Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
06/21/2024
Section Cited
CCR
87411(a) | 1
2
3
4
5
6
7 | 87411(a) Facility personnel shall at all times be sufficient in numbers & competent to provide the services necessary to meet resident needs…This requirement has not been met as evidence by:**
Based on records review of alarm response system and interivews with multiple staff | 1
2
3
4
5
6
7 | Licensee failed to ensure staff responded appropriately to call bell system and meet resident care needs in a timely manner. Licensee shall conduct staff training on how call bells will be responded to and provide a 7 day alarm response log to Licensing along with training verification by POC due date 7/11/2024. In addition, Licensee to submit |
 | 8
9
10
11
12
13
14 | Administrator did not ensure that staff on duty responded in a timely manner to call system to assist residents (R2 & R3) in care. Call bell response times were between 1-3 hours, which poses an immediate risk to the health and safety of residents in care. | 8
9
10
11
12
13
14 | written statement on how future compliance will be met by POC date 6/21/2024. |
Type B
06/27/2024
Section Cited
HSC
1569.625(b)(1) | 1
2
3
4
5
6
7 | 1569.625(b)(1) A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. | 1
2
3
4
5
6
7 | Facility failed to ensure staff had properly completed training requirements for dementia care and hoyer lift prior to staff providing direct care. Licensee agrees to ensure ALL staff that provide caregiving duties have received hoyer lift training. Training to be |
| 8
9
10
11
12
13
14 | This was not met as evidence by:**
Based upon review of staff records it was found that 12 caregiving staff had received hoyer lift training on 6/13/2024, after resident (R1) had already been residing in the facility for several months requiring hoyer lift assistance. This serves as a potential health & safety risk | 8
9
10
11
12
13
14 | submitted to CCLD by POC date 6/27/2024. Lastly, faciltiy is to ensure all required training for caregiving staff both initial or annual are on fille. |
1
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3
4
5
6
7
8
9
10
11
12
13 | On 6/20/2024, Licensing Program Analysts (LPA’s) Tobola & Mutialu arrived unannounced for the purpose of delivering complaint investigation findings and were greeted by Acting Administrator, Mike Chatman.
LPA’s toured the facility, reviewed resident medication supply and records, reviewed staff and resident records, interviewed staff and made observations during the course of the investigation.
Complaint alleges, centrally stored medications are accessible to residents in care. Based on multiple facility tours, spot check of resident medication supply and records and observations, LPA’s did not find that the facility left medications inappropriately accessible to residents in care. Upon inspection, LPA’s found that medications including narcotics were consistent with medication records for 6 out of 6 residents reviewed. In addition, LPA Tobola observed medication carts to be secured when transferred throughout the facility and upon observation of med tech staff medication passes. Due to a lack of corroborating evidence, the allegation is found to be unsubstantiated.
Continued onto LIC9099-C
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| Unsubstantiated | Estimated Days of Completion: |
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