Community Care Licensing

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024

Document Has Been Signed on 02/22/2024 02:11 PM - It Cannot Be Edited

FACILITY NAME: CHATEAU SABELLE	FACILITY NUMBER: 415600105
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/23/2024 Section Cited CCR 87608(a)(5)(B)	1 2 3 4 5 6 7	POSTURAL SUPPORTS Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met, as 3 residents are observed with 2 half bed	1 2 3 4 5 6 7	Plan/proof of corrections to be submitted to CCLD BY DUE DATE Bottom half bed rails for client #2 are removed from bed in LPA's presence
	8 9 10 11 12 13 14	rails on their beds, forming full bed rails. Licensee failed to prohibit use of full bed rails, which poses an immediate health, safety or personal rights risk to clients in care. Clients #1, #2, #3 are observed with 2 half bed rails on their beds; C3 has 2 half rails on one side of the bed only.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024

Document Has Been Signed on 02/22/2024 02:11 PM - It Cannot Be Edited

FACILITY NAME: CHATEAU SABELLE	FACILITY NUMBER: 415600105
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/07/2024 Section Cited CCR 87465(h)(5)	1 2 3 4 5 6 7	INCIDENTAL MEDICAL CARE 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 7 plastic medisets are observed with clients' meds	1 2 3 4 5 6 7	Staff shall immediately cease pre-pouring medications. Plan/proof of correction shall be submitted to CCLD BY DUE DATE
	8 9 10 11 12 13 14	in small plastic containers. Each mediset contains 6 clients' meds for one day. Licensee failed to ensure that medications are maintained in originally received container, which poses a potential health, safety or personal rights risk to clients in care.	8 9 10 11 12 13 14
Type B 03/07/2024 Section Cited CCR87465(h)(6)	1 2 3 4 5 6 7	INCIDENTAL MEDICAL CARE A record of centrally stored prescription medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started & expiration, prescription number and	1 2 3 4 5 6 7	Administrator to ensure that all clients' medications are recorded on Centrally Stored Medications Records. Plan/proof of corrections to be sent to CCLD BY DUE DATE
	8 9 10 11 12 13 14	instructions: This requirement was not met, as 4 Rx medications for client #6 and 1 med and 4 OTC supplements for client #5 are not recorded on Centrally Stored Medications Records. Licensee failed to ensure meds are logged in CSMRs, which poses a potential health, safety or personal rights risk.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Audrey Jeung TELEPHONE: (650) 266-8891 LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2024