Community Care Licensing

Document Has Been Signed on 12/20/2024 03:44 PM - It Cannot Be Edited

FACILITY NAME:	J & M HAPPY GUEST HOME		FACILITY NUMBER:	374601811
ADMINISTRATOR/ DIRECTOR:	MARIA DELGADO		FACILITY TYPE:	740
ADDRESS:	10264 AMBASSADOR AVE		TELEPHONE:	(858) 693-3428
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92126
CAPACITY: 6		CENSUS: 5	DATE:	10/30/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:00 PM
MET WITH:	Licensee, Maria Delgado		TIME VISIT/ INSPECTION COMPLETED:	07:15 PM

SUPERVISORS NAME: Robyn Clark LICENSING EVALUATOR NAME: Natasha Persaud LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024

Link to Parent Document Below:

FACILITY NAME: J & M HAPPY GUEST HOME	FACILITY NUMBER: 374601811
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2024

Type A

Section Cited

CCR

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 interviews and record review, the licensee did not obtain written orders from a physician for 5 out of [R1-R5] residents, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/31/2024
	Plan of Correction
1 2 3 4	Licensee stated she will obtain written orders for every prescription and nonprescription PRN medication and place them in the resident's file. Licensee explained needing more time to obtain the orders. Licensee agreed to schedule medication training by POC due date and complete training within 2 weeks.

Type A

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care. The following requirements shall apply to medications which are centrally stored: Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations the licensee did not ensure pills were stored in its originally received container for 5 out of 5 [R1-R5] residents, by loose medications in resident’s baskets/medication storage containers, which posed a potential health and safety risk to residents in care.
	POC Due Date: 10/31/2024
	Plan of Correction
1 2 3 4	Licensee stated she was uncertain how the pills were loose and not in its original container. Licensee agreed to attend medication training along with staff. Licensee will schedule training by tomorrow, POC due date, provide proof of scheduled training and submit proof of training within 2 weeks.

SUPERVISOR'S NAME: Robyn Clark LICENSING EVALUATOR NAME: Natasha Persaud LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024

Link to Parent Document Below:

FACILITY NAME: J & M HAPPY GUEST HOME	FACILITY NUMBER: 374601811
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2024

Type B

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 record review, the licensee did not ensure staff had a health screening and TB test results on file for 1 out of 4 [S2] staff which poses/posed a potential health and safety risk to persons in care.
	POC Due Date: 11/27/2024
	Plan of Correction
1 2 3 4	Licensee stated staff will obtain a health screening and TB test results. Licensee will submit proof of documentation by POC due date.

SUPERVISOR'S NAME: Robyn Clark LICENSING EVALUATOR NAME: Natasha Persaud LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024

Link to Parent Document Below:

FACILITY NAME: J & M HAPPY GUEST HOME	FACILITY NUMBER: 374601811
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2024

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not ensure the facility was in good repair for 5 out of 5 [R1-R5] residents, due to a torn screen on the sliding door, flickering light in the main bathroom, and shower in main bathroom having debris/mold which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/27/2024
	Plan of Correction
1 2 3 4	Licensee stated she will repair or replace screen and light, as well as clean the shower by POC due date.

Type B

Section Cited

CCR

87307(a)(3)(C)

(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations and interviews, the licensee did not ensure appropriate bedding was on 5 out of 5 [R1-R5] residents which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/27/2024
	Plan of Correction
1 2 3 4	Licensee stated she will ensure appropriate bedding is on all residents beds by POC due date.

SUPERVISOR'S NAME: Robyn Clark LICENSING EVALUATOR NAME: Natasha Persaud LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024

Link to Parent Document Below:

FACILITY NAME: J & M HAPPY GUEST HOME	FACILITY NUMBER: 374601811
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2024

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 record review, the licensee did not comply with the section cited above in 1 out of 4 [S1] staff by not having First Aid/CPR training which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/27/2024
	Plan of Correction
1 2 3 4	Licensee stated she will attend First Aid and CPR training and provide proof of training by POC due date.

