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13 | Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced facility visit to complete and delivery finding for a complaint investigation received on 3/10/2021. LPA phoned facility for prescreening for COVID-19 precautions.An alyst also self-screened for having no known symptoms or exposure. Analyst followed facility's screening, wore a surgical mask and maintained distance during the visit. LPA discussed with Administrator the conclusion for complaint and the finding.
During the investigation, LPA reviewed documents including, but not limited to two resident files; Medical Records, Physician Reports, Medication Administration Records (MARS), Staff Phone Numbers, and Centrally Stored Medication Logs. LPA interviewed residents, current administrator, and family members. Administrator admitted that no incident reports could be found, except an internal incident report for resident (R1). Previous management company wiped all the computers clean onsite. New management company West Bay Senior Living became effective April 1, 2021.
It was determined in the course of the investigation based on the information provided through documentation, the allegation Resident did not receive medical care in a timely manner was substantiated meaning that there was a preponderance of evidence to prove that the allegations occurred as reported. The preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. The following deficiencies were cited on 9099-D per Title 22, Division 6 of the California Code of Regulations.
Failure to correct the deficiencies may result in civil penalties.
Exit interview was conducted with Administrator. Copy of the reports were provided to Administrator LIC 9099, LIC 9099-D, Appeal Rights, Confidential Names list (LIC811), and Client Record Review (LIC 858).
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| Substantiated | Estimated Days of Completion: |
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
06/22/2021
Section Cited
CCR
87468.2(a)(1)(4) | 1
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7 | 87468.2(a)(1)(4) 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:
(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.
(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 requirement is not met as evidenced by:
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7 | Licensee will submit a plan via email to LPA by 6/22/21 as to how the facility will ensure there is sufficient staffing to meet resident needs for personal care and medical treatment.
ruth.wallace@dss.ca.gov
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14 | Based on LPA’s review of resident (R1’s) medical documents, interviews, and observations the licensee did not to seek medical treatment, care, or have sufficient staffing needs for R1. R1 fell and was not able to receive help from staff for approximately two hours after yelling numerous times during that time period. R1 finally was able to get back to bed to call the front desk. This poses an immediate health and safety risk to residents in care. | 8
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Type B
06/28/2021
Section Cited
CCR
87411(a)(d) | 1
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7 | 87411(a)(d) Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports…
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:
This requirement is not met as evidenced by:
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7 | Licensee will submit a plan via email to LPA by 6/28/21 as to how the facility will ensure all personnel have sufficient numbers and competent to provide services to meet resident needs. Job training and skills need to be included in plan for safe and effective job performance for residents.
ruth.wallace@dss.ca.gov
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14 | Based on LPA’s review of resident (R1’s) medical documents, interviews, and observations the licensee did not have sufficient staffing, job training, or skill evidenced by safe and effective job performance for R1. This poses a potential health and safety risk for residents in care. | 8
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