MARGARET'S CARE HOME

Official classification

Type A

Official code

87204(a)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above by not ensuring that the facility was within the fire clearance of 5 ambulatory and 1 non-ambulatory residents. It was learned that 2 out 3 residents were determined to be non-ambulatory based on physicians records. This poses is an immediate health, safety, and health risks to persons in care.

Official plan of correction

POC Due Date: 10/08/2025 Plan of Correction Administrator will provide a statement of correction to LPA by 10/08/2025. Statement of correction will include LIC200 and request for new fire clearance.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This is not met as evidenced by: Based on interview and record review, the Licensee did not ensure that they have provided an incident report to the department after an incident that occured on 10/08/2023. This poses an potential health, safety, and personal rights risks to persons in care.

Official plan of correction

Facility Administrator stated that a review of the section, 87211(a)(1)(D), will be conducted. A statement of correction, along with proof of staff training for no less than (1) hour in duration, for the cited section will be completed and submitted to the LPA's email at arielle.pascua@dss.ca.gov. by the due date of 10/30/2023 COB. Information submitted must include attendees, trainers, and information discussed.

Deadline recorded: Oct 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

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 Based on observation and record review, the licensee did not comply with the section comply with the section cited above in by not ensuring that the current staff members do not have a current First Aid/CPR certificate. It was observed that First Aid certificate has expired on 06/30/2021 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/10/2023 Plan of Correction Licensee shall provide a statement of acknowledgement of above Section. Staff who do no thave current First Aid/CPR certificates shall obtain certification by POC date. A copy of current First Aid/CPR shall be provided to the LPA by POC date.

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 observation, interview, and record review, the licensee did not comply with the section above in by not ensuring that S1 did not have a criminal record clearance prior to working at the facility which poses an immediate health, safety and personal rights risks to persons in care.

Official plan of correction

POC Due Date: 10/10/2023 Plan of Correction Licensee shall provide a statement of acknowledgement of above section. Licensee shall obtain criminal record clearance from the department. An immediate $500 civil penalty will be assessed.

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

87465(h)(5) Each residents medication shall be stored in its original recieved contrained. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in LPA observed medication to be pre-poured into 2 other medication dispensers prior to providing it to the 6 out of 6 residents which poses an immediate health, safety, or personal rights risks to the persons in care.

Official plan of correction

POC Due Date: 09/22/2022 Plan of Correction Licensee will stop pre-pouring medication and leave it in it's intended bottle. Licensee agrees to read and fully understand the regulation provided by the LPA. Licensee will conduct further training for all employees and send in a copy of the training and sign in sheet to the LPA by 09/22/2022 POC date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) Maintanence and Operation The facility shall be clean, safe, and sanitary and in good repair at all times. Maintenance shall include provision of maintanence 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 observation, the licensee did not comply with the section cited above in by LPA observed the backyard to be unmaintained and has an overgrowth of plants which poses a potential health, safety, or personal rights risks to the persons in care.

Official plan of correction

POC Due Date: 10/12/2022 Plan of Correction Licensee agrees to landscape the backyard and clear any hazards present and send in a picture to the LPA's email by 10/12/2022.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.This regulation was not met by evidence by: Based on observation: Licensee did not ensure cabinet that holds medications was locking properly making the medications accessible to the residents in care. This poses an immediate risk to the residents.

Official plan of correction

Licensee will send a letter acknowledging the undestanding of the regulation and a picture showing the lock has been repaired by POC date.

Deadline recorded: Oct 5, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87464 (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This regulation was not met by evidence by: Based on observation, Licensee did not have a sign-in policy available upon entry to ensure compliance with symptom screening and to record contact information (for reporting requirements to public health officer and contact tracing).

Deadline recorded: Oct 15, 2021. A deadline is not proof that correction was completed.