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25 | Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit to conduct a Health & Safety Welfare Check. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Site Manager Anafe Rivera.
During today’s visit, LPA performed a facility tour / welfare check, collected and reviewed select resident care records, and interviewed staff. Staff interviews corroborated to show:
a) On 02/10/2024 during the overnight shift, Resident #1 (R1) closed the drain of their sink in their private bathroom, and then let the sink faucet run continuously. [See LIC811 Confidential Names List for a description of person identifiers use in this report.] Staff, who were not required to be awake at this time, were not immediately aware of the problem. The result was that water spilled onto the facility’s floor, flooding R1’s bedroom, two adjacent bedrooms and their corresponding bathrooms, and one edge of the facility’s dining room. Multiple staff spent a few hours cleaning up the water. None of the facility’s residents needed to be relocated. Per LPA review of CCLD’s database, the Department did not receive a written report from Licensee describing this incident, as was required to be submitted within seven (7) days of occurrence.
b) On 02/16/2024, R1 passed away at the facility, under the concurrent care of a hospice agency. Per LPA review of CCLD’s database, the Department did not receive a written report from Licensee describing R1’s death, as was required to be submitted within seven (7) days of occurrence.
[CONTINUED ON LIC 809-C] |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
04/19/2024
Section Cited
CCR
87211(a)(1)(D)
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7 | 87211 Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency…within seven days of the occurrence of any of the events specified...(D) Any incident which threatens the welfare, safety or health of any resident." | 1
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7 | Licensee agreed to compose an LIC624 Incident Report describing the February 2024 sink-flooding incident, and to send a copy of the LIC624 to the CCLD San Diego Regional Office (CCLASCPSanDiegoRO@dss.ca.gov). Licensee agreed to utilize a third-party source to retrain its facility managers on Regulation 87211 Reporting Requirements. Licensee agreed to E-mail LPA the training sign-in sheet by the POC due date. Licensee also agreed to arrange for a third-party licensed mold inspector to examine the facility and provide a formal recommendation as to whether remediation repairs are required. Licensee agree to E-mail the mold inspector's report to LPA, by the POC due date. |
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14 | This requirement was not met, as evidenced by: Based on records and interviews, there was an incident which threatened their welfare of 6 of 6 residents (R1 through Resident #6), and Licensee did not submit a written incident report for it to the licensing agency within seven days of incident occurrence. This posed a potential health, safety, and personal rights risk to persons in care. | 8
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Type B
04/19/2024
Section Cited
CCR87211(a)(1)(A)
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7 | 87211 Reporting Requirements: "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency…within seven days of the occurrence of any of the events specified...(A) Death of any resident from any cause regardless of where the death occurred…” | 1
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7 | Licensee agreed to compose an LIC624A Death Report describing R1’s death and the circumstances leading up to it, and to send a copy of the LIC624A to the CCLD San Diego Regional Office (CCLASCPSanDiegoRO@dss.ca.gov). Licensee agreed to utilize a third-party source to retrain its facility managers on Regulation 87211 Reporting Requirements. Licensee agreed to E-mail LPA the training sign-in sheet by the POC due date. |
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14 | This requirement was not met, as evidenced by: Based on records and interviews, Licensee did not submit a written report to notify the licensing agency of the death of 1 of 6 residents (R1) in care, within seven days of their death. This posed a potential health and safety risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
04/19/2024
Section Cited
HSC
1569.317
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7 | 1569.317 Absentee Notification Plan for Missing Residents: “Every residential care facility for the elderly…shall…develop and comply with an absentee notification plan…The plan shall include…a requirement that an administrator of the facility, or his or her designee, inform the resident’s authorized representative when that resident is missing from the facility…and the circumstances in which [they] shall notify local law enforcement.” | 1
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7 | Licensee agreed to write an Absentee Notification Plan/policy meeting the requirements of CA H&S Code 1569.317, and to train all its staff on it. Licensee also agreed to place a copy of said Absentee Notification Plan in the care file for every current and future client in care, right next to (i.e., as an addendum to) that client’s Needs and Services Plan. Licensee agreed to E-mail the Plan and the training sign-in sheet to LPA, by the POC due date. |
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14 | This requirement was not met, as evidenced by: Based on records and interviews, licensee’s staff did not develop an absentee notification plan for 6 of 6 residents (R1 through Resident #6), which posed a potential safety risk to persons in care. | 8
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Type B
04/19/2024
Section Cited
CCR87705(j)
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7 | 87705 Care of Persons with Dementia: “(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.” This requirement was not met, as evidenced by: | 1
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7 | During today’s visit: Licensee activated (turned on) the auditory alarms at each exterior door (other than the lobby front door). Licensee agreed to retrain its staff to keep all such alarms activated 24/7. Licensee agreed to E-mail a copy of the staff training sign-in sheet to LPA, by the POC due date. |
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14 | Based on records and interviews, during today’s visit, Licensee did not have continuously active auditory devices or other staff alert features to monitor exits, which posed a potential safety risk to 2 of 5 residents (R3 and R4) in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
04/19/2024
Section Cited
CCR
87458(b)(1)
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7 | 87458 Medical Assessment: “(b) The medical assessment shall include…: (1) A physical examination of the resident…and results of an examination for communicable tuberculosis…” This requirement was not met, as evidenced by: | 1
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7 | Per staff interviews and corroborated by LPA observation, R2 has not recently shown any symptoms consistent with tuberculosis (TB). Licensee agreed to coordinate with R2’s physician and/or responsible party, as needed, to have R2 tested for tuberculosis. Licensee agreed to place written proof of a negative TB test result in R2’s care chart, and to E-mail a copy of the proof to LPA, by the POC due date. Licensee also agreed to retrain all facility staff who are directly involved with the admissions/move-in process on Regulation 87458, titled “Medical Assessment,” and to submit the training sign-in sheet to LPA, by the POC due date. |
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14 | Based on records review and manager interview: Licensee did not ensure that the medical assessment for 1 of 5 residents (R2) included the results of an examination for communicable tuberculosis, which posed a potential health and safety risk to persons in care. | 8
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