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25 | Licensing Program Analyst (LPA) Michelle Echeverria arrived at the facility unannounced to conduct a Case Management Visit. This case management visit is in response to a report sent to CCL on 12/12/23. LPA was greeted and met by Staff Danielle Baysinger at the front door. LPA introduced self and stated purpose of the visit. LPA phone called the Licensee/Administrator Roy Baysinger to inform him about the unannounced case management visit.
On 12/13/23, LPA Echeverria was notified about discrepancies found by IRC on the clients medication and P&I records.
During today's visit, LPA did a health and safety check, toured the facility, review medication and P&I records. During the tour of the facility, LPA observed the following: window screens missing on the kitchen dining window, living room window, staff bedroom window, and client's bedroom window; a locked side gate on the outside/right side of the facility with an obstructing path on the outside/left side gate next to the garage door; and an unlocked closet where medication and knives are stored. LPA also observed discrepancies while reviewing records. Accessible client records found in the living room, the emergency disaster plan was not updated, the administrator's certificate was expired during 09/2021-09/2023, P&I client records were not accurate and were missing receipts, MARS did not match actual medication provided to clients, and missing incident reports for the medication and P&I discrepancies.
Deficiencies were issued during this visit. An exit interview was conducted where this report LIC809, LIC809D and appeal rights were, reviewed, discussed and then provided to staff, Danielle Baysinger. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
12/18/2023
Section Cited
CCR
80075(k)(1)
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7 | 80075(k)(1) Health Related Services
(k) The following requirements shall apply to medications which are centrally stored:
(1) Medication shall be kept in a safe and locked place that is not accessible...centrally stored medication. This requirement is not met as evidenced by: | 1
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7 | Staff replaced the broken lock on the closet door where medication and sharps are stored. Staff stored the medication on the table inside the locked staff bedroom. Licensee stated that he will host a training with staff on 80075(k)(1) and submit proof to LPA by 01/02/24. |
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14 | Based on observation, the staff did not comply with the section cited above in making medication and sharps inaccessible to clients which poses an immediate health, safety or personal rights risk to persons in care. | 8
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Type B
01/02/2024
Section Cited
CCR80088(b)
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7 | 80088(b) Furniture, Fixtures, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris. This requirement is not met as evidenced by: | 1
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7 | Licensee states that he will replace the window screens in the kitchen, living room, staff bedroom, and client bedroom and submit proof of receipt and picture after installation to LPA via email by POC due date. |
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14 | (h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following:
(1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
01/02/2024
Section Cited
CCR
80072(a)(7)
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7 | 80072(a)(7) Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights...., the following: (7)Not to be locked in any room, building, or facility premises by day or night. This requirement is not met as evidenced by: | 1
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7 | Licensee states that he will remove the lock on the outside right side gate of the facility. Licensee states that he will remove the items obstructing the path from the side exit door of the garage that leads to the outside left side gate. |
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14 | Based on observation, the licensee did not comply with the section cited above by locking and obstructing the paths to the left and right side gates on the outside which poses a potential health, safety or personal rights risk to persons in care. | 8
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Type B
01/02/2024
Section Cited
CCR85064(b)
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7 | 85064(b) Administrator Qualifications and Duties
(b) All adult residential facilities shall have a certified administrator. This requirement was not met as evidenced by: | 1
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7 | Licensee states that he will submit a statement of understanding on regulation 85064(b) and a copy of the renewed certificate and submit proof to LPA via email by POC due date. |
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14 | Based on observation and record review, the licensee did not comply with the section cited above by having an expired administrator certificate from 09/2021-09/2023 which poses a potential health, safety or personal rights risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
01/02/2024
Section Cited
CCR
80026(h)(1)
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7 | 80026(h)(1) Safeguards for Cash Resources, Personal Property, and Valuables of Residents
(h) Each licensee shall maintain accurate records of accounts of...following:(1) Records of..filed in chronological order. This requirement is not met as evidenced by:
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7 | Licensee states that he will submit statement of understanding on 80026(h)(1) and submit proof to LPA via email by POC due date. |
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14 | Based on observation and record review, the licensee did not comply with the section cited above by having accurate records and receipts for all clients P&I which poses a potential health, safety or personal rights risk to persons in care.
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Type B
01/02/2024
Section Cited
CCR80075(b)
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7 | 80075(b) Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement is not met as evidenced by: | 1
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7 | Licensee states that he will host a training with staff on regulation 80075(b) and submit proof of signed attendance sheet to LPA via email by POC due date. |
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14 | Based on observation and record review, the licensee did not comply with the section cited above by ensuring that clients were assisted with their medication which poses a potential health, safety or personal rights risk to persons in care.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
01/02/2024
Section Cited
HSC
1565(d)
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7 | 1565(d) Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee, administrator, or...updated as necessary.
This requirement is not met as evidenced by: | 1
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7 | Licensee states that he will update the Emergency Disaster Plan and submit proof by providing a copy to LPA via email on POC due date. |
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14 | Based on observation and record review, the licensee did not comply with the section cited above by having an updated emergency disaster plan which poses a potential health, safety or personal rights risk to persons in care.
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Type B
01/03/2024
Section Cited
CCR80070(c)(1)
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7 | 80070(c)(1) Client Records
(c) All information and records obtained from or regarding clients shall be confidential.
(1) The licensee shall be responsible for safeguarding the confidentiality of record contents. This requirement is not met as evidenced by: | 1
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7 | Licensee states that he will store records inside the locked closet and make it inaccessible to clients or the public. Licensee will submit a statement of understanding on 80070(c)(1) and submit proof to LPA via email by POC due date. |
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14 | Based on observation, the licensee did not comply with the section cited above by having client records accessible which poses a potential health, safety or personal rights risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
01/02/2024
Section Cited
CCR
80061(b)(1)(E)
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7 | 80061(b)(1)(E) Reporting Requirements
(b) Upon the occurrence, during the operation of.......seven days following the occurrence of such event. (1) Events reported shall include the following: (E) Any....health or safety of any client. This requirement is not met as evidenced by: | 1
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7 | Licensee states that he will host a training with staff on regulation 80061(b)(1)(E) and submit proof of signed attendance sheet to LPA via email by POC due date. |
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14 | Based on observation and record review, the licensee did not comply with the section cited above by not reporting to CCL the discrepancies for clients P&I and medication which poses a potential health, safety or personal rights risk to persons in care | 8
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