GLEN PARK AT OJAI

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 (a)(1) Reporting Requirements (a) Each licensee shall... (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when the facility did not submit incident reports for a residents hospitalization, and staff are not aware of the manadated reporting requirements which poses...

Official plan of correction

Administrator agreed to submit a statement of understanding of regulation 87211, will submit incident report for R1 as soon as possible, and conduct mandated reporting training for all staff. Administrator agreed to submit proof of training and SIR by 7/14/23. a potential health and safety risk to residents in care.

Deadline recorded: Jul 14, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(j)

Regulation authority

CCR

What the official deficiency says

87465 (j) In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated... needed emergency medical services and for assisting residents as needed with self-administration of medications....and staff. This requirement is not met as evidenced by Based on interview and record review, the licensee did not comply with the above cited section, as no staff scheduled during the overnight shift have medication training and staff were unaware of the facility's plan to meet residents' medical needs, which poses a potential health risk to persons in care.

Official plan of correction

ED stated one NOC staff was recently trained on medication administration. ED agreed to ensure a trained staff is present during the NOC shift at all times. ED will provide additional training on the facility's plan to meet residents' medical needs. ED will provide proof of staff schedule showing trained staff at night and proof of training on the facility plan by POC due date.

Deadline recorded: Dec 4, 2025. A deadline is not proof that correction was completed.

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 interview and record review, the licensee did not comply with the section cited above in 2 residents that were not administered their morning medications on 10/09/25 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/21/2025 Plan of Correction Administrator stated they will be providing MedTech that did not provide the medication with additionall medication training and provide proof to LPA by 10/21/25

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 one of four restrooms that hot water temperature measued at 124 degrees F which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/15/2025 Plan of Correction POC CLeared, water tempearute was adjusted.

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 record review, the licensee did not comply with the section cited above in two staff who did not have annual training on file which poses a potential health, safety risk to persons in care.

Official plan of correction

POC Due Date: 10/28/2025 Plan of Correction Administrator will ensure both staff obtain all required training and submit proof to LPA by 10/28/25.

Official classification

Type A

Official code

1569.312(a)

Regulation authority

HSC

What the official deficiency says

HSC 1569.312(a) Basic services requirements. Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2.This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above. Facility staff failed to properly transfer R1 which caused R1 to sustain a skin tear on their left leg. This posed an immediate health and safety risk to residents in care.

Official plan of correction

S1 is no longer working at the facility. Licensee will submit a plan how they will ensure staff to properly transfer residents. Submit to CCL by due date.

Deadline recorded: Oct 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

CCR 87465(a)4 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility....(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by: Based on record review and interviews, the licensee did not comply with the section cited above as medications are not being given to R1 and failed to provide R1’s CSDMR which posed an immediate health and safety concern to persons in care.

Official plan of correction

Licensee agreed to review section cited and submit a statement of understanding, how they plan to ensure residents will receive their medications as prescribed, and how they will ensure staff properly documents medication on the CSMDR and submit to CCL by POC due date.

Deadline recorded: Oct 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(c)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited as licensee waited 10 days to report this incident, which posed a potential personal rights risk to residents in care.

Official plan of correction

Licensee will provide a written understanding of reporting requirements to CCL on or before 10/22/2024.

Deadline recorded: Oct 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87224(a-b)

Regulation authority

CCR

What the official deficiency says

87224(a)The licensee may evict a resident... Thirty (30) days written notice to the resident is required ..(b) upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. ...This regulation is not met as evidenced by: Based on interviews and record review, the ED did not ensure that they provided R1 and/or their responsible person with a proper eviction notice and did not get prior approval from licensing, which posed an immediate health and safety risk to resident(s) in care.

Official plan of correction

Executive Director agrees to read and review Regulation 87224 Evictions Procedures and submit a letter of undestanding, and train all staff that provide notices on the proper way to evict residents in care and provide proof to CCL by 10/05/2024.

