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
26
27
28
29
30
31
32 | It was further alleged that staff are in a room at night, and if residents need something they have to knock on a staff door for assistance. LPA found that, through interviews with residents and staff that night shift staff sleep during the night, and do not remain awake to assist and direct residents. The facility was found to have dementia residents in care via R2's Physician's Report, and that comes with a requirement that there is awake staff. Thus, this allegation was SUBSTANTIATED.
It was then alleged that staff tie a resident to a chair at night to prevent them from wandering into other resident's rooms. Through interviews with staff, LPA found that R2 is restrained to a rocking chair in the living room with a sheet to prevent R2 from walking throughout the facility at night. Staff were found to sleep after R2 is asleep in their chair. Thus, this allegation was SUBSTANTIATED.
It was also alleged that there are three residents sharing the same room. Upon inspection, LPA observed three residents, Resident 4 (R4), Resident 5, (R5), and Resident 6 (R6) sharing the same bedroom. Thus, this allegation was SUBSTANTIATED.
The facility was issued 4 citations per Title 22. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.
An exit interview was conducted where a copy of this report was discussed with and provided along with copies of the LIC9099, LIC9099-C, LIC9099-D, LIC811, and Appeal Rights. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
03/10/2023
Section Cited
CCR
87705(4)(a) | 1
2
3
4
5
6
7 | Care of Persons with Dementia
(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
(A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement was not being met as evidenced by: | 1
2
3
4
5
6
7 | Licensee agrees to develop a plan how they are going to address staff sleeping at night time, and submit to LPA by POC date. |
 | 8
9
10
11
12
13
14 | Based on interviews with staff, LPA found that staff sleep during the night shift. Administrator is aware of this, and found that as long as nothing is going on, it was permitted. This is an immediate health and safety risk to residents in care. | 8
9
10
11
12
13
14 | |
Type A
03/10/2023
Section Cited
CCR
87468.2(a)(4) | 1
2
3
4
5
6
7 | Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This was not being met as evidenced by: | 1
2
3
4
5
6
7 | Licensee agrees to submit in-service training regarding the personal rights of residents in care, and submit to LPA by POC date. |
| 8
9
10
11
12
13
14 | Based on staff interviews, LPA found that R2 was secured to a rocking chair at night to prevent them from walking throughout the facility. This presents an immediate personal rights risk to residents in care. | 8
9
10
11
12
13
14 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
03/23/2023
Section Cited
CCR
87307(a)(2)(D) | 1
2
3
4
5
6
7 | 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. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (D) Not more than two residents shall sleep in a bedroom. This requirement was not being met as evidenced by: | 1
2
3
4
5
6
7 | Licensee stated that they will relocate a resident from Room #6 to adhere to the regulation and submit proof of such by POC date. |
| 8
9
10
11
12
13
14 | Based on observation, and interview, LPA found three residents residing in the same room. This presents a potential health and safety and personal rights risk to residents in care. | 8
9
10
11
12
13
14 | |
Type B
03/16/2023
Section Cited
CCR
87307(a)(3)(B) | 1
2
3
4
5
6
7 | 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. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This was not being met as evidenced by: | 1
2
3
4
5
6
7 | Licensee stated they will provide a chest of drawers to the resident and provide proof of such to LPA by POC date. |
| 8
9
10
11
12
13
14 | Based on LPA observation, and interview with staff, R1 has clothes in plastic bags on their floor. LPA did not observe a chest that was capable of storing all of R1's belongings. | 8
9
10
11
12
13
14 | |