Community Care Licensing

Document Has Been Signed on 08/08/2024 11:48 AM - It Cannot Be Edited

FACILITY NAME:	FOUR SEASONS CARE HOME		FACILITY NUMBER:	347004228
ADMINISTRATOR/ DIRECTOR:	IOAN NAGY		FACILITY TYPE:	740
ADDRESS:	8322 CENTRAL AVENUE		TELEPHONE:	(916) 910-9419
CITY:	ORANGEVALE	STATE: CA	ZIP CODE:	95662
CAPACITY: 6		CENSUS: 3	DATE:	08/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Administrator, Ioan Nagy		TIME VISIT/ INSPECTION COMPLETED:	12:00 PM

SUPERVISORS NAME: Laura Munoz LICENSING EVALUATOR NAME: Talwinder Bains LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024

Link to Parent Document Below:

FACILITY NAME: FOUR SEASONS CARE HOME	FACILITY NUMBER: 347004228
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2024

Type A

Section Cited

CCR

87465(c)(2)

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on medications count, record review and staff's interviews, it was noted that for resident, R2- No update medications order list for resident R2 for 2024 in thier file, Expired Eye Drops x4 bottles, Aspirin 81mg (wrong medication), Alendronate Sodium Tablet-70mg-1tablet every friday with start date 06/17/24, sholud have 5 tablets out of 12 but count was 8 tablets ON HAND and FOR R1- Bupropion HCL 150MG-1 tablet twice a day with start date 05/21/24,180 tablets filled 05/21/24, count was OVER 69 tablets ,Simvastin 20 mg, 100 tablets filled on 05/17/24, start date- 05/17/24, 19 tablets extra during today's count which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2024
	Plan of Correction
1 2 3 4	Administrator shall send a letter of understanding of this Regulation by 08/09/24 to Department and shall ensure to have updated Med List for all residents, shall keep proper record of Centrally Stored Log for all medications. All POC documents are due by 08/09/24.

Section Cited

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

SUPERVISOR'S NAME: Laura Munoz LICENSING EVALUATOR NAME: Talwinder Bains LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024

Link to Parent Document Below:

FACILITY NAME: FOUR SEASONS CARE HOME	FACILITY NUMBER: 347004228
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2024

Type B

Section Cited

CCR

87202(a)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observations, facility has one fire extinguisher which was last serviced in 2022 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	The Licensee agrees to have the fire extinguisher serviced and will send a receipt and/or photograph of the fire extinguisher having been serviced. The receipt/photograph will be due by the POC due date - 08/22/24.

Type B

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	LPA observed that facility's laundry room has no lock on the door and has disinfectants, cleaning solutions which were accessible to residents and poses a potential health and safety risks to residents in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	Licensee will send the letter of understanding of this regulation and will train staff regarding this regulation and will send training documents to CCL. POC due date - 08/22/24.

SUPERVISOR'S NAME: Laura Munoz LICENSING EVALUATOR NAME: Talwinder Bains LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024

Link to Parent Document Below:

FACILITY NAME: FOUR SEASONS CARE HOME	FACILITY NUMBER: 347004228
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2024

Type B

Section Cited

CCR

87555(b)(8)

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations in pantry and kittchen area, LPA found mulpile food items with expired dates which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2024
	Plan of Correction
1 2 3 4	Administrator shall submit a letter of understanding of this Regulation to CCL and ensure that all expired food items will be removed. Addiontionaly, facility shall ensure that plan will be implemented to remove all expired food items in future. All POC documents are due by 08/22/24.

Type B

Section Cited

CCR

87506(b)

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff's interview and record review, the licensee did not comply with the section cited above as LPA found , Missing Consent Form, Pre-Admission Appraisal, Personal Belongings form, Personal Rights Form for Resident,R1 file and Missing Consent Form, Personal Belongings form, Personal Rights Form for Resident,R2 file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/31/2024
	Plan of Correction
1 2 3 4	Administrator will send a letter of understanding of this Regulation and will ensure that all residents files have all required documents per this Regulation and send proof to CCL once completed. All POC documents are due by 08/31/24.

SUPERVISOR'S NAME: Laura Munoz LICENSING EVALUATOR NAME: Talwinder Bains LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024

Link to Parent Document Below:

FACILITY NAME: FOUR SEASONS CARE HOME	FACILITY NUMBER: 347004228
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2024

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff's interview and record review, the licensee did not comply with the section cited above as facility was Not doing required fire and disaster quarterly drills which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/08/2024
	Plan of Correction
1 2 3 4	Facility shall conduct fire and disaster quarterly drill and will keep the record for Departmental review. All POC documents are due by 09/08/24.

Section Cited

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

SUPERVISOR'S NAME: Laura Munoz LICENSING EVALUATOR NAME: Talwinder Bains LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024