Community Care Licensing

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 622-2621 LICENSING EVALUATOR NAME: Alicia Delmundo TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023

FACILITY NAME: COLONIAL ACRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 019200664
	VISIT DATE: 11/09/2023

FACILITY NAME: COLONIAL ACRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 019200664
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2023

Type A

Section Cited

CCR

87303(e)(5)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for the shower area in the 2 bathrooms with not non-skid mats or strips which pose an immediate safety and/or personal rights risk to persons in care.
	POC Due Date: 11/10/2023
	Plan of Correction
1 2 3 4	Administrator to purchase non-skid mats or have strips inslalled. Pictures to be submitted by 11/10/23.

Type A

Section Cited

CCR

87555(b)(8)

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for the expired sour cream which poses an immediate health risk to persons in care.
	POC Due Date: 11/10/2023
	Plan of Correction
1 2 3 4	Staff discarded the item. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures bu 11/10/23.

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 622-2621 LICENSING EVALUATOR NAME: Alicia Delmundo TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023

Document Has Been Signed on 11/09/2023 09:43 PM - It Cannot Be Edited

FACILITY NAME: COLONIAL ACRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 019200664
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2023

Type A

Section Cited

CCR

87465(h)(1)(C)

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for mediications in the storage box with broken lock and Albuterol soltuon in one of ther residents' rooms which pose an immediate health, safety and/or personal rights risk to persons in care.
	POC Due Date: 11/10/2023
	Plan of Correction
1 2 3 4	Staff locked the items. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures bu 11/10/23.

Type A

Section Cited

CCR

87465(a)(4)

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: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for facility not having the 4 medications for resident (R1) which were on the list of order which poses an immediate health risk to person in care.
	POC Due Date: 11/10/2023
	Plan of Correction
1 2 3 4	Administrator to check with the doctor and if no llonger needed. to obtain discontinued order. Otherwise, obtain the medicaitons. Proof to be submitted by 11/10/23.

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 622-2621 LICENSING EVALUATOR NAME: Alicia Delmundo TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023

Document Has Been Signed on 11/09/2023 09:43 PM - It Cannot Be Edited

FACILITY NAME: COLONIAL ACRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 019200664
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2023

Type B

Section Cited

HSC

1569.625(b)(2)

(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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for S3 not having the required annual training on file which poses/posed a potential safety and/orpersonal rights risk to persons in care.
	POC Due Date: 11/23/2023
	Plan of Correction
1 2 3 4	Administrator to have the staff complete the training and submit proof by 11/23/23.

Type B

Section Cited

CCR

87463(c)

(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, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 out of 5 residents' LIC625 with no signatures of residents' responsible person; it's not clear whether or not the assessment been discussed which pose a potential personal rights risk to persons in care.
	POC Due Date: 11/23/2023
	Plan of Correction
1 2 3 4	Administrator to meet with the residents' responsible persons and have the LIC625 signed. Self-certificattion to be submitted by 11/23/23.

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 622-2621 LICENSING EVALUATOR NAME: Alicia Delmundo TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023

Document Has Been Signed on 11/09/2023 09:43 PM - It Cannot Be Edited

FACILITY NAME: COLONIAL ACRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 019200664
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2023

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above for not conducting disaster drills which poses a potential safety risk to persons in care.
	POC Due Date: 11/23/2023
	Plan of Correction
1 2 3 4	Administrator to have drills conducted and submit copy by 11/23/23,

Type B

Section Cited

CCR

87411(c)(1)

87411 Personnel Requirements - General (c) (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for S1, S4 and S5 expired first aid certificates which pose a potential safety and/or personal rights risk to persons in care.
	POC Due Date: 11/23/2023
	Plan of Correction
1 2 3 4	Administrator to have the staff complete the training and submit copies of certificates by 11/23/23.

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 622-2621 LICENSING EVALUATOR NAME: Alicia Delmundo TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023

Document Has Been Signed on 11/09/2023 09:43 PM - It Cannot Be Edited

FACILITY NAME: COLONIAL ACRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 019200664
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2023

Type A

Section Cited

CCR

87705(f)(2)

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for shave cream, shaver, glucose lancets, and ointment unlocked in resident's room which pose an immediate safety and/or personal rights risk to persons in care.
	POC Due Date: 11/10/2023
	Plan of Correction
1 2 3 4	Staff locked all the items. In addition, administrator to add to in-service and submit copy of training topic with attendees signatures by 11/10/23.

Type A

Section Cited

CCR

87309(a)

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for unlocked utility room and storage where bleach and cleaning supplies are kept which pose an immediate health and safety risks to persons in care.
	POC Due Date: 11/10/2023
	Plan of Correction
1 2 3 4	Administrator lock the room and storage. In addition, administrator to add to in-service and submit copy of training topic with attendees signaures by 11/10/23.

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 622-2621 LICENSING EVALUATOR NAME: Alicia Delmundo TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023

Document Has Been Signed on 11/09/2023 09:43 PM - It Cannot Be Edited

FACILITY NAME: COLONIAL ACRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 019200664
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2023

Type B

Section Cited

CCR

87615(a)(5)

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: (5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for R1 who is dependent on staff with all activities of daily living which poses a potential safety and/or personal rights risk to persons in care.
	POC Due Date: 11/23/2023
	Plan of Correction
1 2 3 4	Administrator to submit an exception request with supporting documents by 11/23/23.

Type B

Section Cited

CCR

87705(c)(5)

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for R3's LIC602A over a year old which poses a potential health and/or personal rights risk to persons in care.
	POC Due Date: 11/23/2023
	Plan of Correction
1 2 3 4	Administrator to arrange a doctor's appointment and submit a copy of LIC602A by 11/23/23.

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 622-2621 LICENSING EVALUATOR NAME: Alicia Delmundo TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023

Document Has Been Signed on 11/09/2023 09:43 PM - It Cannot Be Edited

FACILITY NAME: COLONIAL ACRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 019200664
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2023

Type B

Section Cited

CCR

87608(a)(3)

87608 Postural Supports (a)(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for not having doctor's order on R1's file for half bed rails which poses a potential safety and/or personal rights risks to person in care.
	POC Due Date: 11/23/2023
	Plan of Correction
1 2 3 4	Administrator to obtain doctor's order and submit copy by 11/23/23.

Type B

Section Cited

CCR

87506

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for R1's LIC622 not recording the dates medications were filled and started which pose a potential health, safety or personal rights risk to person in care.
	POC Due Date: 11/23/2023
	Plan of Correction
1 2 3 4	Administrator to check all the residents' LIC622 and complete accordingly. Self-certification to be submitted by 11/23/23.

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 622-2621 LICENSING EVALUATOR NAME: Alicia Delmundo TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023

Document Has Been Signed on 11/09/2023 09:43 PM - It Cannot Be Edited

FACILITY NAME: COLONIAL ACRES RESIDENTIAL CARE HOME	FACILITY NUMBER: 019200664
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2023

Type B

Section Cited

CCR

87411(f)

87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned,...... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for S3 not having LIC503 Health Screening and TB test on file which pose a potential health risk to persons in care.
	POC Due Date: 11/23/2023
	Plan of Correction
1 2 3 4	Administrator to have the staff TB tested and have the LIC503 completed. Copy to be submitted by 11/23/23.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Bennett Fong TELEPHONE: (510) 622-2621 LICENSING EVALUATOR NAME: Alicia Delmundo TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023