Type B

Section Cited

CCR

87465(a)(8)

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above for 5 out of 5 [R1-R5] residents by not having dressing, bandages, antiseptic solution, and current First Aid manual which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/27/2024
	Plan of Correction
1 2 3 4	Licensee stated she will purchase the items and place them in the First Aid kit by POC due date.

SUPERVISOR'S NAME: Robyn Clark LICENSING EVALUATOR NAME: Natasha Persaud LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024

Link to Parent Document Below:

FACILITY NAME: J & M HAPPY GUEST HOME	FACILITY NUMBER: 374601811
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2024

Type B

Section Cited

HSC

1569.695(b)

(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews and record review, the licensee did not conduct training on the Emergency Disaster Plan for 4 out of 5 staff, which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/27/2024
	Plan of Correction
1 2 3 4	Licensee stated she will conduct emergency disaster training and place proof of training in facility file by POC due date.

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 interviews and record review, the licensee did not conduct disaster drills for 4 out of 5 staff, which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/27/2024
	Plan of Correction
1 2 3 4	Licensee stated she will start conducting and documenting disaster drills. Licensee will place proof of training in facility file by POC due date.

SUPERVISOR'S NAME: Robyn Clark LICENSING EVALUATOR NAME: Natasha Persaud LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024

Link to Parent Document Below:

FACILITY NAME: J & M HAPPY GUEST HOME	FACILITY NUMBER: 374601811
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2024

Type B

Section Cited

CCR

87465(i)

Incidental Medical and Dental Care. Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews the licensee did not ensure prescriptions are being destroyed appropriately for 5 out of 5 [R1-R5] residents, which poses a potential health and safety risk to residents in care.
	POC Due Date: 11/27/2024
	Plan of Correction
1 2 3 4	Licensee stated she didn’t know she couldn’t throw the medications away in the trash. Licensee stated she will document all medications requiring destruction and package them up and take them to the pharmacy for destruction. Licensee will attend medication training along with staff and provide proof of training.

Type B

Section Cited

CCR

87613(a)(2)

Prior to admission of a resident with a restricted health condition, the licensee shall: Ensure that facility staff who will participate in meeting the resident’s specialized care needs complete training provided by a licensed professional sufficient to meet those needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews and record review, the licensee did not ensure staff have documented training on Stage 2 wound care and indwelling catheter for 2 out of 5 [R1-R2] residents, which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/27/2024
	Plan of Correction
1 2 3 4	Licensee and staff will attend training on restricted health care conditions regarding Stage 2 wound care and indwelling catheter and provide proof of training by POC due date.

SUPERVISOR'S NAME: Robyn Clark LICENSING EVALUATOR NAME: Natasha Persaud LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024

Link to Parent Document Below:

FACILITY NAME: J & M HAPPY GUEST HOME	FACILITY NUMBER: 374601811
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2024

Type B

Section Cited

CCR

87506(a)

Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified 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 5 out of 5 [R1-R5] residents, by having incomplete or missing required documentation which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/27/2024
	Plan of Correction
1 2 3 4	Licensee stated she will update residents records to ensure all required documentation in on file by POC due date.

Type B

Section Cited

CCR

87465(h)(6)

The following requirements shall apply to medications which are centrally stored: The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews and record review, the licensee did not document centrally stored medications for 5 out of 5 [R1-R5] residents, which poses a potential health and safety risk to residents in care.
	POC Due Date: 11/27/2024
	Plan of Correction
1 2 3 4	Licensee stated she will document the Centrally Stored Medication Destruction Record for all residents and place it in the resident's file by POC due date.

SUPERVISOR'S NAME: Robyn Clark LICENSING EVALUATOR NAME: Natasha Persaud LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024

Link to Parent Document Below:

FACILITY NAME: J & M HAPPY GUEST HOME	FACILITY NUMBER: 374601811
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/30/2024

Type B

Section Cited

CCR

87633(d)

The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client’s care needs are being met at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews and record review, the licensee did not ensure a current plan including pressure injuries were on file for 1 out of 5 [R1] residents, which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/27/2024
	Plan of Correction
1 2 3 4	Licensee stated she will obtain a current hospice care plan and ensure resident hospice records has required documentation 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: Robyn Clark LICENSING EVALUATOR NAME: Natasha Persaud LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024