Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
04/18/2024
Section Cited
HSC
1569.312(a)
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7 | 1569.312(a) Basic services requirements
Every facility required to be licensed under this chapter shall provide at least the following basic services:
(a) Care and supervision as defined in Section 1569.2.
This requirement is not met as evidenced by:
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7 | The facility shall conduct an in-service training on basic services with staff to go over what and how staff shall ensure that residents do not AWOL. Administrator shall send the in-service training materials, plan on how staff will ensure residents do not AWOL and a signature sheet of all staff who attended. |
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14 | Based on interviews and records review, the facility did not comply with section cited above in 1569.312(a). R1 AWOL'D from facility. The LIC 602 states the resident was not allowed to leave the facility unassisted. This presents an immediate health and safety risk to the resident in care. | 8
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14 | A statement of correction will also be completed and submitted to LPA Lee. The Administrator shall email the date of the in-service training, plans to ensure resident do not AWOL and statement of acknowledgement to LPA by POC date 04/18/2024 end of day 5:00 PM. Administrator will also conduct a house rules meet with residents. |
Type B
04/19/2024
Section Cited
CCR87705(c)(5)
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7 | 87705(c)(5) Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
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7 | The facility designated Administrator stated that all residents diagnosed with dementia and all resident will be scheduled for a medical appointment with their attending licensed medical professional to obtain an updated medical assessment in order to address any changes in their care needs related to dementia care.
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14 | Based on record review, the licensee did not comply with the section cited above. Facility residents diagnosed with dementia did not have an updated annual medical assessment which poses a potential health, safety, or personal rights risk to persons in care. | 8
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14 | Administrator will send copies of (R1) new LIC 602 and other residents who needs a medical assessment to LPA Lee. A statement of correction and understanding of the regulation cited, along with copy of updated annual medical assessment, will be completed and submitted into LPA Lee by POC dated 04/19/2024 by end of day. Licensee will email LPA Lee medical assessment appointment for all 6 residents by 04/19/2024.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
04/19/2024
Section Cited
CCR
87211(a)(1)(D
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7 | 87211(a)(1)(D) Reporting Requirement
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below…
(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement is not met as evidenced by:
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7 | The administrator agrees to review the regulation cited. A statement of correction and understanding of the regulation will be completed and submitted into LPA Lee at pang.lee@dss.ca.gov by POC date 04/19/2024 end of day 5:00 PM. The administrator will ensure that a written report will be submitted to the department and the resident’s responsible party for all incidents. |
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14 | Based on interviews and records review, the licensee did not ensure that an incident where (R1) AWOL from the facility was not reported to the department which poses an potential health, safety, or personal rights risk to persons in care.
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Type B
04/19/2024
Section Cited
CCR87405(d)
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7 | 87405 Administrator - Qualifications and Duties
d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
(2) Knowledge of and ability to conform to the applicable laws, rules, and regulations.
This requirement is not met as evidenced by:
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7 | The administrator agrees to review the regulation cited. A statement of correction and understanding of the regulation will be completed and submitted into LPA Lee at pang.lee@dss.ca.gov by POC date 04/19/2024 end of day 5:00 PM. |
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14 | Based on interviews and records review a resident AWOL from the facility and the licensee did not notify the department and provided a LIC 624 incident report which poses an potential health, safety, or personal rights to persons in care. | 8
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