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32 | Based on record review the facility’s staffing schedule shows that the facility has an awake night staff 7 days a week from 11PM- 6AM, however, based on interview with 3 staff and the Administrator, it was stated that the facility does not actually have an awake night staff during that time period.
During record review, it was also found that the staff are falsifying the resident’s progress notes. Based on staff interview, R1 began showing symptoms of a cough starting on 11/29/2024, however, R1’s progress notes wrote “none” under the “illness” section. The progress notes shows that R1 symptoms began on 12/2/2024 when R1 showed symptoms on 11/29/2024.
During today’s visit, LPAs was informed that R2 stayed home from day program because R2 is diagnosed with an infection disease. Administrator states they have not completed a follow-up appointment with R2’s doctor to confirm if R2’s infectious disease is gone. During visit, LPAs observed staff was not wearing Personal Protective Equipment (PPE) supplies. Administrator states they are washing R2’s beddings daily in high temperature and cleaning and disinfecting R2’s room daily. During visit, LPAs observed R2 was walking around the facility and sitting in the common areas. When the remainder of the residents arrived from day program, LPAs did not observe the staff disinfect the area R1 was sitting in throughout the day, prior to residents sitting down in the same area.
Based on review of the facility's infection control plan, the staff are to use PPE supplies when caring for residents with an infectious disease and to clean and disinfect the facility daily and as needed. LPAs observed the staff are not following their infection control plan.
Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator, Remedios “Remy” Bose and a copy of the report and appeal rights were provided. Page 2 of 2. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
12/12/2024
Section Cited
CCR
80061(b)
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7 | (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. This requirement is not met as evidenced by: | 1
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7 | Licensee will submit the incident reports for R1 and R2 to the Department and to the Regional Center. Licensee will submit the incident reports by POC due date of 12/12/2024. |
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14 | Based on interview, record review and observation the licensee did not ensure to report to the Department of R1's urgent care visit and diagnosis of multiple rib fractures and R2's infectious disease which poses/posed an immediate health, safety and personal rights risk to persons in care. | 8
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Type A
12/12/2024
Section Cited
CCR80012(a)
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7 | (a) No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: | 1
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7 | Licensee will ensure that their staffing schedule going forward will reflect their actual staffing schedule. Licensee will submit a statement of understanding of the section cited to LPA Dolores by POC due date 12/12/2024. |
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14 | Based on interview, record review and observation the licensee did not ensure the facility's documentation was accurate to reflect the correct staffing schedule and progress notes of R1's symptoms which poses an immediate health, safety and personal rights risk to persons in care. | 8
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14 | Licensee will provide staff training on proper documentation. Licensee will submit in-service staff training record to LPA Dolores by POC due date 12/12/2024. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
12/12/2024
Section Cited
CCR
80075(a)
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7 | (a) The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement is not met as evidenced by: | 1
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7 | Licensee will provide staff training on being proactive and reporting changes of conditions in a timely manner to the Administrator. |
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14 | Based on interview, record review and observation the licensee did not ensure R1 was provided timely medical attention as R1 began to show signs of discomfort on 11/29/2024 and was brought to urgent care on 12/02/2024 which poses/posed an immediate health, safety and personal rights risk to persons in care. | 8
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14 | Licensee will provide the in-service training record to LPA Dolores via email by POC due date of 12/12/2024. |
Type A
12/12/2024
Section Cited
CCR85075.4(c)
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7 | (c) The licensee shall bring observed changes, including but not limited to unusual weight gains or losses, or deterioration of health condition, to the attention of the client's physician and authorized representative, if any. This requirement is not met as evidenced by: | 1
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7 | Licensee will submit a plan in writing to ensure the resident's authorized representative and physician is informed of a change of condition, to LPA Dolores via email by POC due date of 12/12/2024. |
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14 | Based on interview, record review and observation the licensee did not comply with the section cited wherein the licensee did not report R1 and R2's change of condition to their authorized representative and physician which poses an immediate, health, safety and personal rights risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
12/12/2024
Section Cited
CCR
85095.5(a)
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7 | (a) A licensee shall ensure that infection control practices are maintained as follows: This requirement is not met as evidenced by: | 1
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7 | Licensee will provide staff in-service training on the facility's infection control plan. Licensee will submit the training document to LPA Dolores via email by POC due date of 12/12/2024. |
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14 | Based on interview, record review and observation the licensee did not ensure staff were following their infection control plan while R2 is diagnosed with an infectious disease which poses an immediate health, safety, and personal rights risk to persons in care. | 8
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