stated she will send plan of action by POC date, 02/09/2024.

Official classification

Type B

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 record review and interview, the licensee did not comply with the section cited above. LPA reviewed S1's name in gaurdian, and S1 is not associated with the facility. ADM stated she has not associated S1 to the facility. ADM stated S1 has been working at the facility since October 2023. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/09/2024 Plan of Correction ADM stated she will associate S1. ADM stated she will send letter of understanding regarding the regulation. ADM stated she will send the letter by POC date, 02/09/2024.

Official classification

Type B

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 observation, the licensee did not comply with the section cited above. While auditing R1's medications, LPA's observed two loose medication tablets sitting in the bottom of the medication plastic container, which holds the medication bottles. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/09/2024 Plan of Correction ADM stated she will send plan of action on how the facility will ensure medications are stored in its orginal container. ADM stated she will send plan of action by POC date, 02/09/2024.

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 interview, the licensee did not comply with the section cited above. ADM stated she has not conducted a drill. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/09/2024 Plan of Correction ADM stated she will conduct a drill and send documentation to LPA that a drill has taken place. ADM stated she will send by POC date, 02/09/2024.