SERENITY VILLA

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's/staff observation, interview & record review, the licensee did not comply with the section cited above by not providig garbage cans with cover lids to resident's bedrooms and bathrooms which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/12/2025 Plan of Correction Licensee agrees to provide garbage cans with well-fitted covers and will submit self-certification LIC9098 form to CCL by POC due date to clear the citation.

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 LPA's/staff observation, interview and record review, the licensee did not comply with the section cited above in two out of seven resident's care plans were not signed by their responsible parties which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/12/2025 Plan of Correction Licensee agrees to have resident's responsible parties sign their care plans and will submit self-certification LIC9098 form to CCL by POC due date to clear the citation.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(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 is not met as evidenced by: Deficient Practice Statement Based on observation, the Licensee/Administrator did not comply with the section cited above in 4 out of 4 fire extinguishers were not serviced since December 21, 2023 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/15/2025 Plan of Correction Licensee/Administrator will contact the Fire Department to have fire extinguisher serviced. Administrator agreed to submit self-certification form as a proof of Correction (POC) that fire extinguisher have been serviced and charged by a fire extinguisher service company or the Fire Department by POC due date of 1/15/2025.

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/Administrator did not comply with the section cited above in that a cleaning cart with chemicals was left unattended in the residents hallway which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/15/2025 Plan of Correction Licensee/Administrator to ensure all chemicals and cleaning agents are inaccessible to residents. Licensee to conduct refresher training and review regulation for all staff. Licensee/Administrator will submit self-certification that chemicals and cleaning agents are inaccessible by POC date of 1/15/2025.

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: 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 that two Caregivers (S1) and (S2) were not associated with the facility in Guardian which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/15/2025 Plan of Correction Licensee/Administrator to associate S1 and S2 on in the Guardian system and submit proof of doing so by POC due date of 1/15/2025

Official classification

Type A

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 that resident's (R1) had a whole tablet of an unidentifiable medication loose in the medication bin. In addition, resident's (R2) prescription for Aripiprazole had no prescription label on the bottle or in the medication bin. Both incidents pose an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/15/2025 Plan of Correction Facility to conduct in-service training for all staff that handles medications to ensure their understanding of medication management that loose medication are not allowed at any time. Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 1/15/2025

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA/Licensee's observation, spot check, records review and interview, the licensee did not comply with the section cited above in 4 out of 7 medications reviewed for residents in care were not given according to the physician's orders, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/10/2024 Plan of Correction Licensee agrees to contact a pharmacy to come and review their medication management. All staff will receive training after audit is complete to ensure compliance with regulation. Licensee will submit proof of pharmacy audit by POC due date to clear the deficiency.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes in physical… & that appropriate assistance is provided when such observation reveals unmet needs...This requirement has not been met as evidence by: Based on interviews conducted and records review. Facility did not observe change of condition in R1 after blister popped out of R1’s right foot, which poses an immediate risk to the health and safety of the residents in care.

Official plan of correction

Administrator/Licensee agrees to submit a written plan in how staff will assess resident’s pressure injuries after a change of condition by POC due date. $500 immediate civil penalty

Deadline recorded: Dec 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(B)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require… (1) A written report shall be submitted to the licensing... & person responsible for the resident within 7 days…(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement has not been met as evidence by: Based on LPA’s records review and interviews conducted Administrator did not ensure that CCL was notified of incidents involving R1’s Stage II pressure injury, which poses a potential health & safety risk to residents in care.

Official plan of correction

The Licensee will ensure all incidents that threaten the safety of residents are reported to CCL per regulation. Administrator to review regulation, conduct staff training on reporting requirements. Signed statement that the regulation was reviewed and sign in sheet for all staff trained to be submitted by POC due date.

Deadline recorded: Dec 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a)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 & procedures for the safety and well-being of residents, employees, and visitors. This requirement is not met: Based on records review and interviews conducted with Licensee, the facility did not ensure that front entrance was operating properly, which poses a potential risk to the health and safety of residents in care.

Official plan of correction

The licensee has provided a receipt from repair company dated 10/1/2023 as proof of service. Deficiency is cleared.

Deadline recorded: Oct 25, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203-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: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 1 out of 5 emergency exits was locked with a combination lock, inabeling anyone not having the combination the ability to exit. This poses an immediate health, safety risk to persons in care. **Immediate Civil Penalty assessed in the amount of $500.

Official plan of correction

POC Due Date: 12/21/2022 Plan of Correction Licensee to ensure walkways and exits are unobstructed. Licensee to review fire code regulations and submit plan to address wandering residents and safety concerns with outside individuals entering facility within fire clearance regulations.POC due date 12/21/2022.