BELMONT VILLAGE SUNNYVALE

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

POSTURAL SUPPORTS A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. This requirement is not met, as MD orders are not maintained for half bed rails for clients #1, #2, #5, #7, and residents in rooms #408, #342, #223, #203, #207, #125, #102. Licensee failed to ensure that MD orders are maintained for residents who use half bed rails, which poses a potential health, safety or personal rights risk to clients in care.

Official plan of correction

Written MD orders for half bed rails for referenced clients shall be obtained and copies shall be sent to CCLD BY DUE DATE

Deadline recorded: Apr 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(13)

Regulation authority

CCR

What the official deficiency says

PERSONAL RIGHTS Residents in all residential care facilities for the elderly shall have ... the following personal rights... To have access to individual storage space for private use. This requirement is not met, as closets and/or storage spaces of residents #12 and #13--in rooms 203 and 207 respectively--are locked and not accessible to residents as requested by clients' powers of attorney. Licensee failed to ensure that residents have access to their individual storage spaces, which poses a potential health, safety or personal rights violation.

Official plan of correction

Plan/proof of correction to be sent to CCLD BY DUE DATE, which may include exception requests with supportive documentation.

Deadline recorded: Apr 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

INCIDENTAL MEDICAL CARE 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 client #8 is not able to self store/admin medications, per MD, but Ibuprophen (2), Tylenol and Tumms are stored in bathroom. Licensee failed to ensure that medications are inaccessible to clients who cannot self store/admin meds, which poses an immediate health or safety risk to clients in care.

Official plan of correction

Ibuprofen, Tylenol and Tumms were removed from client's bathroom in LPA's presence Deficiency corrected and cleared

Deadline recorded: Apr 6, 2026. A deadline is not proof that correction was completed.

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 report incidents and death reports to the Department within 7 days of the occurrence which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee will work out a plan to ensure incidents are submitted within reporting requirements. Licensee will submit a statement of understanding of the section cited, to LPA Dolores via email by POC due date.

Deadline recorded: Aug 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision ... means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living ... taking medications, money management, or personal care. This requirement was not met as evidenced by:Based on the interviews and record reviewed, the facility did not provide care and supervision for R1. R1 had a change of condition and was not reported, and the facility did not take action on R1's change of condition, which led to R1's hospitalization.

Official plan of correction

Administrator stated to submit a plan of correction by the POC due date to provide the staff training of responsibility for providing care and supervision to residents and reporting resident's change in condition, and submit the training log to CCL office.

Deadline recorded: Jul 4, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility... shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on the interviews and records reviewed, the facility did not assist or arrange medical care appropriately to the resident condition and needs when R1 had a change of condition, this poses/posed a immediate health and safety risk to persons in care.

Official plan of correction

Administrator stated to submit a plan of correction by the POC due date and provide the staff training of arranging or assisting to arrange medical care for residents if residents have change in condition, and submit the training log to CCL office.

Deadline recorded: Jul 4, 2024. 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 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 5 out of 11 counts wherein 5 residents PRN medications were not properly documented 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: 05/03/2024 Plan of Correction Licensee will submit a statement of understanding of the section cited above and the 5 residents centrally stored medication records to LPA Dolores via email POC due date.

Official classification

Type B

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. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 1 out of 6 counts wherein LPA was unable to review a staff member's health screeing and TB result which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/03/2024 Plan of Correction Licensee will submit a statement of understanding of the section cited above and the staff member's health screening report to LPA Dolores via email by POC due date.

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 observation, interview, and record review the licensee did not comply with the section cited above in 2 out of 6 counts wherein LPA did not observed 2 staff members file contained at least 20 hours of annual training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/03/2024 Plan of Correction Licensee will submit a statement of understanding of the section cited above and a written plan to ensure staff will be up to date with training to LPA Dolores via email by POC due date.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. ... and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This was not met as evidenced by: Based in interviews & record reviews, no calls were made to 911 to send R1 to emergency room for further assessment when R1 fell during outing which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee to submit a plan to ensure compliance to provide Incidental and Medical care to residents. Licensee to submit by POC due date

Deadline recorded: Mar 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (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: During record review, 5 out of 6 residents with dementia whose records were reviewed did not have a physician's report that was updated annually, which poses a potential safety risk to residents in care. Deficient Practice Statement During record review, 5 out of 6 residents with dementia whose records were reviewed did not have a physician's report that was updated annually, which poses a potential safety risk to residents in care.

Official plan of correction

POC Due Date: 05/02/2023 Plan of Correction Licensee agrees to review all physician's reports for residents with dementia and schedule appointments to update their physician's reports as needed by POC date. Licensee agrees to submit updated copied of R2-R6's physician's reports once they are updated to CCL.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (c) 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 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on review of staff records, 2 out of 5 reviewed staff did not have current First Aid Certifications, which poses a potential safety risk to residents in care. Deficient Practice Statement Based on review of staff records, 2 out of 5 reviewed staff did not have current First Aid Certifications, which poses a potential safety risk to residents in care.

Official plan of correction

POC Due Date: 05/02/2023 Plan of Correction Licensee agrees to update S1 and S2's first aid certifications and submit copies of the updated certifications to CCL by POC date. Licensee also agrees to audit all staff first aid certifications to ensure that all staff have updated first aid certifications. Licensee agrees to submit a Proof of Correction Statement by POC date.

Official classification

Type A

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 was not met as evidence by: Based on document review and investigation, there was no evidence that the facility reassessed R1 after the fall. R1’s Reappraisal was not updated for the facility to develop the care plan to meet resident’s needs. This poses an immediate risk to the health of the resident.

Official plan of correction

Licensee agrees to conduct staff training in ensuring care and supervision are provided to residents whose conditions have changed due to medical assessment or observations with updated care plans and submit the training plan to CCL by POC date.

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

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(a) (4) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all the following personal rights: 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. Facility did not discuss plan of care instruction with staff to ensure R1 receive the care and supervision as a result R1 had 3rd fall sustained a right hip fracture. This poses an immediate risk to the health of the resident.This requirement was not met as evidence by: Based on investigation record review and interview, the facility did not update the care plan for R1 to ensure that resident received care, supervision and services that meet resident’s needs.

Official plan of correction

Licensee agrees to submit plan in writing on care and supervision of residents such as but not limited to falls to CCL by POC date.

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