L & S GENTLE CARE

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 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on Licesing Program Analyst observation, the licensee did not comply with the section cited above in that water temperature in faucets used by residents including dementia residents for personal care such as shaving and grooming measured at 139.3 F, 139.2 F, and 137.8 F which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/28/2025 Plan of Correction Facility to submit written plan of water temperature log to ensure compliance by tomorrow Plan of Correction due date of 8/29/2025. Facility to submit water temperature log with 2 weeks of water temperature reading that are within allowable range of 105 to 120 degrees F. Pictures of water temperature to be shown with thermometer and thermometer reading present in picture. Log and pictures to be submitted by Plan of Correction due date on 9/12/2025.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on an observation/review, LPA observed/reviewed photos of a FaceTime still photo that was taken when the resident was getting changed which is an immediate health, safety and personal rights risk to the residents in care

Official plan of correction

Licensee shall submit a an LIC 9098 understanding the regulation. Licensee shall submit a Plan for Future Compliance and how this plan will be implemented. Licensee shall retrain ALL staff that provide Care and Supervision regarding Personal Rights. Plan of Correction due on November 27, 2023.

Deadline recorded: Nov 27, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(1)(d)

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, 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 report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by: LPA learned that the facility was made aware about the incident in early October 2023 and failed to report to the Department of Social Services-Community Care Licensing Division which presents an immediate health, safety and personal rights risk to the residents in care.

Official plan of correction

Licensee shall submit a an LIC 9098 understanding the regulation. Licensee shall submit a Plan for Future Compliance and how this plan will be implemented. Licensee shall retrain ALL staff that provide Care and Supervision regarding Reporting Requirements. Plan of Correction due on November 27, 2023.

Deadline recorded: Nov 22, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and medication record review, the licensee did not comply with the section cited above in 2 out of 6 residents were missing medication that were supposed to be retained in the Medication Closet which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/30/2023 Plan of Correction Plan of Correction shall include following up with the prescribing physician and/or pharmacy to fill the scripts. In additon, facility licensee shall submit a LIC 9098-self certification form and to submit a plan for future compliance.

Official classification

Type A

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(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: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 2 out of 6 residents that are diagnosed with Dementia did not have the required annual medical assessment as outlined in Title 22 reguatlions which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2023 Plan of Correction Plan of Correction shall include submitting a plan for future compliance and also reviewing ALL Medical Assessments to ensure that residents who are diagnosed with Dementia have had a annual medical assessment as outlined in Title 22 regulation. In addition, Licensee shall submit an LIC 9098-Self Certification understanding the regulation.

Official classification

Type A

Official code

87203

Regulation authority

CCR

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 Observation, Licensee did not comply by obstructing two facilty exits. which poses an immediate health, safety or personal rights risk to persons in care.**Immediate Civil Penalty assessed in the amount of $500.

Official plan of correction

Licensee to ensure all exits are free from obstruction and are accessible at all times. Administrator to provide self-certification that they have read and understand regulation by POC due date 6/27/22.

Deadline recorded: Jun 27, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:4) The licensee shall assist residents with self-administered medications as needed This requirement was not met, when facility 1 of 4 residents, when staff did not provide resident medcation as prescribed by their physcian, which poses an immediate health and safety concern.

Official plan of correction

Administrator will provide staff with additional medication training. Administrator will document time, topics and participants in the training by POC due date 07/07/22

Deadline recorded: Jul 7, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(b)

Regulation authority

CCR

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 incidents involving R1, R2 and R3 were reported to Community Care Licensing, which poses a potential health and saftey concern to resident in care.

Official plan of correction

Administrator to submit a written statement that they understand the regulation 87211(a)(1)(B) and provide incident reports that have not been reported to Licensing by POC due date 7/7/22.

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