YERBA BUENA RESIDENTIAL CARE HOME

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 and designee record review, the licensee did not comply with the section cited above in that staff S2 and S4 did not have required number of continuing annual training hours completed, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2026 Plan of Correction Facility to submit training certificates for S2 and S4 in the required subject matters and duration of hours by plan of correction due date.

Official classification

Type B

Official code

1569.69(a)(2)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and designee observation and record review, the licensee did not comply with the section cited above in that taff S2, S3, S4, and S5 did not have the required medication training completed, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2026 Plan of Correction Facility to submit medication training certificates/logs for staff S2, S3, S4, and S5 by plan of correction due date.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (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 is not met as evidenced by: Deficient Practice Statement Based on LPA and designee observation and record review, the licensee did not comply with the section cited above in that resident (R2) medication count off; prescription Lisinopril count of 100 was started on 4/2/26 but 16 pills remain which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2026 Plan of Correction Facility to submit plan to conduct one hour of in-service medication training for all staff administering medication. Training to be conducted no later than 7/8/26. Training log to be submitted to CCL no later than 7/8/26.

Official classification

Type B

Official code

87470(a)(2)(A)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, the licensee did not comply with the section cited above in that Room #2 was found to have a soiled brief in an uncovered waste basket, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/09/2025 Plan of Correction Staff immediately removed brief and replaced waste basket with one that has a tight fitting cover. Deficiency cleared.

Official classification

Type B

Official code

87303(f)

Regulation authority

CCR

What the official deficiency says

(f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and caregiver observation, the licensee did not comply with the section cited above in that room #2 had urine present in an uncovered bedside commode, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/09/2025 Plan of Correction Staff immediately emptied commode and replaced commode with one that was new, had a lid, and had an internal screwing cover. Deficiency cleared.

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 and Admin observation and record review, the licensee did not comply with the section cited above in that S2, S3, and S4 did not have the required number of annual trianing hours completed, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/06/2025 Plan of Correction Facility to submit proof of required annual training hours completed by plan of correction due date.,

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 and Admin observation,, the licensee did not comply with the section cited above in that facility was pre=pouring medications, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/16/2025 Plan of Correction Facility to submit LIC9098 self-certifying that facility will immediately stop pre-pouring medications, by plan of correction due date.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Personnel Requirements – General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by licensee as evidenced by: elopement of R1, which poses an immediate potential health, safety, and personal rights risk to resident in care.

Official plan of correction

Facility to submit LIC9098 self-certifying they have reviewed all of the most recent physician reports of residents and will ensure all staff are aware of the abilities and needs of all residents.

Deadline recorded: Oct 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin observation, the licensee did not comply with the section cited above in that Staff (S1) does not have a Health Screen on file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/21/2024 Plan of Correction Facility to submit to CCL picture of completed Health Screen for S1 by plan of correction due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 LPA and Admin conversation and observation, the licensee did not comply with the section cited above in that Per caregiver, the electricity in room #3 has been out for 2-3 days. When Admin arrived they said they were not aware of any outage in room #3 which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/21/2024 Plan of Correction Facility to submit work order and paid invoice for the electricity repair for room #3 to CCL by POC due date of 6/21/2024.

Official classification

Type B

Official code

87303(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin observation, the licensee did not comply with the section cited above in that Sharps container containing sharps was left open on the kitchen floor and accessible to residents, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/17/2024 Plan of Correction Facility placed Sharps container in medication room which is inaccessible to residents. Deficiency cleared.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. 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 that Residents R1 and R2 require two person assists per Physician's Report and Appraisal Needs and Services Plan. However facility only has one NOC shift employee scheduled per NOC shift. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/05/2024 Plan of Correction Facility to submit to CCL proof adequate staffing to provide two person assist during all shifts by POC due date. Proof to include staff members LIC501 and acceptance of employment offer.

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs and caregiver observation, the licensee did not comply with the section cited above in that several heads of cauliflower found to have several brown and black spots, sandwich bag containing black avocado, bag of tomatoes with 3 tomatoes showing black spots and white rings, applesauce pouches with expiration date of 5/31/24, head of cabbage/lettuce in bag with brown liquification, box of snack pack of jello with expiration of 5/17/24, and open items in refrigerator covered but not labeled with a date of opening, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/17/2024 Plan of Correction Facility disposed of several heads of cauliflower found to have several brown and black spots, sandwich bag containing black avocado, bag of tomatoes with 3 tomatoes showing black spots and white rings, applesauce pouches with expiration date of 5/31/24, head of cabbage/lettuce in bag with brown liquification, box of snack pack of jello with expiration of 5/17/24, during LPA Inspection. Deficiency Cleared.

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 and Admin conversation and observation, the licensee did not comply with the section cited above in that medications are prepoured which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/21/2024 Plan of Correction Facility to submit LIC9098 to CCL self-certifying they will not prepour medications. LPAs advised Admin that medications can be prepared at the beginning of the day for the current day.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

87202 Fire Clearance: (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidenced by: Based on the inspection from the LPAs, Assistant Fire Marshall and the Senior Code Enforcement Officer, it was determined that the structure in the back was not STD 850 fire clearance approved. This presents an immediate health, safety and personal rights risk to the residents in care. Civil Penalty Asssessed in the amount of $500.00.

Official plan of correction

Plan of Correction shall include caregivers to vacate the property in the back. In addition, Administrator to provide a written statement on how future compliance will be met along with an LIC 9098-Self Certification to be forwarded to the LPA. Plan of Correction due on August 22, 2023.

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

Official classification

Type A

Official code

87207

Regulation authority

CCR

What the official deficiency says

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by: Documents provided by the licensee were emailed on August 2, 2023 to the LPA reflecting a City of Santa Rosa Fire Department Inspection report that had falsified verbiage regarding the structure clearance

Official plan of correction

Plan of Correction shall include that the Administrator conducts staff training regarding documents and retaining correct documents to be provided to licensing upon request. In addition, Administrator to provide a written statement on how future compliance will be met along with an LIC 9098-Self Certification to be forwarded to the LPA. Plan of Correction due date August 28, 2023.

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

Official classification

Type A

Official code

87355(a)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and Guardian Review, the licensee did not comply with the section cited above in 1 out of 2 staff members were not background cleared which poses an immediate health, safety or personal rights risk to persons in care. Civil Penalty Assessed.

Official plan of correction

POC Due Date: 07/26/2023 Plan of Correction Plan of Correction shall include a statement regarding future compliance. Licensee shall fill out at LIC 9098 Self-Certification form reading and understanding the regulation as it relates to Criminal Record Clearance. Furthermore, Licensee shall associate any individuals that provide care and supervision to residents in care.

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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 1 out of 6 resident bedrooms. Resident bed had two half rails placed together running the full length of the bed which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/13/2022 Plan of Correction Licensee removed one half rail during inspection. Deficiency cleared during inspection on 05/13/2022