ROYAL OAKS HOME CARE

Official classification

Type B

Official code

87208(a)(7)

Regulation authority

CCR

What the official deficiency says

The licensee shall have and maintain a current, written definitive plan of operation for the facility…Any significant …shall be submitted to the licensing agency for approval…shall contain the following: (7) Sketches, showing dimensions, of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as records review revealed the facility sketch has not been updated, which poses a potential, health and safety risk to residents in care.

Official plan of correction

POC Due Date: 02/20/2026 Plan of Correction Administrator agreed to submit an updated facility sketch to CCLD via email by POC date.

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 Based on record review the licensee did not comply with the section cited above as S1 and S2 did not have current First Aid Certificates on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/03/2025 Plan of Correction POC cleared during the visit. S1 and S2 provided sufficient first aid certificates during the visit.

Official classification

Type B

Official code

87303(i)

Regulation authority

CCR

What the official deficiency says

(i) Facilities shall have signal systems which shall meet the following criteria: 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; the exit door alarms not working properly which poses/posed a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 02/21/2024 Plan of Correction Ms. Antig stated that the company will come out to fix the problem and ensure all exit door alarms are working properly. Submit a self-certification letter and work order invoice.

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 interview and record review, the licensee did not comply with the section cited above in 2 out of 2 staff training records reviewed did not have proof of required training completed which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 02/26/2024 Plan of Correction Ms. Antig stated that she will have staff required training completed for staff 1 and 2; will submit copyof the complete and accurate training record for staff 1 and 2 by plan of correction date.

Official classification

Type B

Official code

1569.69(a)(2)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. 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 2 out of 2 staff files reviewed; staff 1 and 2 did not recieve required shadowing and training hours to assist with medications. This poses a potential health, and safety risk to persons in care.

Official plan of correction

POC Due Date: 02/26/2024 Plan of Correction Ms. Antig stated that she will prepare and dispense resident medication until staff 1 and 2 complete required medication training including shadowing provided by a skilled professional.

Official classification

Type B

Official code

87467(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Prior to, or within two weeks of the resident's admission, 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, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. 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 5 out of 6 resident files reviewed; R1,2,3,4,5 did not have a completed needs and services plan. This poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/23/2024 Plan of Correction Ms. Antig stated she will complete the needs and services plan for R1,2,3,4, and 5; ensure it is reviewed and signed by all parties. Submit copies to CCL by POC date.

Official classification

Type B

Official code

87705(c)(3)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: (A) Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living; 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 2 out of 2 staff files reviewed; staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/26/2024 Plan of Correction Ms. Antig stated she will ensure all training requirement ae met for staff 1 and 2; Ms. Anitg will submit proof of training hours are complete according to regulation for staff 1 and 2. Submit records of training hours for staff 1 and 2 by POC date.

Official classification

Type A

Official code

87705(f)(1)

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: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations, the licensee did not comply with the section cited above as there were two pairs of scissors found in two unlocked drawers in the hall bathroom, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/10/2023 Plan of Correction Staff removed the scissors and placed them in a locked cabinet in the bathroom. Administrator will conduct training with all staff regarding keeping dangerous items inaccessible to residents. Administrator will provide evidence of this training to CCL on or before 02/10/2023.

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, 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: Deficient Practice Statement Based on LPA's observations, the licensee did not comply with the section cited above as vitamins were observed in the open staff room and cleaning supplies were observed in the open garage adjacent to the kitchen, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/10/2023 Plan of Correction Staff locked the staff room and garage door making the viatmins and cleaning supplies inaccssible. Administrator will conduct training with all staff regarding keeping dangerous items inaccessible to residents. Administrator will provide evidence of this training to CCL on or before 02/10/2023.

Official classification

Type A

Official code

87615(a)(2)

Regulation authority

CCR

What the official deficiency says

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (2) Gastrostomy tubes. Based on observation, interview and record review, the licensee did not comply with the section cited above, as R1 has a g-tube, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator will contact R1's physician to determine if R1 will be placed on hospice as originally planned. If not, R1's responsible party will be contacted and R1 will be immediately relocated to an appropriate facility. Administrator will submit evidence of this to CCL on or before 11/28/2022.

Deadline recorded: Nov 28, 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

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, there were lighters accessible in the unlocked garage, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/07/2022 Plan of Correction Administrator removed the lighters from the garage and placed them in a locked cabinet. Administrator will conduct training with all staff regarding keeping dangerous items inaccessible to residents. Administrator will provide evidence of this training to CCL on or before 02/07/2021.

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, 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: Deficient Practice Statement Based on LPA's observation there were vitamins and medications in a kitchen cabinet not securely locked in the kitchen; Lysol and Calmoseptine in an unlocked cabinet in the bathroom; and laundry detergent in the unlocked garage, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/07/2022 Plan of Correction Administrator immediately secured the items noted above. Administrator will conduct training with all staff regarding keeping dangerous items inaccessible to residents. Administrator will provide evidence of this training to CCL on or before 02/07/2021.