Community Care Licensing

SUPERVISOR'S NAME: Czarrina A Camilon-Lee TELEPHONE: (916) 263-4723 LICENSING EVALUATOR NAME: Kevin Gould TELEPHONE: (619) 672-5924 LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023

Document Has Been Signed on 03/08/2023 04:40 PM - It Cannot Be Edited

FACILITY NAME: OHANA HOSPITALITY	FACILITY NUMBER: 347004197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2023

Type A

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs review of staff records, the licensee did not comply with the section cited above in 2 out of 3 staff files reviewed did not have any record of a staff health screening report or TB test for present staff members which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/09/2023
	Plan of Correction
1 2 3 4	Licensee has agreed to, by the POC due date, to schedule the appointments for Health screening for the two staff members identified as not having a current health screening and TB test.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee TELEPHONE: (916) 263-4723 LICENSING EVALUATOR NAME: Kevin Gould TELEPHONE: (619) 672-5924 LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023

Document Has Been Signed on 03/08/2023 04:40 PM - It Cannot Be Edited

FACILITY NAME: OHANA HOSPITALITY	FACILITY NUMBER: 347004197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2023

Type B

Section Cited

HSC

1569.605

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on an interview with the licensee, the licensee did not comply with the section cited above as the facility does not currently have any liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/22/2023
	Plan of Correction
1 2 3 4	licensee has agreed to obtain liability insurance by the POC due date.

Type B

Section Cited

CCR

87412(a)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs review of staff files, the licensee did not comply with the section cited above for two out of three staff files reviewed where the licensee could not provide any staff file documentation other than CPR/first aid and criminal record clearances which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	LPAs provided licensee directions for all forms required for a staff file. Licensee will ensure staff files are complete by the POC due date.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee TELEPHONE: (916) 263-4723 LICENSING EVALUATOR NAME: Kevin Gould TELEPHONE: (619) 672-5924 LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023

Document Has Been Signed on 03/08/2023 04:40 PM - It Cannot Be Edited

FACILITY NAME: OHANA HOSPITALITY	FACILITY NUMBER: 347004197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2023

Type B

Section Cited

CCR

87411(d)

(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:
	Deficient Practice Statement
1 2 3 4	Based on LPA review of staff records the licensee did not comply with the section cited above in two of three staff files reviewed as there were no record of training hours provided to staff which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	Licensee will ensure facility staff receive all required staff training by the POC due date. Licensee will also submit a written plan of correction on the steps facility will put in place to ensure all staff receive required training.

Section Cited

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

SUPERVISOR'S NAME: Czarrina A Camilon-Lee TELEPHONE: (916) 263-4723 LICENSING EVALUATOR NAME: Kevin Gould TELEPHONE: (619) 672-5924 LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023

Document Has Been Signed on 03/08/2023 04:40 PM - It Cannot Be Edited

FACILITY NAME: OHANA HOSPITALITY	FACILITY NUMBER: 347004197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2023

Type B

Section Cited

HSC

1569.625(b)(1)

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA review of staff records and the present of two residents with a diagnosis of dementia, the licensee did not comply with the section cited above in two out of three staff files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	licensee will ensure staff receive dementia care training that meets requirements. Licensee will submit evidence of staff training to the department by the POC due date.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee TELEPHONE: (916) 263-4723 LICENSING EVALUATOR NAME: Kevin Gould TELEPHONE: (619) 672-5924 LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023

Document Has Been Signed on 03/08/2023 04:40 PM - It Cannot Be Edited

FACILITY NAME: OHANA HOSPITALITY	FACILITY NUMBER: 347004197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2023

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 LPA review of staff records, the licensee did not comply with the section cited above in two out of three staff files reviewed and the presence of two residents on hospice with no documented hospice training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	licensee will ensure staff receive hospice care training that meets requirements. Licensee will submit evidence of staff training to the department by the POC due date.

Type B

Section Cited

CCR

87463(a)

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on of resident records, the licensee did not comply with the section cited above in two out of four resident records reviewed which documented two residents with dementia and their physician reports had not been updated annually which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Licensee has agreed to make an appointment with the resident's primary care physician by the POC due date and provide evidence of the appointment to Licensing.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee TELEPHONE: (916) 263-4723 LICENSING EVALUATOR NAME: Kevin Gould TELEPHONE: (619) 672-5924 LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023

Document Has Been Signed on 03/08/2023 04:40 PM - It Cannot Be Edited

FACILITY NAME: OHANA HOSPITALITY	FACILITY NUMBER: 347004197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2023

Type B

Section Cited

CCR

87705(c)(3)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of staff files, the licensee did not comply with the section cited above in two of three staff files reviewed did not address training requirements for care with residents of dementia which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/31/2023
	Plan of Correction
1 2 3 4	licensee will ensure staff receive dementia care training that meets requirements. Licensee will submit evidence of staff training to the department by the POC due date.

Type B

Section Cited

CCR

87705(c)(6)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of resident files LPAs observed two residents with dementia who did not have documented annual reappraisals, the licensee did not comply with the section cited above in two out of four staff files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/24/2023
	Plan of Correction
1 2 3 4	Licensee has agreed to make an appointment with the resident's primary care physician by the POC due date and provide evidence of the appointment to Licensing.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee TELEPHONE: (916) 263-4723 LICENSING EVALUATOR NAME: Kevin Gould TELEPHONE: (619) 672-5924 LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2023