Community Care Licensing

Document is an Amendment of Original Document on 08/21/2024 04:16 PM

SUPERVISOR'S NAME: Lourdes Montoya TELEPHONE: (916) 956-7332 LICENSING EVALUATOR NAME: Edward Kim TELEPHONE: (714) 293-1237 LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024

Document Has Been Signed on 08/21/2024 04:00 PM - It Cannot Be Edited

FACILITY NAME: SWEETWATER SENIOR CARE	FACILITY NUMBER: 306005261
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2024

Type A

Section Cited

CCR

87202(a)(1)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (1) Nonambulatory persons. 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. LPA observed reviewing resident files that physician's report indicated 4 residents were non-ambulatory and the facility is to operate with 2 non-ambulatory. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	Licensee states they will submit a LIC200, a check for $25 made payable to California Department of Social Services, an old facility sketch, a new facility sketch, and a letter indicating the change for fire clearance to CCLD via email to edward.kim@dss.ca.gov by POC due date August 22, 2024.

Section Cited

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

SUPERVISOR'S NAME: Lourdes Montoya TELEPHONE: (916) 956-7332 LICENSING EVALUATOR NAME: Edward Kim TELEPHONE: (714) 293-1237 LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024

Document Has Been Signed on 08/21/2024 04:00 PM - It Cannot Be Edited

FACILITY NAME: SWEETWATER SENIOR CARE	FACILITY NUMBER: 306005261
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2024

Type B

Section Cited

CCR

87412(f)

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed the facility did not have the personnel files available to inspect and audit at the time of the visit for S1 and S2. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/04/2024
	Plan of Correction
1 2 3 4	Licensee states they will send a LIC501, LIC 503, LIC9052, and all training documents for S1 and S2 to CCLD via email to edward.kim@dss.ca.gov by POC due date September 4,2024.

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 observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed facility does not have a fire/safety drill log at the moment. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/04/2024
	Plan of Correction
1 2 3 4	Licensee states they will conduct quarterly fire/safety drills and create a log. Licensee will send an email of the fire/safety drill log and a completion of a fire/safety drill to CCLD via email to edward.kim@dss.ca.gov by POC due date September 4, 2024.

SUPERVISOR'S NAME: Lourdes Montoya TELEPHONE: (916) 956-7332 LICENSING EVALUATOR NAME: Edward Kim TELEPHONE: (714) 293-1237 LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024

Document Has Been Signed on 08/21/2024 04:00 PM - It Cannot Be Edited

FACILITY NAME: SWEETWATER SENIOR CARE	FACILITY NUMBER: 306005261
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/21/2024

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 observation and record review, the licensee did not comply with the section cited above. LPA observed R3 is missing several pages of the current Physician's report and the most current Appraisal and Needs service plan is from October 14,2022, and R4 last Appraisal and Needs service plan from April 26, 2023. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/04/2024
	Plan of Correction
1 2 3 4	Licensee states they will send an email with the updated Physician's Report and Appraisal and Needs service plan for R3 and Appraisal and Needs service plan for R4 to CCLD via email to edward.kim@dss.ca.gov by POC due date September 4, 2024.

Section Cited

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

SUPERVISOR'S NAME: Lourdes Montoya TELEPHONE: (916) 956-7332 LICENSING EVALUATOR NAME: Edward Kim TELEPHONE: (714) 293-1237 LICENSING EVALUATOR SIGNATURE: DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/21/2024