ST. STEPHEN'S HOME

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(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 Record Review, where one resident(r1) was missing 3 routine medications from her MAR sheet, the licensee did not comply with the section cited above in 1 out of 3 MAR sheets reviewed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction LPA suggests, Licensee should self audit all the clients medications, if mars are missing medications they should be added, if there is cause to call a doctor and get a new medication to address a need that should be done, if there are missing medications that there is an order for, those medications should be ordered. A inventory of each residents medications should be sent to the LPA with pictures of containers for each medication, end of day 8/19 due

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 record review where two residents were missing tylonal pain medication(r1 missing 325mg and r2 missing 500mg), and Interview with staff where one resident(r2 only) being given melatonin without a perscribed order. the licensee did not comply with the section cited above in 2 out of 3 medications/mars reviewed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction LPA is suggesting, the licensee/administratior add herself to a training on medication administration mangement, conducted by a 3rd party.

Official classification

Type B

Official code

87706(a)(1)(C)

Regulation authority

CCR

What the official deficiency says

(a) In addition to the requirements in Section 87705, Care of Persons with Dementia, licensees who advertise, promote, or otherwise hold themselves out as providing special care, programming, and/or environments for residents with dementia or related disorders shall meet the following requirements: (1) In addition to the requirements specified in Sections 87208, Plan of Operation, the licensee shall include in the plan of operation a brief narrative description addressing the following additional information: (C) Staff training describing the required training for direct care staff who provide dementia special care. At a minimum, the description shall include information on training to be provided, as specified in Health and Safety Code sections 1569.625 and 1569.626. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, 3 staff files did not meet the hours requirements in 2025 for 12 hours of standard annual training topics or 8 hours of dementia specific topics. licensee did not comply with the section cited above in 3 out of 3 staff files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/25/2026 Plan of Correction LPA suggest the Liceensee send a plan of future trainings, that discribes topics and timelines for the employees to meet thier annual training goals. due 8/25/26

Official classification

Type B

Official code

87307(a)(3)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement is not met as evidenced by: Deficient Practice Statement Based on Observation, the lpa did not observe a chair in 4 out of 5 clients rooms. the licensee did not comply with the section cited above in which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/25/2026 Plan of Correction LPA suggest chairs be added to the rooms.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation of the evacuation route gate path way there are 3 gates which drag into the ground and 1 resident in a wheelchair, the licensee did not comply with the section cited above in 3 out of 3 evacuation route gates which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/25/2026 Plan of Correction LPa suggests either griding down the gates or rehanging them such that they swing freely and latch closed.

Official classification

Type B

Official code

1569.655(a)

Regulation authority

HSC

What the official deficiency says

(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 90 days’ prior written notice to the residents or the residents’ representatives setting forth the amount of the increase and the reason or reasons for the increase, including a description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review of 1 admission agreement, 2 related invoices, and 1 notification it appears two rases in rent occured for r3, one in 2/2024 from 2500 to 3000 without notification or outlying reason or reasons for the increase and a second in 6/2026 from 3000 to 3200, which did have a notification put was dated 2 days prior, also did not outlay the reason or reasons for the increase. the licensee did not comply with the section cited above in 1 out of 3 client records reviewed which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/25/2026 Plan of Correction LPA suggested Licensee should review t22 procedure for rate increases in an RCFE and send a signed copy of the regulation to the LPA by the POC date

Official classification

Type A

Official code

87465(a)

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: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement was not followed as evidenced by: In record review, The morphine is a controlled substance and is not being recorded properly on a controlled substances log. In interview, perscribed order(1 per 12 hours) conflicts with the administrators statement (PRN). its distribution as a MAR record is questionable, per interview with S1. This requirement not being followed poses a risk to the health, safety, and personal rights of clients in care.

Official plan of correction

POC Suggestion is do a staff training on how to document MAR records, PRNs, medication Refusals, and controlled substances, Medication distruction record. Training should be with a vendor/hospice/homehealth nurse and not the administrator. 8/10/26

Deadline recorded: Jul 10, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(19)

Regulation authority

CCR

What the official deficiency says

22 CCR Section 87468.2(a)(19) – Additional Personal Rights of Residents in Privately Operated Facilities: “To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.” This requirement was not met as evidenced by: Based on record review and interview, the licensee did not provide R1, represented by R1's RP, represented by the complainant, with R1's resident records within two days of receiving a written records request, which poses a potential health, safety, and/or personal rights risk.

Official plan of correction

Licensee agrees to review 22 CCR Sections 87506(c)(1) and 87468.2(a)(19) and write a signed statement acknowledging having done so and asserting that these sections will be complied with in the future. Licensee agrees to send LPA Moleski a copy of this signed statement by the POC due date. Failure to correct this deficiency by the POC due date will result in civil penalties. vincent.moleski@dss.ca.gov

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

Official classification

Type B

Official code

87763(c)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by:LPA Lund observed that resident R1 needs and services plan was dated 6/1/2021. Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/07/2023 Plan of Correction Licensee with provide a needs and services plan for R1 to LPA Lund

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: The facility failed to proper report the incident on the UIR and didn't an proper fall risk plan. which poses an immediate risk to residents in care.

Official plan of correction

Administrator Maria Almendrala will look over the regulation and email LPA Lund understanding of the regultion.

Deadline recorded: May 6, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(d)

Regulation authority

CCR

What the official deficiency says

The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement was not met as evidenced by: The facility failed to give proper 30-day notice to R1. This poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator Maria Almendrala will look over the regulation and email LPA Lund understanding of the regultion.

Deadline recorded: May 19, 2022. A deadline is not proof that correction was completed.