L & S GENTLE CARE II

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (a) The licensee shall ensure that a...complete... record is maintained for each resident in the facility...readily.. for.. licensing staff. This requirement is not met as evidence by: Based on observation, record review and interview, the licensee did not comply in four(4) out of five (5) resident records missing signed personal rights and/or consent for emergency medical treatment which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

Licensee to submit evidence of signed personal rights and consent for emergency medical treatment for R1, R2, R3, and R4 by themselves or their responsible parties when appropriate, as well as certify that all staff have review regulation 87505(a) by 10/03/2025

Deadline recorded: Oct 3, 2025. 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

(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, interview and record review the licensee did not comply with the section cited above in three (3) out of four (4) residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/10/2025 Plan of Correction Licensee immediately removed prescription and non-prescriptiion/PRN medicines not allowed per MD LIC602 reports and Licensee agrees to review regulation 87465(h)(2) before 07/10/2025 and will provide the names and times all the staff at L & S Gentle Care II will have review/training on regulation 87465(h)(2)

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

569.625(b)(2)…[T]raining requirements shall...include an additional 20 hours annually…. This requirement is not met as evidenced by; Based on observation and record review, the licensee did not comply with the section cited above in ensuring that S1 has proof of required annual training which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee agrees to submit proof of S1's annual training to CCL by POC due date of 4/28/2025. Additionally licensee agrees to self certify that they will ensure they have proof of all annual training hours for all staff moving forward to CCL by POC due date of 4/28/2025.

Deadline recorded: Apr 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.69(b)

Regulation authority

HSC

What the official deficiency says

1569.69(b) Each employee...who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. Based on observation and record review, the licensee did not comply with the section cited above in ensuring that S1 has proof of required annual medication training which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee agrees to submit proof of S1's annual medication training to CCL by POC due date of 4/28/2025. Additionally licensee agrees to self certify that they will ensure they have proof of all annual medication training hours for all staff moving forward to CCL by POC due date of 4/28/2025.

Deadline recorded: Apr 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. 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 3 resident files reviewed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/18/2024 Plan of Correction Licensee to submit LIC9098 self-certifying training for staff on the proper documentation and administration of medications completed to CCLD by POC due date 7/18/2024.

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. 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 3 resident records reviewed which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/17/2024 Plan of Correction Licensee shall submit proof of completed and signed Individual Service Plan for R1 and R2 to CCLD by POC due date 8/17/2024.

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 observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 records reviewed which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/17/2024 Plan of Correction Licensee shall submit proof of completion of quarterly emergency disaster drill signed by all staff to CCLD by POC the required due date 8/17/2024.

Official classification

Type B

Official code

871411(c)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: 87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual 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 5 staff files reviewed which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/17/2024 Plan of Correction Licensee shall submit proof of completion of all required annual and annual medication training for S1 and S2 to CCLD by POC due date 8/17/2024.

Official classification

Type B

Official code

87411(c)

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... This requirement is not met as evidenced by: Based on LPA and Admin observation staff memeber S1 did not have their annual training current or completed.

Official plan of correction

Facility to submit LIC9098 self-certifying that S1 has compelted the annual training as required. Facility to submit training log or print out with LIC9098 by POC due date.

Deadline recorded: Apr 12, 2024. 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: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement is not met as evidenced by: Based on LPA observation medication closet housing centrally stored medications was left unlocked, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Admin to administer staff training to ensure that staff know how to properly store centrally stored medication per regulation 87465(h)(2). Admin to submit LIC9098 self-certifying training completed. Admin to submit LIC9098 by Plan of correction due date of January 22, 2024.

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

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87305 Alterations to Existing Building or New Facilities - (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidenced by: Based on observation and statements received, Licensee did not comply with the above regulation in that staff are occupying a constructed bedroom in the garage which does not have a permit. This is a potential health and safety risk to residents in care.