Deadline recorded: Oct 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(1)(B)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements... which are centrally stored: (1) Medications shall be centrally stored...: (B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. This requirement was not met as evidenced by: Based on record review, R1, R2 and R3 cannot have access to medications but all had medication found in their room, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator will ensure all medication technicians are immediately told they must ensure all medications are taken by residents before leaving the room. Formal training will be conducted and evidence of the training will be sent to CCL on or before 10/9/2024.

Deadline recorded: Oct 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(1) Personal 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...This requirment was not met as evidence by: Based on interviews and record review, the licensee did not comply with the section cited above when staff (S1) spoke inappropiately and threw a diaper which posed a potential personal rights risk to residents in care.

Official plan of correction

Administrator suspended S1, and has agreed to review with staff (S1)the regulation 87468.1 (a)(1)-and send proof or self-verification via a letter to the CCLD department by 11/02/2023.

Deadline recorded: Nov 2, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465(a)(4) Incidental Medical and Dental Care. (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply in the section cited above for four out of fifteen residents (R1, R2, R3,R6), due to missed medications, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Executive Director agress they will: 1. Do a medication audit for all residents to assure no other medications have been missed by 8/2/23 and submit proof to CCL. 2.have all staff complete a medication training by 8/4/23 and diabetes (diet) by 8/11/23 & submit proof.

Deadline recorded: Aug 2, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(k)(1)

Regulation authority

CCR

What the official deficiency says

87705(k)(1) Care of Persons with Dementia. The following ...must be met for the licensee to utilize delayed egress devices ... (1) The licensee shall notify the licensing agency immediately after determining the date that the device will be installed. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply in the section cited above, as the licensee installed delayed egress doors without notifying the department, which poses an immediate personal rights risk to residents in care.

Official plan of correction

The Executive Director agreed to the following: 1. Submit a statement of understanding, certifying that the community is unable to and will not engage the delayed egress mechanisms until they obtain the appropriate fire clearance. Statement must be submitted by 7/31/2023

Deadline recorded: Jul 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication...gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the above cited section, as Glade Air Freshener, Windex wipes, and Oxi Clean spray were observed in resident's room with an open door, accessible to residents which poses an immediate safety risk to residents in care.

Official plan of correction

Executive Director locked the cabinet and ensured that all accessible items were secured during today's visit. Training will be provided to all staff on section 87705 and proof of training will be sent to CCL by 04/13/2023.

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

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 (a)(1) (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 requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section as 4 incidents which occurred between 03/02/2023 and 03/06/2023 were not reported to CCL timely, which poses a potential safety and personal rights risk to residents in care.

Official plan of correction

Executive Director agreed to submit incident reports to CCL and Regional Center by close of business on 03/31/2023.

Deadline recorded: Mar 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1Personal Rights of Residents in All Facilities (a)(3)To be free from punishment, humiliation, intimidation, abuse, or other actions...interfering with daily living functions such as eating, sleeping, or elimination.This requirement is not met as evidence by: Based on Interviews, Records obtained and S1 admission. The licensee did not comply with the above cited section as S1 admitting to abusive actions towards residents including incontinence spray, and grabbing residents nose, which poses an immidiate personal rights risk to residents in care.

Official plan of correction

Executive Director provided documentation of coachings for S1. Administrator has suspended S1 today and S1 has been asked to leave the builduing pending a dicision from human resources.Administrator Admisistrator will conduct all staff training of personal rights and mandated reporting and provide proof and submit documentation of attendees to CCL by 04/06/2023.

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

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1Personal Rights of Residents in All Facilities (a)(1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidence by: Based on Interviews, Records obtained and S1 admission. The licensee did not comply with the above cited section as S1 admitted to yelling at residents, multiple staff witnessed S1 yell at residents. Which poses an immidiate personal rights risk to residents in care.

Official plan of correction

Executive Director provided documentation of coachings for S1. Administrator has suspended S1 today and S1 has been asked to leave the builduing pending a dicision from human resources.Administrator Admisistrator will conduct all staff training of personal rights and mandated reporting and provide proof and submit documentation of attendees to CCL by 04/06/2023.

