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32 | (9099-C 1)There is an allegation resident is not accorded dignity in their personal relationships at the facility. Documentation dated 11/21/2019 indicates when doctor’s office called facility outside party in doctor’s office expressed physician’s concern about R1 having a stroke. It was determined R1 was having a medical issue, and Licensee failed to accord R1 with dignity by dismissing R1 and medical professional's concerns. Based on LPAs observations and interviews conducted and record review(s) between 12/12/2019 and 6/15/2020, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.
There is allegation facility is not being kept at a comfortable temperature. Based on LPA observations interviews and record review between 12/12/2020 and 4/23/2020 four out of nine residents interviewed indicated the facility is not at a comfortable temperature. Facility provided information for service providers for facility. According to outside party, “this company has never been contacted to provide service at the facility”. Based on LPAs observations and interviews conducted and record review(s) between 12/12/2019 and 4/23/2020, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.
There is an allegation facility failed to safeguard resident's personal belongings. Complainant alleges dogs at the facility urinating on R1’s property and items were lost. LPA has reviewed and obtained records and interviewed witnesses and staff. It is not possible to confirm that R1’s property was urinated on by dogs at the facility. “Resident Theft and Loss Record” for R1 show certain items were lost and a credit was applied and, therefore, were not safeguarded by the staff. Based upon LPA’s observations, interviews, and records review, between 2/27/2020 and 7/21/2020 the preponderance of evidence standard has been met. Therefore, the allegation is found to be SUBSTANTIATED.
There is an allegation resident's hygiene needs are not being met. Documentation dated 4/20/2020 for R1 reflects-Coccyx/Buttock with blanchable redness noted here, appears to be yeast related. Based on interview from 6/22/2020, outside party indicated the yeast was the result of not being changed/cleaned often enough. Appraisal for R1 indicated services needed for bowel or bladder control-Disposable undergarments/bedpads. Based on LPAs observations and interviews conducted and record review(s) between 12/12/2020 and 6/22/2020, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED (See 9099 C 2). |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
11/04/2020
Section Cited
CCR
87465(g) | 1
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7 | 87465 Incidental Medical and Dental Care- (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis...This requirement was not met as evidenced by: | 1
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7 | Licensee to ensure that residents changes in condition are documented and brought to the attention of the resident's physician, resident's responsible person, and take appropriate action. |
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14 | Based on LPA observation, interview and record review, 911 was not called when R1 experienced symptoms related to possible stroke. Facility did not assist resident in receiving medical attention in a timely manner. This poses an immediate risk to the health & safety of residents in care. | 8
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14 | Licensee agrees to submit a date for conducting training to all staff on regulation 87465 (g) by POC date 11/5/2020, and submit proof of training by POC due date of 11/18/2020. |
Type A
11/04/2020
Section Cited
HSC
1569.269(a)(1) | 1
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7 | 1569.269 Enumerated rights; severability (a)Residents of residential care facilities for the elderly shall have all of the following rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: | 1
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7 | Licensee to ensure all residents are to be treated with dignity and respect at all times. Licensee agrees to sign LIC 9098 attesting understanding of Health and Safety Code 15629,(a)(1) Enumerated Rights. |
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14 | Based on LPA observation, interview and record review, on at least one occasion, Licensee did not treat R1 with dignity. This is an immediate risk to the health, safety and rights of the residents in care. | 8
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14 | Licensee agrees to submit a date for conducting training to all staff on regulation 1569.269(a)(1) by POC date 11/5/2020, and submit proof of training by POC due date of 11/18/2020. |
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32 | (9099 C 2) There is an allegation facility has rodents. Based on LPA observation and interviews between 12/12/2020 and 2/27/2020, revealed information that rodents are making a nest from under a heater of R1's room. LPA observed the hole which appeared to have rodent hair, LPA obtained photo. LPA conducted additional interviews and obtained information that rodent droppings and rodents were observed by other residents. LPA was provided a photograph of a rat trap in a residents bedroom. Based on LPA's observations and interviews conducted and record review(s) between 12/12/2019 and 6/18/2020, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.
There is an allegation the facility is in disrepair. Space heaters were observed in resident’s rooms due to wall heater units not functioning (photos obtained). Licensee indicated space heaters were sufficient for residents in lieu of wall units, Licensee confirmed not functioning. Licensee provided information for maintenance service provider. On 4/23/2020 interview with outside party indicated, company had never been contacted to provide service at the facility, and Licensee made initial contact with the company and has never requested service. Disconnected heater wiring observed (photo obtained). Based on LPA's observations and interviews conducted and record review(s) between 12/12/2019 and 6/18/2020, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.
Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights given.
Signature on File.
(See 9099-D) |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
11/04/2020
Section Cited
CCR
87303(a) | 1
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7 | 87303 Maintenance and Operation -(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by: | 1
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7 | Licensee to ensure facility is in good repair. Licensee agrees to develop a plan to ensure facility HVAC system is working, and facility is at a comfortable temperature and submit plan to CCL by POC due date of COB 11/5/2020. Licensee agrees to submit proof of repair by 11/18/2020. |
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14 | Based on observation and interview licensee did not ensure heating system is working or facility is kept at a comfortable temperature. This poses an immediate risk to the health, safety or rights of residents in care. | 8
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Type B
11/04/2020
Section Cited
CCR
87625(b)(7) | 1
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7 | 87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (7) Ensuring that the condition of the skin exposed to urine and stool is evaluated regularly to ensure that skin breakdown is not occurring. This requirement was not met as evidenced by: | 1
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7 | Licensee to ensure there is a care plan in place for all residents whose skin is exposed to urine and feces and are at risk of skin breakdown. Licensee agrees to work with a skilled professional to develop care plans/strategies to ensure R1 does not develop skin breakdown and is kept clean. Licensee agrees to submit care plan by POC due date of 11/18/2020. |
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14 | Based on a record review and interviews with staff and outside parties, LPA learned that facility did not appropriately monitor R1’s skin that was exposed to urine and feces to ensure that skin breakdown was not occurring which presents a potential risk to the health, safety or rights to residents in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
11/04/2020
Section Cited
CCR
87211(1)(D) | 1
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7 | 87211-Reporting Requirements-(1) A written report shall be submitted to the licensing agency ...within seven days...of any of the events specified..(D)Any incident which threatens the welfare, safety or health of any resident...This requirement is not met as evidenced by: | 1
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7 | Licensee agrees to ensure that all Incident Reports are submitted to CCL according to Title 22 Regulations. Licensee agrees to submit LIC 9098 regarding understanding regulations of written incident reports according to Title 22 by POC date of 11/18/2020. |
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14 | Based on LPA observation, interview, and record review. Licensee failed to report R1's change in condition and multiple emergency room visits. This poses a potential risk to the health, safety or personal rights of residents in care. | 8
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Type B
11/04/2020
Section Cited
CCR
87217(b) | 1
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7 | 87217 (b) Safeguards for Personal Property. Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. This requirement has not been met as evidenced by: | 1
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7 | Licensee agrees to ensure that all residents property is safeguarded. Licensee will develop a written plan of how the facility will safeguard residents’ personal property going forward. Plan to be submitted to CCL by POC date 11/18/2020. |
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14 | . Based on LPA observation, interview and record review Licensee did not ensure residents personal property was safeguarded, Inventory for R1 listed items that were lost. This poses a potential risk to the health, safety or personal rights of residents in care. | 8
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