PENNGROVE SHANGRI-LA

Official classification

Type B

Official code

87463(h)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and observation the licensee did not comply with the section cited above in two out of three residents did not have annually updated medical assessment and service plan in file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/03/2026 Plan of Correction Licensee or Administrator to submit to CCL completed and updated medical assessment and service plank for two residents to CCL by POC due date of 8/03/2026.

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 in two out of two resident bathroom faucets measured 131.1 degrees F & 132.4 degrees F 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 to submit a 10 day water temperature log. Log to be started on 08/08/2025 and end on 08/18/2025. Log to include date, location of sink, water temperature, and time of temperature check and submitted to CCL by POC due date of 08/18/2025.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. 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 finding toxins-laundry detergent observed in laundry closet unlocked (see pics) & cleaning supplies observed in unlocked cabinet in garage (see pics), sharps observed in kitchen drawer with broken lock 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 shall provide refresher training for all staff on the requirements of 87309 and will provide proof of completion to CCL as well as Licensee to submit self certification (by 8/8/25) they understand the regulation and fix lock on kitchen drawer containing sharps (fix drawers) . Submit proof of new locks and trainings of staff, POC due date is 8/15/2023 to clear the deficiency.

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 LPA's & LIcensees observation, interview , and record review, the licensee did not comply with the section cited above in spot medication count found five out of five resident medication to not be recorded as required on the Centrally Stored Medication Record which poses/posed a potential health, safety or personal rights risk to persons in care. The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year.

Official plan of correction

POC Due Date: 08/15/2025 Plan of Correction Facility to submit LIC9098 self-certifying all medications for all residents is listed on their respective Centrally Stored Medication logs .

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 LPA & Licensee observation, the licensee did not comply with the section cited above in 5 out of 5 residents medications were pre-poured for the entire day, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2025 Plan of Correction Facility to conduct in-service training for all staff to review regulation 87465(h)(5). Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 8/15/2025.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: 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 4 out of 4 resident files which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/09/2024 Plan of Correction Licensee to submit self certifcation that reappraisals for all residents have been completed by 09/09/2024.

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. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. 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 three out of three railings to be loose and wobbly, bathroom cabinet door to be in poor condition falling off the hinge, and the air vent located on floor found to be rusted and bent which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/09/2024 Plan of Correction Licensee to provide a written plan indicating when noted items will be repaired and how residents in care will be ensured while items are being fixed by POC due date, 9/9/2024.

Official classification

Type B

Official code

1569.69

Regulation authority

HSC

What the official deficiency says

§1569.69 Employees assisting residents with self-administration of medication; training requirements (b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and 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. 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 4 out of 4 staff files reviewed did not have required medication training. Which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/26/2024 Plan of Correction Licensee to provide proof of staff medication training by 09/26/2024.

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 in 4 out of 4 areas (see pics) in the facility had disinfectants/cleaning solutions inaccessible to clients which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/04/2023 Plan of Correction Licensee shall provide refresher training for all staff on the requirements of 87309 and will provide proof of completion to CCL as well as Licensee is designating additional locked cabinets in laundry area and fix lock on cabinet in garage for cleaning solutions to be safely stored. POC due date is 8/04/2023 to clear the deficiency.

Official classification

Type A

Official code

87309(b)

Regulation authority

CCR

What the official deficiency says

(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above. 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 3 bags of medications for disposal were stored in unlocked kitchen cabinet which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/04/2023 Plan of Correction LIcensee to dispose of medication at appropriate location and send proof of receipt to CCL by POC due date of 8/4/2023

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 LPA’s observation of many medication bottles in unlocked kitchen cabinet, medications were accessible to residents in care. This is an immediate Health and Safety risk to residents in care. LIcensee removed medications during visit.

Official plan of correction

POC Due Date: 08/04/2023 Plan of Correction Administrator agrees to submit self-certification that all medications are locked and inaccessible to residents in care. Administrator agrees to submit POC to CCL by 8/4/2023

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705(f)(1)Care of Persons w/Dementia - The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).This requirement is not met as evidenced by This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, knives were found in unlocked kitchen drawer accessible to residents which poses an immediate health, Safety risk to residents in care. LPA toured the facility at 11:01 AM & observed unlocked sharps. (Photos taken)

Official plan of correction

POC Due Date: 08/04/2023 Plan of Correction Administrator to ensure that all sharp objects are stored in a locked storage inaccessible to residents at all times. Administrator to submit an LIC 9098 self certification that all items that can constitute danger to residents have been made inaccessible with a written statement signed by staff that staff understands this regulation to CCL by POC of 8/4/2023.

