NARRATIVE |
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 | Sheriff report documentation dated 12/27/2020 indicates “Elderly Male just showed up” (R1). Information was provided during interview that R1 during 12/27/2020 incident was transported back to facility. LPA conducted tele-visit with Rose Mahawar, Manager to obtain additional information for 12/27/2020 incident due to CCL not receiving incident report. Incident report was received on 3/5/2021. Based on LPAs observations, interviews and record reviews the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
There is an allegation facility does not have adequate staff to meet residents care needs. On 10/30/2020 LPA contacted facility to conduct tele visit. Administrator was reflected as working on the schedule but when LPA called the facility LPA was told by staff he was asleep. Administrator called LPA and said he was asleep and is on call on Fridays. LPA asked for updated schedules to reflect which staff were actually working. Schedules indicate facility going to one NOC shift staff on 10/28/2020. Interviews revealed and schedules obtained reflect that there is only one caregiver staff on AM shift. Multiples interviews on 2/24/2021 and 3/2/2021 confirmed facility does not have adequate staff to meet resident care needs. Interview with outside party on 3/5/2021 confirmed facility is short-staffed. Addressed in another allegation, R1 AWOL’d from the facility on three different occasions indicating facility does not have sufficient staffing. Based on LPAs observations, interviews and record reviews the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
There is an allegation facility failed to report resident AWOL. R1 wandered away from the facility on 11/10/2020 and 12/27/2020. Facility did not report to CCL within regulatory time frames. Tele-visit was conducted with Rose Mahawar on 3/5/2021 LPA requested Incident report for 12/27/2020 incident which was received on 3/5/2021. 11/10/2021 incident report was received from Administrator on 2/25/2021. Incident report for 1/3/2021 incident was received by CCL on 1/12/2021. Based on LPA observations, interview and record review the preponderance of evidence standard has been met, therefore the above allegation 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) |
Request Denied
Type A
03/09/2021
Section Cited
CCR
87411(a) | 1
2
3
4
5
6
7 | 87411(a) 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. This requirement was not met as evidenced by: Based on LPA observation, interview and | 1
2
3
4
5
6
7 | Licensee to ensure staff are sufficient in numbers to meet the needs of residents. Licensee agrees to submit updated staffing schedule, showing 24-hour coverage to meet the needs of residents. Updated staffing schedule to be submitted to CCL by POC date of COB 3/9/2021. |
 | 8
9
10
11
12
13
14 | record review, facility did not provide supervision resulting in R1 leaving the facility on three occasions. This is an immediate risk to the Health, Safety and Rights of residents in care. ***Civil Penalty of $250.00 is being issued for repeat violation within the last 12 months. | 8
9
10
11
12
13
14 |  |
Type B
03/22/2021
Section Cited
CCR
87211(a)(1)(D) | 1
2
3
4
5
6
7 | Reporting Requirements- (a) Each licensee shall furnish..(1) A written report shall be submitted…within seven days…(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by:
Based on LPA observation, interview | 1
2
3
4
5
6
7 | Licensee to ensure incidents are reported to CCL according to regulation. Administrator /Manager agrees to train all staff on reporting requirements and submit proof of training by POC due date of 3/22/2021. |
 | 8
9
10
11
12
13
14 | and record review incident reports were not sent to CCl within 7 days when R1 AWOL’d from the facility three times. This is a potential risk to the Health, Safety and Personal Rights of residents in care. ***Civil Penalty of $250.00 issued for repeat violation issued within the last 12 months. | 8
9
10
11
12
13
14 |  |