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

Official classification

Type B

Official code

87633(h)

Regulation authority

CCR

What the official deficiency says

87633 Hospice Care of Terminally Ill Residents(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident’s record: (4) A copy of the resident’s current hospice care plano hspice agency, and the resident; or the resident's Health Care Surrogate Decision Maker if the resident is incapacitated. This requirement was not met as evidenced by: Licensee had no records regarding R1's and R2's hospice care, including no hospice care plan or hospice care provider visits, which posed a potenital risk to resident in care.

Official plan of correction

Administrator will submit a written plan for obtaining and retaining hospice care plans and hospice records. This will be provided to CCL by 03/30/2023. Also provide copy of the hospice care plan for R1 and R2 by 03/30/2023.

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

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on LPA's observations and record review, the licensee did not comply with the section cited above as over-the-counter medications and toxic substances were observed accessible to residents which poses an immediate health risk to persons in care.

Official plan of correction

Staff placed toxic items in an inaccessible location during facility visit. Staff will provide documentation of scheduled staff training to CCL by 7/30/22.

Deadline recorded: Jul 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on LPA's observations and record review, the licensee did not comply with the section cited above as razors and gardening tools were observed accessible to residents which poses an immediate health and safety risk to persons in care.

Official plan of correction

Staff locked room with razors and will provide documentation of tools inaccessible to residents to CCL by 7/30/22. Staff will provide documentation of scheduled staff training regarding 87705(f)(1) to CCL by 7/30/22.

Deadline recorded: Jul 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)(c)

Regulation authority

CCR

What the official deficiency says

87464 Basic services (f)(1)(c) " Care and supervision " means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as R1 and R2 left the facility unassisted which poses an immediate health and safety risk to persons in care.

Official plan of correction

Staff stated that they provide documentation of scheduled staff training regarding elopement protocols to CCL by 7/30/22 and they will conduct a reappraisal for R1 and provide documentation of staff training and reappraisal to CCL 8/8/22.

Deadline recorded: Jul 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.269(a)(2)

Regulation authority

HSC

What the official deficiency says

1569.269 Enumerated rights; severability(a)(2) Residents of residential care facilities for the elderly shall have all of the following rights: To be granted a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone... This requirement is not met as evidenced by Based on LPA’s observations and record review, the licensee did not comply with the section cited above as LPA observed video cameras in the common areas of the facility which poses a potential personal rights risk to persons in care.

Official plan of correction

Staff stated that they will contact the licensee regarding turning off the video cameras and will provide documenation that they have been turned off to CCL by 8/8/22.

Deadline recorded: Aug 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Based on LPA's observations, the licensee did not comply with the section cited above as a toilet and sink was added to a storage room and a wall added to the medication room which poses a potential safety and personal rights risk to persons in care.

Official plan of correction

Staff stated that she will submit a building permit for the toilet and sink in the prior storage room and the wall placed in the medication room along with an updated facility sketch to CCL by 8/8/22

Deadline recorded: Aug 8, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care Services(a)(5) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication review, the licensee did not comply with the section cited above in 3 out of 7 resident medications which poses an immediate health risk to persons in care.

Official plan of correction

Staff stated they will they will give resident medications as prescribed and will provide documentation of scheduled staff medication training to CCL 7/30/22. Staff will provide documentation of staff training to CCL by 8/8/22.

Deadline recorded: Jul 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(g)(1)

Regulation authority

CCR

What the official deficiency says

87217 Safeguards for Resident Cash, Personal Property, and Valuables (g)(1) Records of residents' cash resources maintained as a drawing account shall include a ledger accounting...for each resident, and supporting receipts filed in chronological order. Each accounting shall be kept current. This requirement is not met as evidenced by: Based on LPA’s observations and record review, the licensee did not comply with the section cited above as the facility did not keep a ledger of the accounting for R1's cash resources which poses a potential personal rights risk to persons in care.

Official plan of correction

Staff stated that they will review and comply with the regulation and will submit documentation stating this to CCL by 8/3/22.