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

87463(c) Reappraisals- (c)The licensee shall arrange a meeting with the resident, the resident’s representative... when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first... This requirement has not been met as evidenced by: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA/Licensee's file review showing that resident's care plans for 2 out of 2 residents (R1 & R2) were not been performed and signed by the resident of their representative within last 12 months. This is a potential risk to the health and safety of residents in care.

Official plan of correction

POC Due Date: 08/31/2023 Plan of Correction Administrator agreed to review all resident's care plans, update them accordingly and send self-certification that this process had been done to CCL by POC due date.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411(c)(1) PERSONNEL REQUIREMENTS GENERAL; Staff shall receive first aid training from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on staff files review & interview with Licensee, the facility did not ensure that all staff have current 1st aid. LPA learned that 1 of 4 staff (S1) does not have proof of current first aid certification which poses a potential health & safety risk to residents in care.

Official plan of correction

POC Due Date: 08/18/2023 Plan of Correction Licensee to ensure that all staff have current first aid certification at all times. Licensee to submit proof of First Aid Certification for staff S1 to CCL by POC date of 8/18/2023

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 in 2 out of 2 residents w/dementia which poses an immediate health, safety or personal rights risk to persons in care.Facility has 2 residents w/diagnosis of dementia -kitchen draw with sharps wasnt locked,unlocked toxins under bathroom sink & kitchen cabinet under the sink wasn't locked, unlocked ODC meds in staff room and toxins in garage.

Official plan of correction

POC Due Date: 06/03/2022 Plan of Correction Facility to ensure that all medications, toxins, and sharps are locked and inaccessible to residents at all times. Facility licensee agrees to submit a selfcertification to the Department that all toxins, medications, sharps, and other items that might be of danger to residents in care has been properly lock by POC due date of 6/3/2022 in order to clear citation and avoid CPs.

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 4 residents' reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.LPA learned that Resident R1 most resent reappraisal dated 9/28/2020 and Resident R3 reappraisal dated 11/2/2020.

Official plan of correction

POC Due Date: 06/16/2022 Plan of Correction Facility to ensure that reappraisals are conducted at least every 12 months and/or any time there is a change of condition. Facility to provide Department with a copy of update reappraissal for residents R1 & R3 signed by resident and/or responsible party by POC due date of 6/16/2022 in order to clear citation and avoid civil penalties. (CP)

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355(e)(1) Criminal Record:All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility:Obtain a California clearance or a criminal record exemption ... This requirement is not met as evidenced by:Based on obs. & file review,the licensee didnot comply w/section cited above in 1 out of 2 staff fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.LPA interviewed Adm & learned that staff S1started working on 11/20/21,however has no fingerprint clearance > (CP)

Official plan of correction

Facility to ensure that all staff is fingerprint cleared and associated to the facility before working in a licensed facility. Facility to submit a self certification to the Department as proof that staff S1 who is not fingerprint cleared will not be working, voluntering, and/or residing at the facility until fingerprint cleared by POC date of 2/4/2022.

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

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

Fire Clearance:All facilities shall maintain a fire clearance approved by the city,county, or city & county fire department, or district providing fire protection services... This requirement is not met as evidenced by: Based on observation & interview licensee didn't comply with this section above in 1 of 1 facility fire clearance on file which poses an immediate risk to health & safety of residents in care. Facility has a staff sleeping rest area room that was build in the garage. (see pic, CP)

Official plan of correction

Licensee to breakdown the staff sleeping area in the garage and immediately stop having staff sleep in the garage. Licensee to submit photos of the garage space cleared of the staff sleeping area/items as described in the report.Licensee also toensure that staff won't be sleeping in facility common areas and/or submit updated sketch for fire clearance & maintain no staff until clearance granted. Submit POC no later than 9/10/2021.

Deadline recorded: Sep 10, 2021. A deadline is not proof that correction was completed.