Community Care Licensing

SUPERVISOR'S NAME: Lauren Crocker TELEPHONE: (916) 895-5033 LICENSING EVALUATOR NAME: Ivan Avila TELEPHONE: 530-895-5033 LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023

Document Has Been Signed on 05/17/2023 01:58 PM - It Cannot Be Edited

FACILITY NAME: RNCARE HOUSE @ EAST ROSEVILLE	FACILITY NUMBER: 312700888
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2023

Type A

Section Cited

CCR

87555(a)

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above in that the facility's 2-day perishable and 7-day non-perishable food supply is insufficient (photos taken and detail of observation on LIC812) and spoiled food was observed in the cabinet, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	The facility shall provide a plan to the Department on the facility's food handling practices, to include but not limited to, ensuring that the facility ALWAYS has a sufficient food supply for both 2-day perishable and 7-day non-perishable, along with frequency of grocery shopping and review of stored food for expired and spoiled items. Plan will be implemented after submission.

Type A

Section Cited

HSC

1569.695(f)

(f) A facility shall have both of the following in place: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews with staff, the licensee did not comply with the section cited above in that the facility has been placing poles in the sliding glass doors in a residents bedroom and in the back of the house rendering them inoperable to staff and emergency personnel, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	The facility shall remove the poles from the sliding doors. All exits shall be free from obstruction at all times and staff and emergency personnel shall have access to all exits. ***Cleared during today's visit***

SUPERVISOR'S NAME: Lauren Crocker TELEPHONE: (916) 895-5033 LICENSING EVALUATOR NAME: Ivan Avila TELEPHONE: 530-895-5033 LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023

Document Has Been Signed on 05/17/2023 01:58 PM - It Cannot Be Edited

FACILITY NAME: RNCARE HOUSE @ EAST ROSEVILLE	FACILITY NUMBER: 312700888
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2023

Type B

Section Cited

CCR

87412(a)

(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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews with staff, the licensee did not comply with the section cited above, there was no personnell records avialable for review, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	The licensee shall compile and retain complete personnel records for all staff that work or are present in the facility. These files shall be available for review for licensing upon request. Send proof of completed staff files to the Department by May 31, 2023.

Type B

Section Cited

CCR

87506(b)

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviews, the licensee did not comply with the section cited above in resident files -R1 needs single sided admission agreement, R1 & R2 need the facility representative needs to sign the admission agreement, All 3 residents missing a signed peronal rights form and safeguard for personal property, R3 missing emergency ID, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	The licensee shall compile and retain complete residentl records for all residents that are accepted or retained in the facility. These files shall be available for review for licensing upon request. Send proof of correction of missing information in resident records by May 31, 2023.

SUPERVISOR'S NAME: Lauren Crocker TELEPHONE: (916) 895-5033 LICENSING EVALUATOR NAME: Ivan Avila TELEPHONE: 530-895-5033 LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023

Document Has Been Signed on 05/17/2023 01:58 PM - It Cannot Be Edited

FACILITY NAME: RNCARE HOUSE @ EAST ROSEVILLE	FACILITY NUMBER: 312700888
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2023

Type B

Section Cited

CCR

87458(b)(1)

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on a record review, the licensee did not comply with the section cited above in that R1 is missing a TB test clearance on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	The licensee shall obtain a TB test clearance and retain a copy in R1s file by 5/31/23. Send proof of TB test clearance once obtained as correction to the Department.

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 interviews and record reviews, the licensee did not comply with the section cited above in that the facility is not conducting emergency disaster or fire drills and/or there is no documentation of drills being conducted, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	The facility shall begin conducting emergecy disaster drills per requirements (on all shifts) and documenting these drills as proof available for review. Send proof of first drill along with paln for ongoing drills per title 22 regulations.

SUPERVISOR'S NAME: Lauren Crocker TELEPHONE: (916) 895-5033 LICENSING EVALUATOR NAME: Ivan Avila TELEPHONE: 530-895-5033 LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023

Document Has Been Signed on 05/17/2023 01:58 PM - It Cannot Be Edited

FACILITY NAME: RNCARE HOUSE @ EAST ROSEVILLE	FACILITY NUMBER: 312700888
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2023

Type B

Section Cited

CCR

87608(a)

(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: 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 that R3 is using half bedrails as postural supports but there are no physician orders on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	The licensee shall obtain MD orders for R3 for 1/2 bedrails as postural supports and retain a copy in the residents file. Send proof of correction.

Type B

Section Cited

CCR

87705(c)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations the licensee did not comply with the section cited above in that there were a number of items either missing or not safe guarded as required for residents with dementia (knives accessible, stove range accessible, out-dated MD report, exits not alarmed, etc.), which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/31/2023
	Plan of Correction
1 2 3 4	The licensee shall review 87705 and enusre the facility is taking all required precautions for residents with dementia. Send proof of identified issues that have been fixed (including noted items listed above).

SUPERVISOR'S NAME: Lauren Crocker TELEPHONE: (916) 895-5033 LICENSING EVALUATOR NAME: Ivan Avila TELEPHONE: 530-895-5033 LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023

Document Has Been Signed on 05/17/2023 01:58 PM - It Cannot Be Edited

FACILITY NAME: RNCARE HOUSE @ EAST ROSEVILLE	FACILITY NUMBER: 312700888
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2023

Type A

Section Cited

CCR

87207(a)

All facilities shall maintain a fire clearance approval by the city , county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above in that the handle on the fire door for the hall leading to resident bedrooms the handle is reversed so that the lock is outside, inaccessible to residents. There is also a wedge next to the fire door for proping the door open which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2023
	Plan of Correction
1 2 3 4	The licensee shall remove the handle that locks residents in the hall and replace it with a handle that does not have a lock and shall no longer utilze the wedge that props the door open. ***Cleared during visit***

Section Cited

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

SUPERVISOR'S NAME: Lauren Crocker TELEPHONE: (916) 895-5033 LICENSING EVALUATOR NAME: Ivan Avila TELEPHONE: 530-895-5033 LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023