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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
019201119
Report Date:
03/23/2024
Date Signed:
03/23/2024 09:57:50 PM
Document Has Been Signed on
03/23/2024 09:57 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ABOVE & BEYOND RCFE, INC.
FACILITY NUMBER:
019201119
ADMINISTRATOR:
NERI, MAX
FACILITY TYPE:
740
ADDRESS:
23652 NEVADA ROAD
TELEPHONE:
(510) 821-0871
CITY:
HAYWARD
STATE:
CA
ZIP CODE:
94541
CAPACITY:
6
CENSUS:
5
DATE:
03/23/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:05 AM
MET WITH:
Leticia Velasco/Licensee and
Max 'Mike' Neri/Admininistrator
TIME COMPLETED:
10:00 PM
NARRATIVE
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.On this day, March 23, 2024, at 11:05 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Marlyn Joaquin and Raul Pangilinan, and informed the reason for visit. LPA called and spoke over the phone with Leticia Velasco, licensee, who authorized Marilyn Joaquin to be with LPA to start inspection. Licensee and Max 'Mike' Neri, administrator, arrived at 11:35 a.m. and 11:40 a.m.. respectively.
Facility submitted the LIC9282 Infection Control Plan on June 29, 2022.
LPA started the inspection with Marlyn Joaquin, and continued with the licensee and administrator. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables.
Facility has smoke and carbon monoxide detectors that were observed functional. Hot water temperature in the ensuite bathroom was tested. Fire extinguisher was observed fully charge with tag showed serviced February 13, 2024. Facility disaster drill records checked.
LPA reviewed 5 residents and 4 staff files, and interviewed 2 staff and 2 residents. Medications were checked, and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources.
LPA observed the following:
-at 11:19 a.m., unlocked medication cabinets.
-at 11:20 a.m., residents medications in the refrigerator in the kitchen.
...continued on 809C (page 2)
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 622-2621
LICENSING EVALUATOR NAME:
Alicia Delmundo
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/23/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ABOVE & BEYOND RCFE, INC.
FACILITY NUMBER:
019201119
VISIT DATE:
03/23/2024
NARRATIVE
1
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Page 2
-at 11:24 a.m., knives in unlocked kitchen cabinet, and scissors and pizza cutter in kitchen drawers without lock.
-at 11:32 a.m., scissors in drawer without lock in the living room.
-at 11:34 a.m., medication in unlocked staff room.
-at 11:41 a.m., Aleve, Glucosamine. Bengay in one of residents rooms.
-at 11:52 a.m., Lysol, Windex, Barbasol in cabinet without lock in the ensuite bathroom.
-at 11:55 a.m., hot water at 125.1 degrees Fahrenheit.
-at 11:59 a.m., peritoneal cleansers and ointments in the common bathroom..
-at 12:01 p.m., trash cans without lid in one of the residents' rooms and living room.
-at 12:06 p.m., Oxygen tanks, pails of paint in unlocked storage in the backyard.
-at 12:30 p.m., disaster drills not conducted quarterly; records showed conducted on 1/11/22 and 1/11/24.
-at 2:00 p.m., staff (S3) has no LIC503 Health Screening & TB test result on file, Total hours of training on file is only 22 hours.
-at 2:30 p.m., staff (S4) not fingerprint cleared and associated.
-at 3:15 p.m., resident (R1) LIC602A Physician's Report is over a year old. No LIC625 Appraisal/Needs and Services Plan & doctor's order for half bed rails.
-at 3:50 p.m., R2's half bed rails no doctor's order on file,,
-at 4:05 p.m., no doctor's order on file for R3's half bed rails.
-at 5:00 p.m., R1's 3 medications not recorded on LIC622 Centrally Stored Medication and Destruction Record, Dates filled of other medications incorrectly recorded.
-at 5:35 p.m., R2 has 21 medications on facility's hand but there's only 18 on doctor's order, Facility is only giving only 11 medications of which one (muti vitamins) is given twice daily when order is only once daily. Medications received were not properly recorded on LIC622.
-at 7:00 p.m., R3 has no LIC622 on file. Doctor's order for calcium carbonate-Vit D3 (600 mg-12.5 mcg(500 unit) but the medication on facility's hand os 600 mg-10 mg (400 unit).No doctor's order for half bedrails.
-at 7:05 p.m., no doctor's for R4's half bed rails.
....continued on 809C (pge 3)
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 622-2621
LICENSING EVALUATOR NAME:
Alicia Delmundo
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/23/2024
LIC809
(FAS) - (06/04)
Page:
2
of
13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ABOVE & BEYOND RCFE, INC.