Official plan of correction

... a statement that they understand the regulation and staff will not occupy or sleep in the garage or any common areas (shed, couch, etc). Facility will operate with an awake staff. Licensee to submit plan of correction by 07/13/2023 to Community Care Licensing

Deadline recorded: Jul 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by: Based on observation and statements received, Licensee did not comply with the above regulation in that 2 of 2 fire extinguisher was charged but last serviced 03/15/2022. Fire exits were blocked in Room 2, 3, and 5. This is an immediate health and safety risk to residents in care.

Official plan of correction

POC due by 07/13/2023 to Community Care Licensing. An Immediate Civil Penalty of $500

Deadline recorded: Jul 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical…(5)…Assistance with self-administered medications...(D)...does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section above due to R2 being given their medication crushed up, but does not have a crush order from the doctor (licensee stated R1 spits the pill out) which is an immediate health, safety or personal rights risk to persons in care

Official plan of correction

Administrator to have all staff trained on regulation 87465 and submit medication training documentation (with date, time, duration, subject, attendee's names and signatures) to Community Care Licensing (CCL) by 07/13/2022 attention LPA Karina Canela

Deadline recorded: Jun 29, 2022. 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

87211 Reporting Requirements: (a) Each licensee shall furnish...:(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...(B) Any serious injury...occurring while the resident is under facility supervision. This requirement was not met as evidenced by: Based on record review and interviews conducted: Administrator did not ensure ensure the section above due to not notifying CCL of R1's hospital visit and Restricted health condition (oxygen administraton) as required. This is a potential health, safety and personal rights risk to the residents in care.

Official plan of correction

***A civil penalty was assessed today in the amount of $250 for a repeat violation

Deadline recorded: Jul 13, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

87615 Prohibited Health Conditions: (a) Persons who require health services... specified below shall not be admitted or retained in a residential care facility for the elderly: (1)Stage 3...pressure injuries. This requirement was not met as evidenced by: Based on record review and interviews conducted: Administrator did not ensure the above regulation due to Resident (R1) sustaining a stage 3 pressure injury while in care and Admin did not request or was approved for an exception from CCL to retain R1 with a prohibited condition. This is a potential health, safety and personal rights risk to the residents in care.

Official plan of correction

Administrator to submit a written statement that they understand the regulation 87615(a)(1) and shall be in future compliance. Administrator to submit statement as the Plan of Correction (POC) by due date 06/03/2022 to Community Care Licensing attention LPA Karina Canela to clear the citation

Deadline recorded: Jun 3, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(a)

Regulation authority

CCR

What the official deficiency says

87224 Eviction Procedures: (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required... This requirement was not met as evidenced by: Based on record review and interviews conducted: Administrator did not ensure the above regulation due to issuing a verbal eviction notice to R1's representative and not following proper eviction procedures. This is a potential personal rights risk to the residents in care.

Official plan of correction

Administrator to to review the regulation and submit a written statement that they understand the regulation 87224(a) and shall be in future compliance. Administrator to submit statement as the Plan of Correction (POC) by due date 06/08/2022 to Community Care Licensing attention LPA Karina Canela to clear the citation

Deadline recorded: Jun 8, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(11)

Regulation authority

HSC

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities: (a) Residents... shall have all of the following personal rights:(11) To have their visitors...permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidenced by: Based on record review and interviews conducted: Licensee did not ensure the above regulation due to changing visitation hours to discourage R1's representative from visiting regularly. This is a potential personal rights risk to the residents in care.

Official plan of correction

Administrator to submit a written statement that they understand the regulation 87468.1(a)(11) and shall be in future compliance to allow all resident's visitors to visit during reasonable hours and without prior notice. Administrator to submit statement as the Plan of Correction (POC) by due date 06/08/2022 to Community Care Licensing attention LPA Karina Canela to clear the citation

Deadline recorded: Jun 8, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(1)

Regulation authority

CCR

What the official deficiency says

87202 Fire Clearance:(a) All facilities shall ...Prior to accepting or retaining any of the following types of persons...obtain an appropriate fire clearance approved by the city...fire department...(1) Nonambulatory persons. This requirement was not met as evidenced by: Based on observation, interviews, and record review - Administrator did not ensure the regulation above due to having 4 non-ambulatory residents (R1-R4) in bedrooms that are not approved for non-ambulatory residents. This is an immediate health & safety risk to residents in care.