Deadline recorded: Aug 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

87202 Fire Clearance (a)(2) 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... This requirement is not met as evidenced by: Based on LPA's observation and record review, the licensee did not comply with the section cited above in 1 out of 10 resident records which poses a potential health and safety risk to persons in care.

Official plan of correction

Staff stated that they will provide documentation that they will move R9 to an approved bedridden room with approval of responsible person to CCL by 4/22/22.

Deadline recorded: Apr 22, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

87457 Pre-Admission Appraisal – General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance.. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in 1 out of 10 resident records which poses a potential health and safety risk to persons in care.

Official plan of correction

Staff stated that they will provide documentation of R3s Pre-Admission Appraisal to CCL by 5/2/22.

Deadline recorded: May 2, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on LPA's observations and record review, the licensee did not comply with the section cited above as scissors and gardening tools were observed accessible to residents which poses an immediate health and safety risk to persons in care.

Official plan of correction

Staff removed key from door lock and locked medication room during facility visit and will provide doumentation of locked shed to CCL by 4/22/22. Staff stated that they will provide documentation of staff training of regulation 87705(f)(1) to CCL by 5/2/22.

Deadline recorded: Apr 22, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals(c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months… This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in 9 out of 10 resident records which poses a potential health and safety risk to persons in care.

Official plan of correction

Staff stated that they will arrange a meeting with R1, R3, R4, R5, R6, R7, R8, R9 and R10, amd their representative, if any, and will provide documentation of signed reappraisals to CCL by 5/2/22.

Deadline recorded: May 2, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on LPA's observations and record review, the licensee did not comply with the section cited above as over-the-counter medications and toxic substances were observed accessible to residents which poses an immediate health risk to persons in care.

Official plan of correction

Staff placed houskeeping cart in an inaccessible location, Staff placed toxic items in an inaccessible location, Staff locked upstairs room door and backyard room door during facility visit. Staff will provide documentation of staff training regarding regulation 87705(f)(2) to CCL by 5/2/22.

Deadline recorded: Apr 22, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation. (e)(2)Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature… This requirement is not met as evidenced by: Based on LPA's observations the licensee did not comply with the section cited above as resident bathroom #3's water temperature tested at 77.9 degrees F which poses a potential health and personal rights risk to persons in care.

Official plan of correction

Staff stated that they will provide documentation that they have turned up the water heater temperature and hot water temperature reads between 105 -120 degrees F in room #3's bathroom to CCL by 4/25/22.

Deadline recorded: Apr 25, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care Services (h)(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: Based on LPA’s observations and record review, the licensee did not comply with the section cited above as residents medication was not kept in a safe locked place not accessible to residents which posed an immediate health risk to persons in care.

Official plan of correction

Staff removed keys from door lock and locked medication room door, staff locked medication cart during facility visit. Staff stated that they will provide documentation of staff medication training to CCL by 5/2/22.

Deadline recorded: Apr 22, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (d)(6) The following space and safety provisions shall apply to all facilities: All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based on LPA’s observations and record review, the licensee did not comply with the section cited above as 2 water system tanks are blocking the passageway leading to the outdoor gate which poses a potential safety and personal rights risk to person in care.

Official plan of correction

Staff stated that they will provide documentation of the 2 water system tanks moved from the outside passageway to CCL by 5/2/22.

Deadline recorded: May 2, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.269(a)(2)

Regulation authority

HSC

What the official deficiency says

1569.269 Enumerated rights; severability(a)(2) Residents of residential care facilities for the elderly shall have all of the following rights: To be granted a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone... This requirement is not met as evidenced by: Based on LPA’s observations and record review, the licensee did not comply with the section cited above as LPA observed video cameras in the common areas of the facility which poses a potential personal rights risk to persons in care.

Official plan of correction

Staff stated that they will will not use video cameras without an an approved updated Admission Agreement and Program plan to include the use of video cameras in the common areas of the facility. Staff stated that they will submit a letter to CCL by 4/25/22 indicating this.

Deadline recorded: Apr 25, 2022. A deadline is not proof that correction was completed.