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25 | Licensing Program Analyst (LPA) Marie Rodriguez conducted an unannounced Annual Required inspection. LPA met with Licensee/Administrator Evelina Melkonyan and explained purpose of inspection.
LPA toured the facility with Staff in Charge Irma Perez inside and out, including but not limited to: residents’ and staff bedrooms, bathrooms, common living and dining areas, kitchen, and backyard. Room temperature of facility was comfortable. Bedrooms, kitchen, living room, and dining room were clean and in good repair. There was a sufficient supply of linens. Bathrooms were clean. Showers and toilets had grab bars. Showers had non-skid mats. Hot water temperature was measured at 116 degrees Fahrenheit from the main residents' bathroom.
Licensing forms were posted. There was a sufficient supply of two (2) day perishable and seven (7) day nonperishable food. LPA observed locked storage for medications, sharp tools, cleaning supplies, and toxins. Fire extinguisher, smoke detectors, and carbon monoxide detector were present and fully functional. Delayed egress devices on doors were in place and fully functional.
LPA reviewed all four (4) staff records. All staff have received a criminal record clearance and were associated to facility. First aid certificates of staff were current but would be expiring at the end of this month. Administrator Evelina Melkanyan's administrator certificate expires on 12/23/20.
LPA reviewed all six (6) resident records. Records were not complete.
A FULL REVIEW OF MEDICATIONS AND MEDICATION LOG WILL BE DONE AT A LATER DATE.
(Continued on LIC 809) |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
05/15/2019
Section Cited
CCR
87457(c)(1) | 1
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7 | Pre-Admission Appraisal - General (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. (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.
This requirement has not been met as evidenced by: | 1
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7 | Facility shall ensure all new residents residing at facility will have an LIC 603 Preplacement Appraisal form completed upon admission to facility. Facility shall submit a copy of LIC 603 Preplacement Appraisal form for residents R2 and R6 to the CCLD office by the POC DUE DATE. |
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14 | Based on records review, Facility failed to ensure new residents had a pre-admission appraisal conducted at time of admission which poses a potential risk to the health and safety of residents in care. New residents R2 and R6 did not have an LIC 603 Preplacement Appraisal completed at admission to facility. | 8
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14 | Failure to correct this deficiency by the due date may result in a civil penalty of $100 or more per day. |
Type B
05/15/2019
Section Cited
CCR
87705(c)(5) | 1
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7 | Care of Persons with Dementia Each resident with dementia shall have an annual medical assessment and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
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7 | Facility shall ensure all residents with dementia residing at facility will have an updated annual Physician's Report and Appraisal Needs and Services (ANS) Plan on file. Facility shall submit a copy of the updated Physician's Report and ANS for Resident R1 to CCLD office by the POC DUE DATE. |
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14 | Based on records review, Facility failed to ensure a resident with dementia had a medical assessment and reappraisal done annually which poses a potential health and safety risk to residents in care. Resident R3's last Physician's Report was completed on 10/30/14 and Appraisal Needs and Services Plan was completed on 6/5/17. | 8
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14 | Failure to correct this deficiency by the due date may result in a civil penalty of $100 or more per day. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
05/15/2019
Section Cited
CCR
87458(a) | 1
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7 | Medical Assessment - 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.
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7 | Facility shall ensure a medical assessment has been obtained by physician prior to new residents' admission to facility. Facility shall submit an updated copy of the medical assessment for Resident R4 to CCLD office by the POC DUE DATE. |
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14 | Based on records review, Facility failed to ensure a current medical assessment was obtained for Resident R4 prior to admission to the facility which poses a potential risk to residents in care. R4 only had an old medical assessment completed on 8/13/15 received from former facility in file. | 8
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14 | Failure to correct this deficiency by the due date may result in a civil penalty of $100 or more per day. |
Type B
05/15/2019
Section Cited
HSC
1569.625(b)(2) | 1
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7 | §1569.625 Staff training; legislative findings; contents
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. | 1
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7 | Facility shall submit a written plan describing when staff will receive the required 20 hours of annual training and submit a schedule and/or list of the appropriate classes and hours that will be taken by staff to the CCLD office by the POC DUE DATE. |
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14 | This requirement has not been met as evidenced by:
Based on staff records review, facility failed to ensure staff had the required 20 hours of annual training which poses a potential health, safety, and personal rights risk to residents in care. LPA observed there were no recent training conducted in staff records. | 8
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14 | Failure to correct this deficiency by the due date may result in a civil penalty of $100 or more per day. |
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32 | (Continued from LIC 809)
During LPA’s inspection, the following deficiencies were observed:
- During physical plant tour, LPA observed resident R1 with a full bed rail on bed. Per Staff in Charge, resident is not on hospice. Per review of resident record, there was no approved exception request for full bed rail or physician's order in file. Per Staff in Charge, physician ordered full bed rail for resident but could not find the physician's order for it in resident's file.
- LPA observed new Residents R2 and R6 did not have a Preplacement Appraisal form completed in file.
- LPA observed Resident R3, who is diagnosed with dementia, did not have a current medical assessment or appraisal needs and services plan in file.
- LPA observed Resident R4 did not have a medical assessment completed prior to admission to facility. Staff in Charge stated an LIC 602 Physician's Report was requested to be completed by the resident's physician but hadn't received the completed form yet.
- LPA observed no annual training in staff records. Staff in Charge stated there was no recent training completed by staff.
Deficiencies cited today under California Code of Regulations, Title 22, Division 6, Chapter 8, which follows on LIC 809D. If cited deficiencies are not corrected by due date, civil penalty may be assessed.
This report was reviewed and discussed with Licensee/Administrator Evelina Melkonyan. Appeals Rights given. A copy of report was provided.
The following forms are to be updated and submitted to CCLD by May 15, 2019:
LIC 308 – Designation of Administrative Responsibility
LIC 500 – Personnel Report
LIC 610D – Emergency Disaster Plan
Copy of Administrator’s Certificate
Copy of Liability Insurance
(Continued on LIC 809C) |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
05/02/2019
Section Cited
CCR
87608(a)(5)(B) | 1
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7 | Postural Supports - Bed rails that extend the entire length of the bed (full bed rails) are prohibited except for residents on hospice and their hospice care plan specifies the need.
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7 | Facility shall submit a written Plan of Correction (POC) to describe how facility shall not have full-bed rails without documentation and CCLD approval. Full bed rails shall be removed or an Exception request shall be submitted to CCLD for the approval of a full bed rail and must include supportive documentation. |
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14 | Based on observation and records review, Resident R1 had a full bed rail but was not on hospice and did not have an approved exception request on file. Facility failed to ensure that full bed rails are not used prior to CCLD approval, which poses an immediate health, safety and personal rights risk to residents in care. | 8
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14 | POC to be submitted to CCLD by the POC DUE DATE.
Failure to correct this deficiency by the due date may result in a civil penalty of $100 or more per day. |
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