Community Care Licensing

SUPERVISOR'S NAME: Troy Ordonez TELEPHONE: (916) 263-4832 LICENSING EVALUATOR NAME: Bethany Mirlohi TELEPHONE: (916) 204-8288 LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024

Document Has Been Signed on 04/02/2024 02:44 PM - It Cannot Be Edited

FACILITY NAME: OLYMPUS RIDGE	FACILITY NUMBER: 312701012
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/02/2024

Type B

Section Cited

HSC

1569.618(c)(3)

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 1 out of 2 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Administrator agrees to have Caregiver obtain a current CPR and 1st aid certificate. Copy of certificate to be sent to CCL by 4/26/24.

Type B

Section Cited

HSC

1569.625(b)(2)

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 1 out of 2 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Administrator agrees to complete annual training with all caregivers. Administrator to send into CCL a copy of a training calendar with subject matter. Calendar to be sent into CCL by 4/26/24.

SUPERVISOR'S NAME: Troy Ordonez TELEPHONE: (916) 263-4832 LICENSING EVALUATOR NAME: Bethany Mirlohi TELEPHONE: (916) 204-8288 LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024

Document Has Been Signed on 04/02/2024 02:44 PM - It Cannot Be Edited

FACILITY NAME: OLYMPUS RIDGE	FACILITY NUMBER: 312701012
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/02/2024

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: 04/26/2024
	Plan of Correction
1 2 3 4	Administrator to complete an updated needs and service plan for R1 and R2. Updated plans to be sent into CCL by 4/26/24.

SUPERVISOR'S NAME: Troy Ordonez TELEPHONE: (916) 263-4832 LICENSING EVALUATOR NAME: Bethany Mirlohi TELEPHONE: (916) 204-8288 LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024

Document Has Been Signed on 04/02/2024 02:44 PM - It Cannot Be Edited

FACILITY NAME: OLYMPUS RIDGE	FACILITY NUMBER: 312701012
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/02/2024

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 record review, the licensee did not comply with the section cited above by not completely fire drills which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/26/2024
	Plan of Correction
1 2 3 4	Administrator agrees to complete drills quarterly and document drills. Administrator to complete 1st drill by 4/26/24 and documentation to be sent into CCL by 4/26/24.

Section Cited

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

SUPERVISOR'S NAME: Troy Ordonez TELEPHONE: (916) 263-4832 LICENSING EVALUATOR NAME: Bethany Mirlohi TELEPHONE: (916) 204-8288 LICENSING EVALUATOR SIGNATURE: DATE: 04/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2024