Official plan of correction

Administrator to submit a statement that they understand the regulation and shall be in future compliance. Administrator to request a fire clearance inspection for non-ambulatory and/or bedridden from CCL and submit the required documents by POC due date 05/24/2022 to CCL *** An immediate Civil Penalty in the amount of $500 was assessed.

Deadline recorded: May 24, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance - (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by: Based on record review, observation, and interviews conducted: Administrator did not associate individual (I1) prior to working, residing or being present in the facility. This is a potential safety and personal rights risk to the residents in care.

Official plan of correction

Administrator to associate I1 as required. Administrator to submit a written statement they understand the requirement and will be in future compliance with the regulation by POC due date 05/24/2022 to Community Care Licensing **Civil Penalties assessed in the amount of $500.00 for non-associated individual working and $250 for repeated violation

Deadline recorded: May 24, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87208(c)

Regulation authority

CCR

What the official deficiency says

87208 Plan of Operation: (c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). This requirement was not met as evidenced by: Based on record review, observation, and interviews conducted: Administrator did not ensure the regulation above due to not having an approved dementia program care plan prior to accepting and retaining residents with a diagnosis of dementia. This is a potential safety and personal rights risk to the residents in care.

Official plan of correction

Administrator to submit a statement that they understand the regulation, will be in compliance, and not accept any additonal residents with diagnosis of dementia. Administrator to submit their a copy of their dementia program plan for their facility file. POC due date 05/27/2022 by close of business, 5 PM.

Deadline recorded: May 30, 2022. 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

87309 Storage Space - (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 was not met as evidenced by: Based on observation and interviews, Licensee did not ensure cleaners and disinfectants were stored locked and inaccessible to residents. This is an immediate health & safety risk to the residents in care.

Official plan of correction

Licensee locked cleaners and disinfectants during inspection. Licensee to submit a statement that they understand the requirement and will be in future compliance with the regulation by POC due date 03/08/2022 to Community Care Licensing

Deadline recorded: Mar 2, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance - (e)All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by: Based on record review, observation, and interviews conducted: Licensee did not obtain a criminal record clearance for individual (I1) prior to working at the facility. This is a potential safety risk to the residents in care.

Official plan of correction

Licensee associated I1 during inspection. Licensee to submit a written statement they understand the requirement and will be in future compliance with the regulation by POC due date 03/08/2022 to Community Care Licensing **Civil Penalty assessed in the amount of $100.00

Deadline recorded: Mar 8, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(1)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports - (a) ... the facility shall provide assistance and care for the resident...(1) Postural supports shall be limited to appliances or devices...used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position... This requirement was not met as evidenced by: based on observation, interviews, and record review, licensee did not ensure the regulation above with resident (R1) observed with a lap belt on wheelchair. This is a potential health, saftey and personal rights risk to residents in care.

Official plan of correction

Licensee to request an exception for postural support - lap belt for wheel chair and include supporting documentation. Licensee to submit exception request with supporting documentation to CCL to clear the citation by POC due date 03/08/2022

Deadline recorded: Mar 8, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports -(a)...the facility shall provide assistance and care for the resident...(5) ...(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 was not met as evidenced by: based on observation, interviews, and record review, licensee did not ensure the regulation above with resident (R2) observed with full bed rails. This is a potential health, saftey and personal rights risk to residents in care.

Official plan of correction

Licensee to request an exception for postural support - full bed rails and include supporting documentation or remove the full bedrails. IF half bedrails are used, Licensee shall obtain a perscription from the resident's doctor. Licensee to submit copies of perscriptions for R3 - R6. Licensee to submit an exception request, physician perscription, and supporting documents to CCL to clear the citation by POC due date 03/08/2022

Deadline recorded: Mar 8, 2022. A deadline is not proof that correction was completed.