LOVING HEARTS CARE HOME 111

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. [....] Based on record review, self-incident report, and interviews conducted with R1, caregivers, and Licensee/Administrator, R1 eloped without staff knowledge. The facility did not comply w/section above to address behaviors such as wondering for R1 which poses an immediate Health, Safety risk to residents in care.

Official plan of correction

Licensee/Administrator to submit and updated Appraisal/Needs and Service Plan (LIC625) for R1 to include increased supervision by POC due date 6/3/2024. Licensee/Administrator to provide an updated activity schedule with some activities specific to R1’s needs and proof that these activities are occurring as scheduled; proof of elopement training for staff; and submit LIC9098 that the staff understand the regulation by POC due date 6/13/2024.

Deadline recorded: May 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. 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 in 5 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: 06/12/2024 Plan of Correction Licensee to submit proof of completion of the required training for all staff to CCL by the POC due date 6/12/2024.

Official classification

Type B

Official code

87465(d)(2)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. 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 in 3 out of 5 medications spot checked which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/12/2024 Plan of Correction Licensee to submit aelf-certification including signatures of each employee certifying their understanding of correct maintentance of centrally stored medication logs to CCL by the POC due date 6/12/2024.

Official classification

Type B

Official code

1569.69(a)(2)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. 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 in 5 out of 5 staff records reviewed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/12/2024 Plan of Correction Licensee to submit proof of completion of the required medication training for all staff to CCL by the POC due date 6/12/2024.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 2 out of 2 exits which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/14/2024 Plan of Correction Licensee corrected the deficiency with LPA present. All auditory signals are now operable and properly functioning.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309(a) STORAGE SPACE - 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 evidence by: unlocked chemicals accessible to residents. In addition, LPA found a knife and a pair of scissors located in an unlocked kitchen drawer. Unlocked cleaning supplies in bathroom, laundry room and under kitchen sink. Wheelbarrow with tools in backyard all accessible to residents in care. This poses as an immediate health and safety risk to residents in care.

Official plan of correction

Administrator failed to ensure chemicals and sharps were kept secured and inaccessible to residents in care. Administrator agrees to read and understand the regulation and create a safety checklist for staff to complete and signage posted in the facility to ensure future compliance. Copy of safety checklist and photos of signage submitted to CCL by POC due date 10/26/2023.

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

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e)Water supplies and plumbing fixtures shall be maintained as follows: (2)Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). Based on observation the licensee failed to have hot water temperature between 105 & 120 F in 2 resident's bathrooms which poses an immediate Health, Safety risk for residents in care. LPA observed that hot water temperatures were 134.7.degrees F and 132.4 degrees F.

Official plan of correction

Administrator to ensure water temperature is maintained within regulation - 105 TO 120 F. Licensee to submit a LIC 9098 seff certification that hot water temperature is within regulation by POC date of 10/25/2023 & begin monitoring for the next 7 days. Licensee to submit a 7 day log taken from the resident's bathrooms to CCL by 10/31/2023.

Deadline recorded: Oct 25, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355(e)(2) Criminal Record Clearance. Prior to working, residing or volunteering...all individuals subject to a criminal record review shall request a transfer of a criminal record clearance from another facility or Trustline. This requirement is not met as evidenced by: Based on LPA record review the faciltiy failed to ensure S1 have a finger print clearance before working in the faciltiy which poses an immediate health and safety risk to clients in care.

Official plan of correction

Administrator agrees to submit plan to ensure all individual are finger print cleared before working in the facility, submit to CCL by POC 10/26/2023. Administrator agrees to ensure S1 finger prints are cleared before returning to work in facility. ***Civil Penalty in the amount of $100 was assessed due to facility failing to obtain finger print clearance for S1.

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