Community Care Licensing

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Grace Luk TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023

Document Has Been Signed on 10/25/2023 04:56 PM - It Cannot Be Edited

FACILITY NAME: SHANNEN GUEST HOME	FACILITY NUMBER: 015601262
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

Type A

Section Cited

CCR

87309(a)

(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 by having unlocked cleaning supplies and gardening tools which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/26/2023
	Plan of Correction
1 2 3 4	Licensee locked up the cleaning supplies and gardening tools during inspection. Deficiency cleared. Civil penalty of $250 is being assessed for a repeat violation.

Type A

Section Cited

CCR

87465(c)(2)

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above not having the correct order for R1's Tylenol and having Senna and Docusate Sodium available to R1 which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/26/2023
	Plan of Correction
1 2 3 4	Licensee obtained a new order for R1's Tylenol 500mg and purchased Senna and Docusate during inspection. Deficiency cleared.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Grace Luk TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023

Document Has Been Signed on 10/25/2023 04:56 PM - It Cannot Be Edited

FACILITY NAME: SHANNEN GUEST HOME	FACILITY NUMBER: 015601262
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

Type B

Section Cited

CCR

87411(f)

(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, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 by not having chest x-ray results for S1 which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/22/2023
	Plan of Correction
1 2 3 4	Licensee has agreed to obtain a copy of S1's chest x-ray and submit a copy to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Grace Luk TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023

Document Has Been Signed on 10/25/2023 04:56 PM - It Cannot Be Edited

FACILITY NAME: SHANNEN GUEST HOME	FACILITY NUMBER: 015601262
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

Type B

Section Cited

HSC

1569.618(c)(3)

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 by not having at least one staff on duty that has current CPR training which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/22/2023
	Plan of Correction
1 2 3 4	Licensee has scheduled the CPR training for staff on 11/1/2023. Licensee will submit certification of completion to CCLD by POC date.

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 by not having current annual training which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/22/2023
	Plan of Correction
1 2 3 4	Licensee has agreed to obtain annual training for S2 and S3. Licensee will submit training documents to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Grace Luk TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023

Document Has Been Signed on 10/25/2023 04:56 PM - It Cannot Be Edited

FACILITY NAME: SHANNEN GUEST HOME	FACILITY NUMBER: 015601262
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/25/2023

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 record review, the licensee did not comply with the section cited above by not conducting disaster drill every 3 months which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/22/2023
	Plan of Correction
1 2 3 4	Licensee has agreed to conduct a disaster drill and submit disaster drill document to CCLD by POC date.

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 record review, the licensee did not comply with the section cited above by not having current needs and service plan for R2 and R3 which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/22/2023
	Plan of Correction
1 2 3 4	Licensee has agreed to obtain current needs and service plans for R2 and R3. Licensee will submit copies of the needs and service plans to CCLD by POC date.

SUPERVISOR'S NAME: Harpreet Humpal TELEPHONE: (510) 285-3928 LICENSING EVALUATOR NAME: Grace Luk TELEPHONE: (510) 286-4201 LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2023

FACILITY NAME: SHANNEN GUEST HOME	FACILITY NUMBER: 015601262
	VISIT DATE: 10/25/2023