Community Care Licensing

Document is an Amendment of Original Document on 03/28/2024 08:34 AM

SUPERVISOR'S NAME: Yvonne Flores-Larios TELEPHONE: (510) 286-0517 LICENSING EVALUATOR NAME: Luisa Fontanilla TELEPHONE: (510) 286-7147 LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024

Document Has Been Signed on 03/21/2024 04:34 PM - It Cannot Be Edited

FACILITY NAME: TRI CITY CARE HOME	FACILITY NUMBER: 015601207
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2024

Type A

Section Cited

CCR

87615(a)(1)

(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: (1) Stage 3 and 4 pressure sores (dermal ulcers). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews conducted, the licensee did not comply with the section cited above in having a resident with stage 2, unstageable pressure injury on the right hip and using a wound vacuum which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/21/2024
	Plan of Correction
1 2 3 4	R1 was admitted to hospice care by Anodine Hospice during the visit.

Type A

Section Cited

CCR

87606(c)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews conducted, the licensee did not comply with the section cited above in having R1 who is unable to turn from side to side (bedridden) without an approved bedridden fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/25/2024
	Plan of Correction
1 2 3 4	Within 24 hours, Administrator will notify fire department about R1's bedridden status. By POC date, Administrator will submit to CCL documents to apply for bedridden fire clearance.

SUPERVISOR'S NAME: Yvonne Flores-Larios TELEPHONE: (510) 286-0517 LICENSING EVALUATOR NAME: Luisa Fontanilla TELEPHONE: (510) 286-7147 LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024

Document Has Been Signed on 03/21/2024 04:34 PM - It Cannot Be Edited

FACILITY NAME: TRI CITY CARE HOME	FACILITY NUMBER: 015601207
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2024

Type B

Section Cited

CCR

87705(c)(5)

(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 file review conducted, the licensee did not comply with the section cited above in not having updated medical assessment for 4 out of 5 residents who have Dementia which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/04/2024
	Plan of Correction
1 2 3 4	By POC date, Administrator will send CCL updated medical assessment of the 4 residents who have Dementia.

Section Cited

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

SUPERVISOR'S NAME: Yvonne Flores-Larios TELEPHONE: (510) 286-0517 LICENSING EVALUATOR NAME: Luisa Fontanilla TELEPHONE: (510) 286-7147 LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024

FACILITY NAME: TRI CITY CARE HOME	FACILITY NUMBER: 015601207
	VISIT DATE: 03/21/2024