DIVINE MERCY FAMILY HOME

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, LPA found metal rods placed between the door and the door jam of an emergency exit, preventing the door from opening. This poses an Immediate Safety risk to persons in care. An immediate civil penalty is being issued in the amount of $500.

Official plan of correction

All metal rods were removed. Violation cleared during visit.

Deadline recorded: Apr 21, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(5)(a)

Regulation authority

CCR

What the official deficiency says

87224 Eviction Procedures: (A) The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not provide at least a 60 day written notice to residents or responsible parties regarding the change of ownership of the facility. This poses a potential Health, Safety or Personal Rights risk to persons in care.

Official plan of correction

Licensee sent notices to residents and responsible parties. Cleared during visit.

Deadline recorded: May 8, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions.This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure the exit door alarm was operational and loud enough for staff to be aware of resident leaving. This poses an Immediate Health, Safety or Personal Rights risk to persons in care.

Official plan of correction

Licensee replaced audiable alerts on exit doors. Cleared during visit.

Deadline recorded: Apr 21, 2026. A deadline is not proof that correction was completed.

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 record review, the licensee did not comply with the section cited above in 5 of 6 staff files reviewed. Licensee did not have documentation of completed annual training, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/26/2025 Plan of Correction Licensee agrees to ensure all staff complete the required annual training and documentation of completed training is kept in the staff record. Licensee shall submit a written plan showing how staff will complete annual training and how Licensee will document. Written plan shall be submitted to CCLD by 09/26/2025.

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Medication was prepared in 7 day containers, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/26/2025 Plan of Correction Licensee agrees to prepare resident medication at the time of each assistance with medication. Licensee agrees to submit written plan showing how staff will store and assist residents with medication. Written plan shall be submitted to CCLD by 09/26/2025.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. 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 3 of 5 resident records. Updated appraisals were not completed within the last 12 months, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/26/2025 Plan of Correction Licensee agrees to review resident files and update resident appraisals. Self certification that all appraisals have been updated shall be submitted to CCLD by 09/26/2025.

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 observation, the licensee did not comply with the section cited above. Hot water measured above 120 degrees F at faucets accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/08/2025 Plan of Correction Licensee turned hot water heater down during visit. Licensee shall measure water temperature twice daily for Seven days and submit completed water temperature log to CCL by 08/08/2025.

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 was not met as evidenced by: during to days visit LPA observed a small metal stick that was jammed to the door frame to prevent it from opening. This is an immediate Risk to the health & safety of residents in care.

Official plan of correction

Facility to send in written plan that they understand regulation and how they will ensure staff supervision/alarms is used for resident who may wonder away, instead of blocking an exit door. POC due by 1/25/2025. Civil penalty is being applied for $500.00 for Fire safety violation

Deadline recorded: Jan 25, 2025. A deadline is not proof that correction was completed.