FACILITY NUMBER:
019201119
VISIT DATE:
03/23/2024
NARRATIVE
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Page 3
Administrator submitted on this day the following updated/current documents:
1. LIC308 Designation of Facility Responsibility
2. LIC500 Personnel Report
3. LIC610E Emergency Disaster Plan (9 pages)
4. $3M Liability Insurance certificate
Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $500.00 civil penalty is assessed for staff not fingerprint cleared.
Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in additional civil penalties.
Deficiencies and plan and proof of corrections were discussed with the administrator and licensee.
Exit interview conducted. Appeal Rights, LIC421BG Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 622-2621
LICENSING EVALUATOR NAME:
Alicia Delmundo
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/23/2024
LIC809
(FAS) - (06/04)
Page:
3
of
13
Document Has Been Signed on
03/23/2024 09:57 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ABOVE & BEYOND RCFE, INC.
FACILITY NUMBER:
019201119
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
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 in hot water at 125.1 degrees Fahrenheit.which poses an immediate health, safety and/or personal rights risks to persons in care.
POC Due Date:
03/24/2024
Plan of Correction
1
2
3
4
Corrected.
Administrator adjusted the water temperature to 110 degrees Fahrenheit.
Section Cited
Maintenance and Operation
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 622-2621
LICENSING EVALUATOR NAME:
Alicia Delmundo
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/23/2024
LIC809
(FAS) - (06/04)
Page:
4
of
13
Document Has Been Signed on
03/23/2024 09:57 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ABOVE & BEYOND RCFE, INC.
FACILITY NUMBER:
019201119
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(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 which pose an immediate health, safety and/or personal rights risk to persons in care. LPA observed the following: knives in unlocked kitchen cabinet; scissors and pizza cutter in drawers without lock; Lysol, Windex, Barbasol in cabinet without lock in the ensuite bathroom; peritoneal cleansers and ointments, lighter, scissors in one of the residents rooms; peritnoeal cleaner in the common bathroom
POC Due Date:
03/24/2024
Plan of Correction
1
2
3
4
Administrator and staff lock the items.
In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 3/24/24.
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
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 S4 not fingerprint cleared and associated to the facility which poses an immediate safety and/or personal rights risk to persons in care.
A $500.00 civil penalty is assessed.
POC Due Date:
03/24/2024
Plan of Correction
1
2
3
4
Administrator to have the staff fingerprinted, and will not allow to work until cleared and associated. Proof to be submitted by 3/24/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 622-2621
LICENSING EVALUATOR NAME:
Alicia Delmundo
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/23/2024
LIC809
(FAS) - (06/04)
Page:
5
of
13
Document Has Been Signed on
03/23/2024 09:57 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ABOVE & BEYOND RCFE, INC.
FACILITY NUMBER:
019201119
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.
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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Type A
Section Cited
CCR
87465(h)(1)(C)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others.
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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 622-2621
LICENSING EVALUATOR NAME:
Alicia Delmundo
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/23/2024
LIC809
(FAS) - (06/04)
Page:
6
of
13
Document Has Been Signed on
03/23/2024 09:57 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ABOVE & BEYOND RCFE, INC.
FACILITY NUMBER:
019201119
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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 in cabinets with residents' medications unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/24/2024
Plan of Correction
1
2
3
4
Staff locked the cabinets.
In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 3/24/24.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(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 record review, the licensee did not comply with the section cited above in staff administering R2's multi vitamins twice daily when doctor's order is once daily; Doctor's order for R3's calcium carbonate-Vit D3 (600 mg-12.5 mcg(500 unit) but the medication on facility's hand os 600 mg-10 mg (400 unit).which poses an immediate health and/or personal rights risk to persons in care.
POC Due Date:
03/24/2024
Plan of Correction
1
2
3
4
Administrator to have the medication for R2 administered as ordered and obtain correct medication for R3, and submit proof by 3/24/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 622-2621
LICENSING EVALUATOR NAME:
Alicia Delmundo
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/23/2024
LIC809
(FAS) - (06/04)
Page:
7
of
13
Document Has Been Signed on
03/23/2024 09:57 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ABOVE & BEYOND RCFE, INC.
FACILITY NUMBER:
019201119
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.
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 in having 21 medications on hand for R2 but order on file is only for 18.count which poses an immediate health and/or personal rights risk to persons in care.
