Community Care Licensing

Document Has Been Signed on 05/31/2023 12:22 PM - It Cannot Be Edited

FACILITY NAME:	A1 SENIOR CARE 2		FACILITY NUMBER:	312701001
ADMINISTRATOR:	TACANDONG, DAISYREE		FACILITY TYPE:	740
ADDRESS:	2040 SYMPHONY AVE		TELEPHONE:	(916) 472-4543
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95747
CAPACITY: 6		CENSUS: 5	DATE:	05/31/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Daisyree Tacandong, Administrator		TIME COMPLETED:	12:30 PM

SUPERVISORS NAME: Troy Ordonez LICENSING EVALUATOR NAME: Bethany Mirlohi LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023

Link to Parent Document Below:

FACILITY NAME: A1 SENIOR CARE 2	FACILITY NUMBER: 312701001
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2023

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 2 out of 3 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2023
	Plan of Correction
1 2 3 4	Administrator to obtain a health screening for all staff. Completed health screening to be sent into CCL by 6/28/23.

SUPERVISOR'S NAME: Troy Ordonez LICENSING EVALUATOR NAME: Bethany Mirlohi LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023

Link to Parent Document Below:

FACILITY NAME: A1 SENIOR CARE 2	FACILITY NUMBER: 312701001
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2023

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, the licensee did not comply with the section cited above for all staff records 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	Administrator brought staff records to LPA for review for annual continuation on 5/31/23.

Type B

Section Cited

CCR

87465(h)(6)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year. 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 2 out of 2 persons which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2023
	Plan of Correction
1 2 3 4	Administrator agrees to complete a Centrally Stored Medication Record (CSMR) for each resident in care. CSMR to be sent into LPA by 6/28/23.

SUPERVISOR'S NAME: Troy Ordonez LICENSING EVALUATOR NAME: Bethany Mirlohi LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023

Link to Parent Document Below:

FACILITY NAME: A1 SENIOR CARE 2	FACILITY NUMBER: 312701001
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2023

Type B

Section Cited

CCR

87467(a)(3)

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. 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 2 out of 2 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2023
	Plan of Correction
1 2 3 4	Administrator agrees to complete a needs and service plan for R1 and R2. Completed needs and service plan to be submitted to LPA by 6/28/23.

SUPERVISOR'S NAME: Troy Ordonez LICENSING EVALUATOR NAME: Bethany Mirlohi LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023

Link to Parent Document Below:

FACILITY NAME: A1 SENIOR CARE 2	FACILITY NUMBER: 312701001
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2023

Type A

Section Cited

CCR

87465(a)(4)

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (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 and record review, the licensee did not comply with the section cited above in 1 out of 2 persons which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/01/2023
	Plan of Correction
1 2 3 4	Administrator agrees to dispense R1's medications in the way that doctor orders. In addition, Administrator to obtain physician orders for all OTC medications. Administrator to send doctor orders into CCL by 6/28/23.

Section Cited

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

SUPERVISOR'S NAME: Troy Ordonez LICENSING EVALUATOR NAME: Bethany Mirlohi LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023

Link to Parent Document Below:

FACILITY NAME: A1 SENIOR CARE 2	FACILITY NUMBER: 312701001
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2023

Type B

Section Cited

CCR

87307(a)

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee converted a large closet in common bathroom into a staff breakroom which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2023
	Plan of Correction
1 2 3 4	Administrator agrees to empty closet of staff belongings, and not use closet as a staff breakroom. Administrator to send LPA a picture of the closet empty of staff belongings. Picture to be sent into LPA by 6/28/23.

Section Cited

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

SUPERVISOR'S NAME: Troy Ordonez LICENSING EVALUATOR NAME: Bethany Mirlohi LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023