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32 | Allegation: Resident left on floor for extended period of time.
On 7/25/21 R1 sustained a fall where there was a bump, and laceration that was not bleeding on the back of R1's head. Steven explained that the call system was temporarily not working and that staff was given the directive to check on the outside perimeter residents every 20-30 minutes. Steven stated "to be honest that there is no way to tell how long R1 was left on the floor." There is an entry in the communication logs that revealed Staff #1 (S1), whom was on shift at the time of the fall, and made an entry reporting the incident however, the entry is vague and does not match with what was reported. Additionally in the communication logs reviewed in a different entry it states that R1 stated that they were on the floor calling for help for awhile. The allegation of Resident left on floor for extended period of time is SUBSTANTIATED.
Allegation: Resident not provided comfortable temperature.
LPA conducted a tour of the physical plant. LPA observed that the facility has three separate cooling systems, one for each side of the home. The thermostat where Resident #1 (R1) room is (left side, facing standing at the front door), revealed that it was 79 degrees inside, the current outside temperature at the time of the visit was 98 degrees. LPA did observe a ceiling fan that was not in use in R1s room. LPA conducted interviews and R1 stated that yes at times it does get warm inside of their room. Based on observation and interviews the allegation of Resident not provided comfortable temperature is SUBSTANTIATED.
Allegation: Facility is in disrepair
LPA conducted a tour of the physical plant and observed there to be old Christmas lights still hung, and one of the string of lights hanging down in the front of the facility. Also in the front entrance there were boxes on the table and patio furniture, bunched together. LPA observed in the backyard to certain areas of clutter: wheelchair, several boxes, trash cans, dolly, buckets, storage containers, and cat trees stacked in the backyard, up against the fence and the wall. Therefore the allegation of Facility is in disrepair is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.
An exit interview was conducted and a copy of this report, and appeal rights were provided to Administrator Steven Rajadas. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
08/03/2021
Section Cited
HSC
1569.269(a)(6) | 1
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7 | 1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) 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. Based on observation interview and record review the licensee failed to provide adequate care and supervision 1 out of 1 time. This poses an immediate health, safety and personal rights risk to persons in care.
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7 | The licensee agrees to relocate R1 so that staff can provide adequate care and supervision. The room change has already been made, nothing futher is needed. |
Type B
08/16/2021
Section Cited
HSC
1569.269(a)(10) | 1
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7 | 1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (10)To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental abuse... Based on observation, interview and record review the licensee did not ensure that R1 was not neglected 1 out of 1 times. This poses a potential health, safety and person rights risk to persons in care. | 1
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7 | The licensee agrees to conduct an in-service on care and supervision. Proof is to be submitted to the department by 5pm, on the due date indicated. |
Type B
08/16/2021
Section Cited
CCR
87303(b)(2) | 1
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7 | 87303 Maintenance and Operation
(b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. Based on observation, interview and record review the licensee did not ensure that the facility was kept at a comfortable temperature 1 out of 1 times. This poses a potential health, safety and person rights risk to persons in care.
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7 | The licensee agrees to conduct an in-service on heat induced illnesses and submit proof to the department by 5pm on the due date indicated. |
Type B
08/16/2021
Section Cited
CCR
80087(c) | 1
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7 | 80087 Buildings and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. Based on observation, interview and record review the licensee did not ensure that the facility was free from obstruction 1 out of 1 times. This poses a potential health, safety and person rights risk to persons in care.
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7 | The licensee agrees to move the items to one of the 3 storage sheds on the property by 5pm on submit proof by virtual visit by the due date. Licensee will cotnact LPA by 5pm. |