LE ELEN MANOR, INC.IV

Official classification

Type A

Official code

1569.269(a)(1)

Regulation authority

HSC

What the official deficiency says

Type A - §1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement has not been met as evidence by: Based on interviews with residents and staff, the facility Licensee yells at residents resulting in residents are avoiding making eye contact to prevent Licensee from raising their voice at them, which poses an immediate risk to the health and safety of clients in care.

Official plan of correction

Licensee to ensure all residents are always treated with dignity and respect. Licensee agrees to sign LIC9098 attesting understanding of Health and Safety Code 1569.269, Enumerated Rights by POC due date of 6/12/2025.

Deadline recorded: Jun 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(11)

Regulation authority

CCR

What the official deficiency says

Type B -87468.1 Personal Rights of Residents in All Facilities (a) Residents in all RCFE shall have all of the following personal rights: 11) To have their visitors, including…advocacy representatives, permitted to visit privately during reasonable hours & without prior notice, provided that the rights of other residents are not infringed upon…This requirement has not been met as evidence by: Based on records review and interviews conducted with the Licensee. The Licensee did not ensure the compliance of above regulation due to issuing an addendum to visitation policy to C1 only to discourage C1’s visitors from visiting regularly, which it could be a potential personal rights risk to the residents in care.

Official plan of correction

Licensee will ensure that residents rights are maintained. Licensee will submit a self-certification (LIC9098) that all staff had been notified about regulation by POC due date of 6/20/2025.

Deadline recorded: Jun 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269(a)(1)

Regulation authority

HSC

What the official deficiency says

§1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement has not been met as evidence by: Based on interviews with residents and staff, the facility staff (S1 & S2) yells at residents in average of two to three times per day and Licensee admitted their presence into the resident’s psychiatrist appointments, which poses an immediate risk to the health and safety of clients in care.

Official plan of correction

Licensee agrees to review regulation 1569.269 (a)(1) with staff and submit self-certification that it has been completed, and personal rights of residents outlined by regulation will never be violated by POC due date.

Deadline recorded: Feb 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269(a)(10)

Regulation authority

HSC

What the official deficiency says

§1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (10) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement has not been met as evidence by: Based on interviews with residents and staff, the Licensee have commented of the smell of the residents, which poses an immediate risk to the health and safety of clients in care.

Official plan of correction

Licensee agrees to review regulation 1569.269 (a)(1) with staff, conduct a training with staff, submit self-certification that it has been completed, and personal rights of residents outlined by regulation will never be violated by POC due date.

Deadline recorded: Feb 20, 2025. 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 LPA's observation, records review, and interview with licensee. The licensee did not comply with the section cited above in 2 out of 2 persons which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/07/2024 Plan of Correction The facility will ensure staff are receiving required initial and annual training and how hours will be tracked. Administrator agrees to submit LIC9098 form ensuring compliance with regulation to CCL by POC due date of 6/7/24.

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 LPA's/Administrator observation, interview and records review, the licensee did not comply with the section cited above in five out of six residents (R1, R2, R3, R4 and R5) needs their care plan to be updated, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/07/2024 Plan of Correction Administrator to update and complete resident's Needs & Services Plan, with appropriate signatures of Licensee and Resident or resident's responsible party. Facility to submit LIC9098 form ensuring compliance with regulation to CCL by POC due date of 6/7/24.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's/Administrator observation and records review, the licensee did not comply with the section cited above by not conducting a drill within the last quarter which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/07/2024 Plan of Correction Administrator to conduct a disaster drill and will submit a self-certification form ensuring that drill had been conducted within the last quarter to CCL by POC due date of 6/7/24.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

(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 is not met as evidenced by: Deficient Practice Statement Based on LPA observation, interview and record review Licensee did not ensure S1 was wearing a mask. Also, staff and residents daily temperatures documented as reflected in facility's mitigation plan and current CCL requirements. This poses an immediate risk to the health, safety and personal rights to the residents in care.

Official plan of correction

POC Due Date: 04/15/2022 Plan of Correction Licensee will ensure Personal Rights of residents are maintained. Licensee agrees to submit proof of training for mask requirement for all staff to LPA by close of business 4/15/2022.