Community Care Licensing

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Murial Han TELEPHONE: (619) 209-9761 LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023

FACILITY NAME: AHAU BOARDING CARE HOME	FACILITY NUMBER: 415600358
	VISIT DATE: 12/12/2023

FACILITY NAME: AHAU BOARDING CARE HOME	FACILITY NUMBER: 415600358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/12/2023

Type A

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the chemical storage room was unlocked during the facility tour which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/13/2023
	Plan of Correction
1 2 3 4	The administrator will develop a plan to ensure the chemicals will be locked and inaccessible to residents at all time. The administrator will submit a copy of the plan to CCL by 12/13/2023.

Type A

Section Cited

CCR

87465(c)(2)

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, record review and interview the licensee did not comply with the section cited above as expired medications for 2 out of 3 residents were observed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/13/2023
	Plan of Correction
1 2 3 4	The administrator will review medication for all residents and discard all the expired medication. The administrator will provide a written statement to CCL by 12/13/2023 indicating this has been completed.

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Murial Han TELEPHONE: (619) 209-9761 LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023

Document Has Been Signed on 12/12/2023 05:41 PM - It Cannot Be Edited

FACILITY NAME: AHAU BOARDING CARE HOME	FACILITY NUMBER: 415600358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/12/2023

Type A

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 observation, record review and interview the licensee did not comply with the section cited above as the facility was not able to provide documents that drills were performed accordingly which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/13/2023
	Plan of Correction
1 2 3 4	The administrator will provide a plan to ensure compliance. The plan shall include when the drills will be completed. The administrator will provide a copy of the plan to CCL by 12/13/2023.

Type A

Section Cited

CCR

87608(a)(3)

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 5 out of 5 residents did not have an preadmission which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/13/2023
	Plan of Correction
1 2 3 4	The administrator will provide a statement to ensure all preadmission appraisal is completed prior to admission. The administrator will provide a copy of the statement to CCL by 12/13/2023.

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Murial Han TELEPHONE: (619) 209-9761 LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023

Document Has Been Signed on 12/12/2023 05:41 PM - It Cannot Be Edited

FACILITY NAME: AHAU BOARDING CARE HOME	FACILITY NUMBER: 415600358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/12/2023

Type A

Section Cited

CCR

87608(a)(5)(A)

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 4 out of 5 residents have half bed rails, however, none of them have a physician's order indicating the need for the postural support which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/13/2023
	Plan of Correction
1 2 3 4	The administrator will provide a plan to obtain a written order from the physician for the postural support and the plan shall indicate when the order will be obtained. The administrator will submit a copy of the plan to CCL by 12/13/2023 and will provide a copy of the written physician order to CCL when obtained,

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Murial Han TELEPHONE: (619) 209-9761 LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023

Document Has Been Signed on 12/12/2023 05:41 PM - It Cannot Be Edited

FACILITY NAME: AHAU BOARDING CARE HOME	FACILITY NUMBER: 415600358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/12/2023

Type B

Section Cited

CCR

87113

The license shall be posted in a prominent location in the licensed facility accessible to public view. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA did not observed any required posters during the facility tour including by not limiting to resident's rights, CCL complaint poster, non-discrimination, etc. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/19/2023
	Plan of Correction
1 2 3 4	The administrator will post the required posters and provide a photo of the posters to CCL by 12/19/2023

Type B

Section Cited

HSC

1569.625(b)(2)

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the administrator was not able to provide training records for staff #1 (S1) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/19/2023
	Plan of Correction
1 2 3 4	The administrator will provide a copy of the training records for S1 to CCL by 12/19/2023.

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Murial Han TELEPHONE: (619) 209-9761 LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023

Document Has Been Signed on 12/12/2023 05:41 PM - It Cannot Be Edited

FACILITY NAME: AHAU BOARDING CARE HOME	FACILITY NUMBER: 415600358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/12/2023

Type B

Section Cited

CCR

87457(c)(1)

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in 5 out of 5 residents did have a completed appraisal and service plan which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/19/2023
	Plan of Correction
1 2 3 4	The administrator will complete an appraisal and service plan for all the residents and will provide a copy of the appraisal and service plan to CCL by 12/19/2023.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Murial Han TELEPHONE: (619) 209-9761 LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2023