NARRATIVE |
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25 | Licensing Program Analyst (LPA), Jesse Gardner arrived to the facility to conduct a health and safety check of residents in care with IRC representatives Jessica Zarate, and Minerva Delarosa. LPA was granted entry by Mary Martin, Licensee. LPA toured the facility, and found that there are a total of 1 resident in care; however, at the time of visit, they were at their day program. Based upon this inspection, the LPA noted the following:
- Food supply was noted to not be sufficient to cover the required 7-day non-perishable and 3-day supply of perishables. Additionally, LPA found food that was not labeled, or dated, and LPA found expired perishables. Facility cited.
- LPA found a hole in the facility, facility cited.
- Expired Administrator's Certificate, facility cited.
- Unlocked cabinets that contained medication, Facility cited.
- Unlocked chemical supplies. Facility cited.
- Records were incomplete. C2's medical record did not have a current medication list by C2's physician. Facility cited.
- Garage was unlocked that contained a dangerous item that C2 was said to have by the Licensee.
- Light fixture was broken, as well as the light switch to C1's room did not provide an operating light. Facility cited.
|
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
08/16/2023
Section Cited
CCR
85076(d)(1)
| 1
2
3
4
5
6
7 | Food Service: (d) The licensee shall meet the following food supply and storage requirements:
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not being met as evidenced by: | 1
2
3
4
5
6
7 | Licensee agrees to replenish the food supply to conform with the regulation and provide proof of such to LPA by POC date. |
 | 8
9
10
11
12
13
14 | LPA observed not the required 7-day non perishable and 2-day perishable supply of food in the facility. Additionally, LPA observed expired vegetables in the garage fridge. This is a potential health and safety risk to clients in care. | 8
9
10
11
12
13
14 | |
Type B
08/29/2023
Section Cited
CCR80087(a)
| 1
2
3
4
5
6
7 | Buildings and Grounds: (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not being met as evidenced by: | 1
2
3
4
5
6
7 | Licensee agrees to provide a plan to repair the wall and provide to LPA by POC date. |
| 8
9
10
11
12
13
14 | Based on LPA observation, there was a hole in the wall in the living room. This is a potential health and safety risk to clients in care. | 8
9
10
11
12
13
14 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
08/16/2023
Section Cited
CCR
85064(b)
| 1
2
3
4
5
6
7 | Administrator Qualifications and Duties: (b) All adult residential facilities shall have a certified administrator. This requirement was not being met as evidenced by: | 1
2
3
4
5
6
7 | Licensee agrees to submit a plan to how their Administrator Certificate will be submitted by POC date. |
| 8
9
10
11
12
13
14 | Based on LPA record review, and Licensee interview, LPA found that the Administrator did not submit the required documents in time to keep their certificate current. This poses an immediate health and safety risk to clients in care. | 8
9
10
11
12
13
14 | |
Type A
08/15/2023
Section Cited
CCR80075(k)(1)
| 1
2
3
4
5
6
7 | Health Related Services: (k)..:(1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not being met as evidenced by: | 1
2
3
4
5
6
7 | Licensee replaced the lock to the medication while conducting visit. Additionally, Licensee to conduct in-service training on the cited regulation and submit proof by POC date. |
| 8
9
10
11
12
13
14 | Based on observation, client medications were accessible to clients in care. This is an immediate health and safety risk to clients in care. | 8
9
10
11
12
13
14 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
08/16/2023
Section Cited
CCR
80087(g)
| 1
2
3
4
5
6
7 | Buildings and Grounds: (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not being met as evidenced by: | 1
2
3
4
5
6
7 | Licensee provided a lock to the chemicals during the visit. Additionally, in-service training to be conducted and proof submitted to CCL by POC date. |
| 8
9
10
11
12
13
14 | Based on observation, LPA noted that the cabinet in the kitchen containing chemicals was accessible to clients in care. This poses an immediate health and safety risk to clients in care. | 8
9
10
11
12
13
14 | |
Type B
08/29/2023
Section Cited
CCR80070(b)(10)
| 1
2
3
4
5
6
7 | Client Records: (b) Each record must contain information including, but not limited to, the following: (10) Record of current medications, including the name of the prescribing physician, and instructions, if any, regarding control and custody of medications.This requirement was not being met as evidenced by: | 1
2
3
4
5
6
7 | Licensee agrees to rectify C2's medication list by their physician. Additionally, in-service training to be conducted and proof submitted to CCL by POC date. |
| 8
9
10
11
12
13
14 | Based on observation, LPA found that there was a void of C2's current medication list by C2's physician. This poses a potential health and safety risk to clients in care. | 8
9
10
11
12
13
14 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
08/16/2023
Section Cited
CCR
80087(g)(1)
| 1
2
3
4
5
6
7 | Buildings and Grounds: (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement was not being met as evidenced by: | 1
2
3
4
5
6
7 | Licensee stated that they will replace the lock with a locking mechanism by POC date. Additionally, Licensee will conduct in-service training to all staff and provide proof of such by POC date. |
| 8
9
10
11
12
13
14 | Based on Interview with Licensee, LPA found that C2 took an "electric saw" and sold it. When asked how he obtained it, Licensee stated that C2 took it from the garage. Upon inspection, the garage has a twist lock that allows access from the facility. This poses an immediate health and safety risk to clients in care. | 8
9
10
11
12
13
14 | |
Type B
08/29/2023
Section Cited
CCR80087(d)
| 1
2
3
4
5
6
7 | Buildings and Grounds: (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not being met as evidenced by: | 1
2
3
4
5
6
7 | Licensee agrees to replace and/or fix the light in C1's room, as well as the hallway light. Licensee agrees to conduct in-service training to staff on the cited regulation and provide proof of such by POC date. |
| 8
9
10
11
12
13
14 | Based on LPA observation, LPA found that the light switch doesn't work in C1's room. Additionally, a light fixture was missing a bulb in the hallway. This poses a potential health and safety risk to clients in care. | 8
9
10
11
12
13
14 | |