VILLA CAPRI

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities- In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Per review of records, interviews with staff, S1 and S2, and interviews with other related parties, it was identified that staff (S4, S5) inappropriately handled (R1) when trying to provide incontinent care to them, and R1 was refusing care from the staff. (R1) reacted by screaming and kicking at staff when they handled R1 inappropriately. Staff didn't use a different approach and/or stepping away and allowing some time to the resident to be agreeable to the incontinent care needed. This is a risk to residents personal rights.

Official plan of correction

Licensee/Administrator to ensure all caregiving staff in memory care/journey care unit have " Resident Rightd/Personal Rights " training, ensure both staff, S4 & S5 are included. Submit proof of training, include attendees, date/time spent, topics covered, and qualified trainer's name/title. POC due 3/31/25.

Deadline recorded: Mar 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation 87303€(2) 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 and not more than 120 degree F . This requirement was not met as evidenced by: LPA toured with the Administrator and Maintenace Director, hot water was checked on both florrs and in meory care, 122.F, 121.5F, and 123.4F , this is not within regulation.This is an immediate health and safety risk to residents in care

Official plan of correction

Licensee/Administrator to ensure the facilty's hot water heater/boiler(s) are turned down and monitor the hot water to be within regulation requirement, no lower than 105F and no higher than 120F. Submit a week, 5 day log, of the hot water checks by 6/15/23. Submit plan of correction by 6/9/2023.

Deadline recorded: Jun 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(9)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements 87555(b)(9) The following food service requirements shall apply: Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met as evidenced by: LPA observed that two large boxes of lentil beans they were opened and were not covered and stored appropriately, a large box of rice was open and was not covered and stored appropriately;These items were not covered appropriately to protect the safety and acceptability necessary to prevent contamination; This is an immediate health and safety risk to residents in care

Official plan of correction

License/Administrator to hold an in-service training with all kitchen staff regarding facility’s storage of food, food preparation, and food services to protect the safety and acceptability necessary to prevent contamination. Submit plan of correction in how the facility will correct the deficiency and maintain future compliance with this regulation. Proof of training to include trainer, topics, date, time . spent, attendees, and employee signatures; Submit proof of training by 6/15/23.. Submit plan of correction by 6/9/23

Deadline recorded: Jun 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309(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 wasn't met as evidenced by: LPA observed that the beauty salon in assisted living was unlocked with no staff inside, this left poisons/chemicals, toxins, and other items in the salon accessible to residents in care. This is an immediate health and safety risk to residents in care

Official plan of correction

Licensee/Administrator to ensure all toxins/cleaners/chemicals and any other items that may pose a risk to residents, are locked up and inaccessible at all times. Hold an in-service with all staff regarding storage of above items. Submit proof of training by 6/15/23. Submit plan of correction by 6/9/23.

Deadline recorded: Jun 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: 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 was not met as evidenced by: LPA reviewed five(5) resident records. Resident three(R3) lacked an updated medical assessment as required by regulation. This is a potential health and safety risk to resident(s) in care.

Official plan of correction

Licensee/Administrator to ensure that all residents in memory care have required updated medical assessments, per regulations. Facility to obtain an updated medical assessment on R3; Please submit a copy of resident's medical assessment by POC due date of 6/30/23.

Deadline recorded: Jun 30, 2023. 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. LPA reviewed two incident reports of staff not providing correct medication dosage and/or correct medication for the resident which resulted in two incidents of medication errors. This is a health and safety risk and/or personal rights violation to the residents in care.

Official plan of correction

POC CLEARED BY ADMINISTRATOR PROVIDING INSERVICE ON MEDICATION ASSITANCE TO STAFF THAT GAVE MEDICATION IN ERROR PER REPORTED INCIDENTS (2). Licensee to ensure that all residents are provided medication assistance by qualified staff and that medications are being provided per Physician's Orders. Administrator provided copies of training(s).

Deadline recorded: Oct 15, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(9)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. 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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/09/2022 Plan of Correction The Licensee to submit plan on kitchen's food storage, including ensuring lableing of all stored food items and on fresh made food items, including information/training to all kitchen staff on what are the discard dates of all food items and maintenance plan to ensure food items are appropriately stored, and food items discared when required, ensuring all is done in a timely manner to help ensure health and safety of all residents in care-submit plan by 3/9/22. Submit proof of training by 3/18/22.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/09/2022 Plan of Correction Licensee to ensure all medications in the facility, residents and/or of staff, are locked up and secured at all times. Submit inservice-training of staff to review storage of all medications in the building, including staff's personal medications, are secured to help ensure the health and safety of all resients in care. Submit plan of completing the correction by 3/9/22. Follow up with proof of training, including all staff that attended-by 3/18/22.