POC Due Date:
03/24/2024
Plan of Correction
1
2
3
4
Administrator to check with the doctor if the 3 medications are still needed by R2 and obtain doctor's order. Proof to be submitted by 3/24/24.
Section Cited
Care of Persons with Dementia
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 622-2621
LICENSING EVALUATOR NAME:
Alicia Delmundo
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/23/2024
LIC809
(FAS) - (06/04)
Page:
8
of
13
Document Has Been Signed on
03/23/2024 09:57 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ABOVE & BEYOND RCFE, INC.
FACILITY NUMBER:
019201119
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, he licensee did not comply with the section cited above in Aleve, Glucosamine. Bengay in one of the resident's rooms 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
Administrator and staff locked the items.
In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 3/24/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 622-2621
LICENSING EVALUATOR NAME:
Alicia Delmundo
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/23/2024
LIC809
(FAS) - (06/04)
Page:
9
of
13
Document Has Been Signed on
03/23/2024 09:57 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ABOVE & BEYOND RCFE, INC.
FACILITY NUMBER:
019201119
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(f)(3)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof.
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 in trash can without lid which poses a potential health and/or personal rights risk to persons in care.
POC Due Date:
04/06/2024
Plan of Correction
1
2
3
4
Administrator to purchase trash can with foot pedal operated lid, and submit proof of purchase by 4/06/24.
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.
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 S3 has not having LIC503 Health Screening & TB test on file which pose a potential health and/or personal rights risk to persons in care.
POC Due Date:
04/06/2024
Plan of Correction
1
2
3
4
Administrator to have the staff health screened and TB tested, Proof to be submitted by 4/06/24,
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 622-2621
LICENSING EVALUATOR NAME:
Alicia Delmundo
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/23/2024
LIC809
(FAS) - (06/04)
Page:
10
of
13
Document Has Been Signed on
03/23/2024 09:57 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ABOVE & BEYOND RCFE, INC.
FACILITY NUMBER:
019201119
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on 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 S3 only having total of 22 hours training ofn file which poses a potential health, safety and/or personal rights risk to persons in care.
POC Due Date:
04/06/2024
Plan of Correction
1
2
3
4
Administrator to have the staff complete the training, and submit self-certification by 4/06/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 622-2621
LICENSING EVALUATOR NAME:
Alicia Delmundo
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/23/2024
LIC809
(FAS) - (06/04)
Page:
11
of
13
Document Has Been Signed on
03/23/2024 09:57 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ABOVE & BEYOND RCFE, INC.
FACILITY NUMBER:
019201119
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(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 in for not conducting drills at least every quater which poses a potential safety risk to persons in care.
POC Due Date:
04/06/2024
Plan of Correction
1
2
3
4
Administrator to have drill conducted, and submit proof by 4/06/24.
Type B
Section Cited
CCR
87608(a)(3)
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: (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 record review, the licensee did not comply with the section cited above for not having doctor's orders for R1,R2, R3 and R4's half bed rails which poses a potential health, safety and/or personal rights risk to persons in care.
POC Due Date:
04/06/2024
Plan of Correction
1
2
3
4
Administrator to obtain doctor's order, and submit copies by 4/06/24.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 622-2621
LICENSING EVALUATOR NAME:
Alicia Delmundo
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/23/2024
LIC809
(FAS) - (06/04)
Page:
12
of
13
Document Has Been Signed on
03/23/2024 09:57 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1515 CLAY STREET, STE. 310
OAKLAND
,
CA
94612
FACILITY NAME:
ABOVE & BEYOND RCFE, INC.
FACILITY NUMBER:
019201119
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/23/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(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 in R1's LIC602A over a year old & no LIC625 on file which pose a potential health and/or personal rights risk to persons in care.
POC Due Date:
04/06/2024
Plan of Correction
1
2
3
4
Administrator to obtain an updated LIC602A and complete LIC625 for R1, and submit self-certification.
Type B
Section Cited
CCR
87506(a)
87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above for the following which poses a potential personal rights risk to persons in care: R1's 3 medications not recorded & other medications not proeprly recorded on LIC622; R2's medications not properly recorded on LIC622.
POC Due Date:
04/06/2024
Plan of Correction
1
2
3
4
Administrator to correct the record, and submit self-certification by 4/06/24,
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Bennett Fong
TELEPHONE:
(510) 622-2621
LICENSING EVALUATOR NAME:
Alicia Delmundo
TELEPHONE:
(510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE:
03/23/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/23/2024
LIC809
(FAS) - (06/04)
Page:
13
of
13