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13 | On 7/15/25 Licensing Program Analyst (LPA) M. Garza completed and unannounced case management visit. LPA met with Executive Director, Robert Huntley, explained reason for visit and was permitted entry into the facility. LPA completed a health and safety check on residents in care. LPA observed residents in common areas, bedrooms and in activity room. Currently there are 5 residents on hospice.
During investigation LPA completed interviews and reviewed documentation ((physicians report, admission agreements, pre-placement appraisals, needs and services plans, reassessments, medication lists, CSMR/MARS, charting notes, SIRs for month of June/July 2025, resident information sheets). Interviews conducted disclosed that R1 was left in their wheelchair on the evening of 7/13/25 by staff.
Records review of R2s file shows R2 has a history of anxeity/agression. Interviews conducted disclosed R2 became verbally aggressive with residents and staff on 7/14/25. Review of facitliy schedule show call offs were covered with limited staff.
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| Substantiated | Estimated Days of Completion: |
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
08/01/2025
Section Cited
CCR
87468.2(a)(4) | 1
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7 | 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. | 1
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7 | ED stated they will have documeted conversations with the care staff on the schedule on day of incident. In-Service training will be completed on 30-minute checks for residents. In-service sign in sheets and training material will be provided to CCL by POC date as proof of correction |
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14 | This requirement was not met as evidence by interviews conducted. The licensee did not comply with the section cited above in that the staff on duty left R1 in their wheelchair at night. This poses a potential health safety and or personal rights risk to residents in care. | 8
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Type B
08/01/2025
Section Cited
CCR
87411(a) | 1
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7 | 87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
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7 | ED stated an in-service training will be completed for all staff on residents with behaviors and how to handle them. In-service sign in sheets and training material will be provided to CCL by POC date as proof of correction. |
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14 | This requirement was not met as evidenceew of facitliy schedule show call offs we by LPA interviews and record review. The licensee did not comply with the section cited above in that R2 became verbally aggressive with residents and staff on 7/14/25. Review covered with limited staff. | 8
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