MOM'S PLACE 2

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

87202(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... fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above by having the fire door improperly held open by an industrial doorstop which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Facility staff immediately closed the door during today's visit. Facility representative that the door would remain closed at all times in compliance with fire safety requirements.

Deadline recorded: May 6, 2025. A deadline is not proof that correction was completed.

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 LPA observation, the licensee did not comply with the section cited above when the fire extinguisher in the laundry room was noted to be purchased in 11/2023 has not been replaced or inspected, administrator was unable to provide last report for fire alarm and sprinkler system and the fire door was improperly held open by a string tied to the doorknob since which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/16/2025 Plan of Correction Facility representative immediately closed the door and stated that fire door will be kept closed at all times.

Official classification

Type A

Official code

87309(b)(1)

Regulation authority

CCR

What the official deficiency says

(b) Residents may have access to items specified in subsection (a) for personal use unless there is documentation, as specified in Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, that indicates the resident's or other residents’ safety would be at risk if allowed access. (1) The licensee shall implement reasonable interventions in order to ensure that access to the items specified in subsection (a) does not pose a hazard to other residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record reviewed, the licensee did not comply with the section cited above by having several unlocked closets and drawers containing air freshener, disinfectants, cleaning supplies and bathroom items with three (3) residents at risk which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/16/2025 Plan of Correction Facility representative and staff removed and locked all chemicals and cleaning suppies during today's visit.

Official classification

Type A

Official code

87355(e)(3)

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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 cited above by having Staff #1 not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2025 Plan of Correction Facility representative will associate S1 before POC due date.

Official classification

Type A

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews with staff, the licensee did not comply with the above cited section, as there is not a qualified administrator running the facility due to distance, which posed a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 05/01/2025 Plan of Correction Facility representative, Administrator and/or Licensee will submit paperwork to replace the administrator before POC due date. A statement of understanding from the Licensee Joseph Jose shall be submitted to CCL by 04/18/2025.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(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 requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by having a prescribed medication inside an unlocked closed, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/16/2025 Plan of Correction Medication was immediately removed and locked during today's visit.

Official classification

Type A

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. 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 cited above by having medication with an “opened” date label indication 04/01/2025, written by facility staff. However, the original pharmacy label on the medication container showed a filled date of 11/21/2024 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/18/2025 Plan of Correction Facility representative, administrator or Licensee will have a third party training on medication schedulte for all staff members before POC due date. Once training is complete proof of training with name of trained staff.

Official classification

Type A

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. 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 by having Resident #4 admitted with out proof of TB test which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/18/2025 Plan of Correction Facility representative, administrator or Licensee will schedule an appointment to get R4 TB tested before POC due and submit test result to CCL

Official classification

Type B

Official code

87219(h)(1)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (1) A comfortable, appropriately furnished area such as a living room, available to all residents for their relaxation and for entertaining friends and relatives. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by not having patio furniture to accomodate residents in care which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/30/2025 Plan of Correction Facility representative, Administrator or Licensee will purchase patio furniture and submit proof of purchase before POC due date. A photo of the installed furniture will be requiered once it is delivered.

Official classification

Type B

Official code

1569.695(a)(2)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. 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 by having a low supply of emergency water for staff and residents in care which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/16/2025 Plan of Correction During today's visit staff purchased 5 1-gallon bottles of water.