Community Care Licensing

SUPERVISOR'S NAME: Laura Munoz TELEPHONE: (916) 263-4743 LICENSING EVALUATOR NAME: Cheyenne Ratajczak TELEPHONE: (916) 969-7879 LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2024

Document Has Been Signed on 01/10/2024 03:41 PM - It Cannot Be Edited

FACILITY NAME: BLESSED HOMECARE	FACILITY NUMBER: 342700911
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/10/2024

Type A

Section Cited

CCR

87465(h)(1)(C)

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1out of 1 counts, R1s PRN medication was not centrally stored in R1s room which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/11/2024
	Plan of Correction
1 2 3 4	The PRN medication was moved from the room immediately. Licensee is to submit to LPA Ratajczak a statement of understanding that if a resident is able to centrally store their own medication a locked box is needed for their room.

Section Cited

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

SUPERVISOR'S NAME: Laura Munoz TELEPHONE: (916) 263-4743 LICENSING EVALUATOR NAME: Cheyenne Ratajczak TELEPHONE: (916) 969-7879 LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2024

Document Has Been Signed on 01/10/2024 03:41 PM - It Cannot Be Edited

FACILITY NAME: BLESSED HOMECARE	FACILITY NUMBER: 342700911
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/10/2024

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 2 out of 2 counts, staff files does not have annual trainings which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2024
	Plan of Correction
1 2 3 4	Licensee will submit to LPA Ratajczak a statement of understanding that trainings need to be done annually.

Type B

Section Cited

HSC

87465(e)

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. 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 counts, PRN orders for Naproxen sodium and D3 were not present in R1s file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2024
	Plan of Correction
1 2 3 4	Licensee will submit to LPA Ratajczak a statement of understanding that PRNs for all Residents needs doctor orders. Licensee will also obtain PRN prescriptions for R1s Naproxen sodium and D3.

SUPERVISOR'S NAME: Laura Munoz TELEPHONE: (916) 263-4743 LICENSING EVALUATOR NAME: Cheyenne Ratajczak TELEPHONE: (916) 969-7879 LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2024

Document Has Been Signed on 01/10/2024 03:41 PM - It Cannot Be Edited

FACILITY NAME: BLESSED HOMECARE	FACILITY NUMBER: 342700911
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/10/2024

Type B

Section Cited

HSC

87411(c)(1)

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 staff does not have first aid training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2024
	Plan of Correction
1 2 3 4	Licensee will submit LPA Ratajczak documentation showing S1 has complete their first aid training by POC due date

Section Cited

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

SUPERVISOR'S NAME: Laura Munoz TELEPHONE: (916) 263-4743 LICENSING EVALUATOR NAME: Cheyenne Ratajczak TELEPHONE: (916) 969-7879 LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2024