LUVINHOME,LLC

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 interview and record review, the licensee did not comply with the section cited above in two (2) out of three (3) persons which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/02/2025 Plan of Correction Licensee to provide written copy of most recent " good health " report for S2 as well as, provide copy of completed health physical LIC503 for S1. In addition, licensee to submit letter to Community Care Licensing that the licensee and staff have read CCR 87411(f) and understand the requirement to keep a record of staff health screening on site at all times.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. 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 one (1) out of four (4) persons which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/02/2025 Plan of Correction Licensee submit to letter to Community Care Licensing (CCL) by 10/02/2025 that they have read CCR regulation 87458(c)(1)(A) and provide proof to CCL of evidence of TB testing and negative TB test for R1 by 10/02/2025

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 for... those specified below... shall not be admitted or retained in a residential care facility for the elderly:(1) Stage 3 and 4 pressure injuries. This requirement is not met as evidence by: Based on interviews and record review, administrator did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will submit to Community Care Licensing (CCL) a letter of understanding that they have read and understand Regulations 87615 (Prohibited Health Conditions) and 87616 (Exceptions for Health Conditions) by POC Due Date of 05/08/2025.

Deadline recorded: May 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87645(a)(2)

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...(2) The licensee shall provide assistance in meeting necessary medical and dental needs...This requirement is not met as evidence by: Based on interviews and record review, administrator did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will submit to Community Care Licensing (CCL) a letter of understanding that they have read and understand Regulations 87645 (Incidental Medical and Dental Care) by POC Due Date of 05/08/2025

Deadline recorded: May 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

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, record review, the licensee did not comply with the section cited above in 3 out of 3 staff files reviewed and found missing proof of negative TB results which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/18/2024 Plan of Correction Licensee shall submit proof of negative TB results or proof that an appointment for TB testing has been scheduled for all three staff members (including Licensee) to CCL by POC due date 10/18/2024.

Official classification

Type B

Official code

87467(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to, or within two weeks of the resident's admission, 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, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. 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 3 out of 3 resident files found missing a care plan which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/22/2024 Plan of Correction Licensee shall complete appraisal and needs services plans for R1, R2, and R3, have them signed by each resident or their responsible party and submit them to CCL by POC due date 11/22/2024.

Official classification

Type B

Official code

87616(b)

Regulation authority

CCR

What the official deficiency says

(b) Written requests shall include, but are not limited to, the following: 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 residents observed to have a peg tube feeding without Licensee having applied for an exception fro CCL, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/25/2024 Plan of Correction Licensee shall submit a written request along with the supporting documentation (physician's report, appraisal and needs service plan, statement of how facility will meet the resident's needs and the medical professional who will be caring for the peg tube, as well as statement that staff have been trained for emergency situations, and resident agreement) for an exception regarding R1's peg-tube to CCL by POC due date 10/25/2024.

Official classification

Type B

Official code

87465(h)(a)

Regulation authority

CCR

What the official deficiency says

87465(h)(a) 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 […] includes: (A)The name of the resident for whom prescribed.(B)The name of the prescribing physician.(C)The drug name, strength and quantity.(D)The date filled.(E)The prescription number and the name of the issuing pharmacy.[….] 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 3 out of 3 resident medication records inspected which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/15/2024 Plan of Correction Licensee shall submit new centrally stored and destruction logs for all three residents in care to CCL by POC due date 11/15/2024.

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(observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 2 staff training records reviewed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/22/2024 Plan of Correction Licensee shall submit proof of completion of all required initial training hours for both staff S1 and S2 to CCL by POC due date 11/22/2024.

Official classification

Type B

Official code

1569.625(a)

Regulation authority

HSC

What the official deficiency says

Employees assisting residents with self-administration of medication; training requirements: 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 observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 2 staff medication training records reviewed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/22/2024 Plan of Correction Licensee shall submit proof of completion of all required initial staff medication administration training hours to CCL by POC due date 11/22/2024.

Official classification

Type B

Official code

87555(b)

Regulation authority

CCR

What the official deficiency says

The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. 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 5 instances of expired food found which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/01/2024 Plan of Correction Licensee shall submit a self certification that all food in the facility has been inspected and will ensure that no expired food will be in the facility moving forward to CCL by POC due date 11/01/2022.

Official classification

Type A

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 by having a lose chain on the cabinet door making chemicals accessible, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 10/11/2023 Plan of Correction Administrator tightened chain which made disinfectants, chemicals, cleaning solutions in-accable to residents in care. Deficiency cleared during visit.

