Community Care Licensing

SUPERVISOR'S NAME: See Moua TELEPHONE: (559) -65-7912 LICENSING EVALUATOR NAME: Mai Yang TELEPHONE: 559-772-7402 LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024

Document Has Been Signed on 07/25/2024 08:34 AM - It Cannot Be Edited

FACILITY NAME: MILLBRAE CARE HOME	FACILITY NUMBER: 107202375
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2024

Type A

Section Cited

CCR

87465(c)(2)

87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed and observation, LPA reviewed R2’s MARs and audit medications. R1’s medication Olanzapine and Lorazepam were not administered as directed by physician which poses an immediate health and safety risk for the person in care.
	POC Due Date: 07/25/2024
	Plan of Correction
1 2 3 4	Licensee shall submit documentation of steps the facility will take to ensure facility meets the regulation to Fresno CCL office by POC due date 07/25/24. All staff in-service training shall be completed on Medications. Licensee will submit proof of training materials and staff attendance rooster to the Fresno CCL office by 08/06/24.

Type A

Section Cited

CCR

87465(h)(2)

87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place... not accessible to persons other than employees... 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 when LPA and Administrator Assistant observed R3’s medication that required refrigerated stored unlock in the refrigerator accessible to residents poses an immediate health, safety or personal rights risk to person in care.
	POC Due Date: 07/25/2024
	Plan of Correction
1 2 3 4	Staff immediately locked medications in refrigerated bag. POC cleared.

SUPERVISOR'S NAME: See Moua TELEPHONE: (559) -65-7912 LICENSING EVALUATOR NAME: Mai Yang TELEPHONE: 559-772-7402 LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024

Document Has Been Signed on 07/25/2024 08:34 AM - It Cannot Be Edited

FACILITY NAME: MILLBRAE CARE HOME	FACILITY NUMBER: 107202375
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2024

Type A

Section Cited

CCR

87468.1(a)(2)

87468.1(a)(2) 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: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, LPA and Licensee observed S1’s medication stored the refrigerator unlock which poses an potential health and safety risk to the residents.
	POC Due Date: 07/25/2024
	Plan of Correction
1 2 3 4	Staff immediately locked staff medication. Licensee shall submit documentation of steps facility will take to ensure all staff’s medications are inaccessible to the residents in care to Fresno CCL office by POC due date 07/25/24.

Type A

Section Cited

CCR

87309(a)

87309(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 when LPA observed cleaning chemicals in the laundry room stored unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/25/2024
	Plan of Correction
1 2 3 4	Administrator removed the chemicals and locked in laundry shelf. POC cleared during visit.

SUPERVISOR'S NAME: See Moua TELEPHONE: (559) -65-7912 LICENSING EVALUATOR NAME: Mai Yang TELEPHONE: 559-772-7402 LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024

Document Has Been Signed on 07/25/2024 08:34 AM - It Cannot Be Edited

FACILITY NAME: MILLBRAE CARE HOME	FACILITY NUMBER: 107202375
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2024

Type B

Section Cited

CCR

87465(d)(3)

87465 (d)(3) A record of each dose is maintained in the resident's record. The record shall include the date and time …medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews, observation, and records reviewed, R2’s medications Cholecalciferol and Rosuvastatin were administered daily and were not recorded in the resident’s MARs which poses a potential health and safety risk for the person in care.
	POC Due Date: 07/30/2024
	Plan of Correction
1 2 3 4	Licensee will submit documents of R2’s medications documented in the MARs to Fresno CCL by POC due date 07/30/24.

Type B

Section Cited

CCR

87412(c)

87412(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed and interviews, facility do keep staff trainings records on file and are shredded every year which poses a potential health and safety risk for the person in care.
	POC Due Date: 08/23/2024
	Plan of Correction
1 2 3 4	Facility shall review regulation section 87412 and ensure that all staff have the required training. Proof of trainings is to be submitted to the Fresno CCL office by the POC due date 08/23/24. Proof of training shall include the following: Trainer’s full name; Subject(s) covered in the training; Date(s) of attendance; and Number of training hours per subject.

SUPERVISOR'S NAME: See Moua TELEPHONE: (559) -65-7912 LICENSING EVALUATOR NAME: Mai Yang TELEPHONE: 559-772-7402 LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024

Document Has Been Signed on 07/25/2024 08:34 AM - It Cannot Be Edited

FACILITY NAME: MILLBRAE CARE HOME	FACILITY NUMBER: 107202375
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/24/2024

Type B

Section Cited

CCR

87608(5)(B)

87608 (5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records reviewed, R1 was observed in a full rail bed with no physician’s order which poses a potential health and safety risk for the person in care.
	POC Due Date: 08/06/2024
	Plan of Correction
1 2 3 4	Licensee shall submit physician’s order for R1’s full rail bed and an exception request for the full rail bed to Fresno CCL by 08/06/24.

Type B

Section Cited

CCR

87211(a)(D)

87211(a)(D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and observation, the facility failed to notify the department the facility bathroom is being repaired which poses a potential health and safety risk for the residents in care.
	POC Due Date: 07/30/2024
	Plan of Correction
1 2 3 4	Licensee shall submit a written report to the Fresno CCL when bathroom repaired started and when repair will be completed including how the Licensee will keep the residents safe by the POC due date 07/30/24.

SUPERVISOR'S NAME: See Moua TELEPHONE: (559) -65-7912 LICENSING EVALUATOR NAME: Mai Yang TELEPHONE: 559-772-7402 LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024