Community Care Licensing

Document Has Been Signed on 03/20/2025 05:18 PM - It Cannot Be Edited

FACILITY NAME:	BOYD SENIOR CARE HOME		FACILITY NUMBER:	075601332
ADMINISTRATOR/ DIRECTOR:	PEDIGUERRA, JERRY		FACILITY TYPE:	740
ADDRESS:	345 BOYD ROAD		TELEPHONE:	(925) 256-6500
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY: 6		CENSUS: 5	DATE:	03/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:20 PM
MET WITH:	Jerry Pediguerra, Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:30 PM

SUPERVISORS NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025

Link to Parent Document Below:

FACILITY NAME: BOYD SENIOR CARE HOME	FACILITY NUMBER: 075601332
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/20/2025

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 in by not completing 20hrs annual trainings for S2-S5 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2025
	Plan of Correction
1 2 3 4	Administrator agreed to create a detailed plan with a schedule for staff trainings for S2-S5. In addition, will submit training certificates or in-service training sign in sheets for trainings completed and in progress to CCLD by POC due date.

Section Cited

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

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025

Link to Parent Document Below:

FACILITY NAME: BOYD SENIOR CARE HOME	FACILITY NUMBER: 075601332
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/20/2025

Type B

Section Cited

CCR

87468(c)(2)(A)

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in by not having RCFE complaint poster posted in entry way which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/03/2025
	Plan of Correction
1 2 3 4	Administrator agreed to submit a photo of RCFE Complaint Poster posted in entry way to CCLD by POC due date.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025

Link to Parent Document Below:

FACILITY NAME: BOYD SENIOR CARE HOME	FACILITY NUMBER: 075601332
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/20/2025

Type B

Section Cited

CCR

87463(a)

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. 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 by not having an Appraisal Needs and Services (ANS) for R5 on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2025
	Plan of Correction
1 2 3 4	Administrator agreed to submit a copy of ANS for R5 to CCLD by POC due date.

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 observation, interview, record review, the licensee did not comply with the section cited above in by not conducting quarertly fire/emergency drills for AM/PM shifts which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/17/2025
	Plan of Correction
1 2 3 4	Administrator agreed to self-certify by reading/understanding/complying with the regulation and send a copy of sign-in sheet of all participants that completed the drill to CCLD by POC due date.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025

Link to Parent Document Below:

FACILITY NAME: BOYD SENIOR CARE HOME	FACILITY NUMBER: 075601332
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/20/2025

Type B

Section Cited

CCR

87608(a)(5)(A)

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in by not having doctor's orders for bed rails/hospital beds for R1-R5 on file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2025
	Plan of Correction
1 2 3 4	Administrator agreed to submit copies of doctor's orders for bed rails for R1-R5 to CCLD by POC due date.

Type B

Section Cited

CCR

87608(a)(1)(3)

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. (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 observation, interview, record review, the licensee did not comply with the section cited above in by not having, including but not limited to, a doctor's order for R4's soft ties which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2025
	Plan of Correction
1 2 3 4	Administrator agreed to submit a copy of doctor's order for R4's soft tie to CCLD by POC due date. CCLD is subject to request additional documents.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Lori Alexander-Washington LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025

FACILITY NAME: BOYD SENIOR CARE HOME	FACILITY NUMBER: 075601332
	VISIT DATE: 03/20/2025