Community Care Licensing

SUPERVISOR'S NAME: Liza King TELEPHONE: (916) 263-4752 LICENSING EVALUATOR NAME: Charlie Yang TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2023

FACILITY NAME: MONTEVERDE MANOR II	FACILITY NUMBER: 415600660
	VISIT DATE: 10/15/2023

FACILITY NAME: MONTEVERDE MANOR II	FACILITY NUMBER: 415600660
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/15/2023

Type A

Section Cited

CCR

87202(a)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above since this facility only has an approved bedridden fire clearance to accept and retain (1) bedridden resident in Room #4 only. This Licensee currently has (2) bedridden residents in care at the time of this annual visit which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/16/2023
	Plan of Correction
1 2 3 4	The facility Administrator stated that the proper forms and documents will be completed and submitted into CCL requesting the increase in the bedridden status to be able to accept and retain up to (2) bedridden residents. A statement of correction, along with all relevant forms and documents, will be completed and submitted into CCL by the due date.

Type A

Section Cited

CCR

87303(e)(3)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. 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 in that the hot water that was measured in the resident restrooms were found to be at 122.2 degrees which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2023
	Plan of Correction
1 2 3 4	The facility Administrator stated that the hot water heater will be turned down and the hot water will be measured on a daily basis for (1) week. A statement of correction, along with the hot water temperature readings for (1) week, will be completed and submitted into CCL by the due date.

SUPERVISOR'S NAME: Liza King TELEPHONE: (916) 263-4752 LICENSING EVALUATOR NAME: Charlie Yang TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2023

Document Has Been Signed on 10/17/2023 09:37 AM - It Cannot Be Edited

FACILITY NAME: MONTEVERDE MANOR II	FACILITY NUMBER: 415600660
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/15/2023

Type A

Section Cited

CCR

87412(a)(11)

(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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 [3] out of [4] staff persons did not have a completed health screening report which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/16/2023
	Plan of Correction
1 2 3 4	The facility Administrator stated that the proper forms and documents will be completed and submitted into CCL detailing the completion of the updated health screenings for all facility personnel. A statement of correction, along with all relevant forms and documents, will be completed and submitted into CCL by the due date.

Type A

Section Cited

CCR

87411(c)(1)

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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] staff persons did not have updated and certified First Aid training which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/16/2023
	Plan of Correction
1 2 3 4	The facility Administrator stated that the proper forms and documents will be completed and submitted into CCL detailing the completion of the updated First Aid training for all facility personnel. A statement of correction, along with all relevant forms and documents, will be completed and submitted into CCL by the due date.

SUPERVISOR'S NAME: Liza King TELEPHONE: (916) 263-4752 LICENSING EVALUATOR NAME: Charlie Yang TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2023

Document Has Been Signed on 10/17/2023 09:37 AM - It Cannot Be Edited

FACILITY NAME: MONTEVERDE MANOR II	FACILITY NUMBER: 415600660
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/15/2023

Type A

Section Cited

CCR

87458(a)

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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 [5] facility resident files did not have an annually updated medical assessment as required for residents diagnosed with dementia which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/16/2023
	Plan of Correction
1 2 3 4	The facility Administrator stated that the proper forms and documents will be completed and submitted into CCL detailing the completion of the updated medical assessment for all facility residents. A statement of correction, along with all relevant forms and documents, will be completed and submitted into CCL by the due date.

Type A

Section Cited

CCR

87465(h)(5)

(h) The following requirements shall apply to medications which are centrally stored: (5) 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 observation and record review, the licensee did not comply with the section cited above since it was learned that medications were pre-poured for 48 hours in advance with incomplete documentation of medications when dispensed to the residents. This posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/16/2023
	Plan of Correction
1 2 3 4	The Administrator stated that all medications will no longer be pre-poured and taken out of the original containers until the actual administration of the medications to the residents. A statement of correction, along with proof of in-service for all facility staff handling and dispensing the medications for no less than (1) hour in duration, will be completed and submitted into CCL by the due date.

SUPERVISOR'S NAME: Liza King TELEPHONE: (916) 263-4752 LICENSING EVALUATOR NAME: Charlie Yang TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2023

Document Has Been Signed on 10/17/2023 09:37 AM - It Cannot Be Edited

FACILITY NAME: MONTEVERDE MANOR II	FACILITY NUMBER: 415600660
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/15/2023

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 observation, the licensee did not comply with the section cited above in that there were cracks in the kitchen and restroom flooring. Unused building materials and items were left in the exterior of this facility blocking side exits as well which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2023
	Plan of Correction
1 2 3 4	The facility Administrator stated that all of the flooring will be repaired/replaced to remove any cracks or breaks within the flooring throughout this facility. All unused building materials and items will be cleaned up and removed. A statement of correction, along with photos of the repaired/replaced flooring and exterior grounds, will be completed and submitted into CCL by the due date.

Type B

Section Cited

CCR

87303(c)

(c) All window screens shall be clean and maintained in good repair. 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 in that there were missing window screens and other screens that were in need of repair/replacement which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2023
	Plan of Correction
1 2 3 4	The facility Administrator stated that all of the window screens will be repaired/replaced. A statement of correction, along with photos of the repaired/replaced window screens, will be completed and submitted into CCL by the due date.

SUPERVISOR'S NAME: Liza King TELEPHONE: (916) 263-4752 LICENSING EVALUATOR NAME: Charlie Yang TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2023

Document Has Been Signed on 10/17/2023 09:37 AM - It Cannot Be Edited

FACILITY NAME: MONTEVERDE MANOR II	FACILITY NUMBER: 415600660
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/15/2023

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 [3] out of [5] facility personnel files were missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2023
	Plan of Correction
1 2 3 4	The facility Administrator stated that an audit of all facility personnel files will be conducted. Any missing required forms and documents will be updated and filed appropriately in all facility personnel records. A statement of correction, along with copies of all updated forms and documents, will be completed and submitted into CCL by the due date.

Type B

Section Cited

CCR

87506(a)

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. 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 [3] out of [5] facility resident files were missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/22/2023
	Plan of Correction
1 2 3 4	The facility Administrator stated that an audit of all facility resident files will be conducted. Any missing required forms and documents will be updated and filed appropriately in all facility resident records. A statement of correction, along with copies of all updated forms and documents, will be completed and submitted into CCL by the due date.

SUPERVISOR'S NAME: Liza King TELEPHONE: (916) 263-4752 LICENSING EVALUATOR NAME: Charlie Yang TELEPHONE: (916) 263-4700 LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2023