TERENE MANOR

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on observation and interviews, the licensee did not comply with the section cited above in that two (2) out of five (5) residents reported incidents of verbal and emotional abuse which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to schedule training with an approved outside vendor or Long Term Ombudsmen for all care staff regarding personal rights of residents. Licensee to provide scheduled training date to Community Care Licensing (CCL) by due date of 10/1/2025. Proof of training must include Staff Names and Signatures. Proof of training to be submitted to CCL by POC due date of 10/14/2025.

Deadline recorded: Oct 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1Personal Rights of Residents in All Facilities(a)Residents in all residential care facilities...the following personal rights:(3)To be free from punishment, humiliation, intimidation, abuse, or other actions...such as... interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by:Based on observation and interviews, the licensee did not comply with the section cited above in that two (2) out of five (5) residents reported incidents of verbal and emotional abuse which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to schedule training with an approved outside vendor or Long Term Ombudsmen for all care staff regarding personal rights of residents. Licensee to provide scheduled training date to Community Care Licensing (CCL) by due date of 10/1/2025. Proof of training must include Staff Names and Signatures. Proof of training to be submitted to CCL by POC due date of 10/14/2025.

Deadline recorded: Oct 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Per LPA file reviews, staff, S1, S2, & S3, all lack current CPR certification, the licensee did not comply with the section cited above in [3] out of [4t] staff, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/24/2025 Plan of Correction Licensee to ensure that all staff have current first aid and CPR certification as required for direct care staff. Submit proof of S1, S2, and S3 having obtained CPR certification, copy of certification cards. POC due 1/24/25.

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 Per LPA's file review, there have been two (2) emergency disaster drills held, 12/24 & 10/24, both were earthquake drills; In review of facility emergency disaster drills the requirement has not been met, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/27/2025 Plan of Correction Licensee to ensure the facility has quarterly emergency disaster drills as required. Licensee to submit facility's plan to ensure required emergency disaster drills are held quarterly, and per the direction of one of the drills to be an evacuation drill, and the other drills to be a different emergency scenario. Plan of correction due no later than 1/27/25.

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/Administrator observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 3 staff have not completed their 20 annual training hours requirement, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/13/2024 Plan of Correction Administrator to ensure staff complete their training hours requirement by poc due date. Administrator will submit LIC9098 form to CCL certifying that staff have completed the annual required training hours.

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, interview and record review, the licensee did not comply with the section cited above by not conducting a disaster drill within the last quarter, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/13/2024 Plan of Correction Administrator will conduct a disaster drill with staff and will submit a LIC9098 self-certification form to CCL notifying the department that disaster drill have been conducted by poc due date to clear citation.