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: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023

Document Has Been Signed on 12/14/2023 03:01 PM - It Cannot Be Edited

FACILITY NAME: RNCARE HOUSE @ ROSEVILLE	FACILITY NUMBER: 317005451
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

Type B

Section Cited

CCR

87470(c)

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not complete an infection control plan which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Administrator to complete infection control plan and submit plan into LPA by 1/5/23.

Type B

Section Cited

HSC

1569.605

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not obtain liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Administrator to obtain liability insurance by 1/05/2023. Administrator to send into CCL a copy of liability insurance.

SUPERVISOR'S NAME: Troy Ordonez TELEPHONE: (916) 263-4832 LICENSING EVALUATOR NAME: Bethany Mirlohi TELEPHONE: (916) 204-8288 LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023

Document Has Been Signed on 12/14/2023 03:01 PM - It Cannot Be Edited

FACILITY NAME: RNCARE HOUSE @ ROSEVILLE	FACILITY NUMBER: 317005451
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

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 1 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Administrator agrees for Staff 1 to obtain a current CPR certification. CPR certification to be completed by 1/5/2023 and copy of certificate to be sent into LPA.

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 1 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Administrator will create an training calendar for 2024 with required hours and subject matter documented. Outlined plan to be sent into CCL by 01/05/2024.

SUPERVISOR'S NAME: Troy Ordonez TELEPHONE: (916) 263-4832 LICENSING EVALUATOR NAME: Bethany Mirlohi TELEPHONE: (916) 204-8288 LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023

Document Has Been Signed on 12/14/2023 03:01 PM - It Cannot Be Edited

FACILITY NAME: RNCARE HOUSE @ ROSEVILLE	FACILITY NUMBER: 317005451
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

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 complete quarterly drills which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	administrator agrees to complete quarterly drills at the facility. Administrator to complete a drill by 1/5/23 and document the date, the type of emergency covered by the drill, and the names of staff participating in the drill. Drill and documentation to be sent into CCL by 1/05/23.

Section Cited

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

SUPERVISOR'S NAME: Troy Ordonez TELEPHONE: (916) 263-4832 LICENSING EVALUATOR NAME: Bethany Mirlohi TELEPHONE: (916) 204-8288 LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023