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

87465(h)(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. Medications shall not be set-up more than 24 hours in advance (one-day only). 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 setting medications up for more than 24 hours for 4 of 4 residents which poses an immediate health & safety risk to residents in care. LPA observed containers for 4 residents in a container in the kitchen in a cubby of the cabinet. 7 days of medication is pre-poured at a time, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 10/16/2023 Plan of Correction Licensee to ensure that medication will not be set-up more than 24 hours in advance. Licensee will submit a written verification that staff and licensee understand medication can never be pre-poured under any circumstance for more than 24 hours in advance signed by all staff. In addition, Licensee to conduct in-service training for all staff and to submit a sign in sheet of attendee's to be submitted to CCL no later then 10/16/2023.

Official classification

Type B

Official code

87412(a)(f)

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 (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 observation record review, the licensee did not comply with the section cited above by not having staff and a resident file not located at the facility and not available to the LPA during normal business hours, which posed a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2023 Plan of Correction Administrator will read and understand regulation and submit self certification to CCL no later then POC date.

Official classification

Type B

Official code

87705(k)(3)

Regulation authority

CCR

What the official deficiency says

87705(k)(3) Care of Persons with Dementia-Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. This requirement is not met as evidenced by: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview of licensee the facility failed to conduct fire and earthquake drills in the facility at least once every three months which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 10/14/2023 Plan of Correction Administrator will conduct a fire and earthquake drill no later then the POC date and provide proof to CCL on 10/16/2023

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

87625 Managed Incontinence - (b)...the licensee shall be responsible for the following: (3) Ensuring ...that the facility remains free of odors from incontinence. This requirement was not met as evidenced by: Based on observations and statements received from NBRC, Administrator did not ensure the regulation above due to Resident (R1)'s bedroom having a strong foul odor of urine. This is a potential personal rights and health risk to residents in care.

Official plan of correction

Administrator to train all staff submit copies of staff training on regulation 87626(b)(3). Training to include the date, time, duration, subject, instructor, staff's name and signature. Training to be submitted to Community Care Licensing (CCL) by POC due date 11/04/2022

Deadline recorded: Nov 4, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(5)(A)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports: (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement was not met as evidenced by: Based on observations, statement and review of facility documents, Administrator did not ensure the regulation above due to Resident (R1, R2, R3) having half bed-rails without a doctor's order for assistance with mobility. R3 has a lapbelt in wheelchair. This is a potential personal rights, safety, and health risk to residents in care.

Official plan of correction

Administrator to remove half bed-rails from all resident's beds and submit pictures to LPA as proof of correction by 10/24/22. Administrator to obtain doctor's orders for half bed rails (for assistance with mobility) as required to have half bed-rails in place. Doctor's orders to be submitted to CCL by 11/04/2022 Additionally, Administrator shall request an exception for the lap belt for R3's wheelchair & include supporting documentation (Doctor's order, LIC602, pre-appraisal, and any other supporting documentation such as discharge paperwork). submit exception by 10/24/2022

Deadline recorded: Oct 21, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services: (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident...such as...bathing...This requirement was not met as evidenced by: Based on interviews conducted, Administrator did not ensure the regulation above due to disclosing they were holding off on showers for resident during isolation. This is a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator to submit their plan in writing of how they will ensure residents receive personal assitance and care as needed at all times. Written plan to be submitted to Community Care Licensing by 09/19/2022

Deadline recorded: Sep 19, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met as evidenced by: Based on interviews conducted, Administrator did not ensure the regulation above due to corroborating statements and witnesses of bathroom observed with dired feces on the toilet seat. This is a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator to submit their plan of ensuring the regulation 87303(a). Facility to submit a cleaning log for the facility, including the bathroom for 1 week to Community Care Licensing by POC due date 09/19/2022

Deadline recorded: Sep 19, 2022. A deadline is not proof that correction was completed.

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 as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidenced by: Based on records reviewed and interviews conducted, Administrator did not ensure the regulation above as staff are missing or have not received required training. This is a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator to have all staff receive required training and document for CCL review. Training to include the date, time, duration, subject, instructor, staff name and signature. Trainings to be submitted to Community Care Licensing (CCL) by POC due date 09/23/2022*

Deadline recorded: Sep 23, 2022. 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

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require: (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)... This requirement was not met as evidenced by: Based on records reviewed and interviews conducted, Administrator did not ensure the regulation above due to submitting on 06/30/2022. This is a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator to submit a statement they understand the regulation and will be in future compliance. Administrator to submit statement of future compliance to CCL by POC due date 09/02/2022.

Deadline recorded: Sep 2, 2022. 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 is not met as evidenced by: Based on LPA's observation and interviews, Licensees did not ensure the regulation above by locking the 2 of 2 perimeter gates with dead-bolt locks. This is an immediate health, safety and personal rights risk to residents in care. **Immediate Civil Penalty assessed in the amount of $500.

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