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Inspection visit

Routine inspection

ABOVE & BEYOND RCFE, INC.License 01920111916 citations on this visit
16 citations recorded

Inspector’s narrative

What the inspector wrote

.On this day, March 23, 2024, at 11:05 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Marlyn Joaquin and Raul Pangilinan, and informed the reason for visit. LPA called and spoke over the phone with Leticia Velasco, licensee, who authorized Marilyn Joaquin to be with LPA to start inspection. Licensee and Max 'Mike' Neri, administrator, arrived at 11:35 a.m. and 11:40 a.m.. respectively. Facility submitted the LIC9282 Infection Control Plan on June 29, 2022. LPA started the inspection with Marlyn Joaquin, and continued with the licensee and administrator. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Facility has smoke and carbon monoxide detectors that were observed functional. Hot water temperature in the ensuite bathroom was tested. Fire extinguisher was observed fully charge with tag showed serviced February 13, 2024. Facility disaster drill records checked. LPA reviewed 5 residents and 4 staff files, and interviewed 2 staff and 2 residents. Medications were checked, and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources. LPA observed the following: -at 11:19 a.m., unlocked medication cabinets. -at 11:20 a.m., residents medications in the refrigerator in the kitchen. ...continued on 809C (page 2) Page 2 -at 11:24 a.m., knives in unlocked kitchen cabinet, and scissors and pizza cutter in kitchen drawers without lock. -at 11:32 a.m., scissors in drawer without lock in the living room. -at 11:34 a.m., medication in unlocked staff room. -at 11:41 a.m., Aleve, Glucosamine. Bengay in one of residents rooms. -at 11:52 a.m., Lysol, Windex, Barbasol in cabinet without lock in the ensuite bathroom. -at 11:55 a.m., hot water at 125.1 degrees Fahrenheit. -at 11:59 a.m., peritoneal cleansers and ointments in the common bathroom.. -at 12:01 p.m., trash cans without lid in one of the residents' rooms and living room. -at 12:06 p.m., Oxygen tanks, pails of paint in unlocked storage in the backyard. -at 12:30 p.m., disaster drills not conducted quarterly; records showed conducted on 1/11/22 and 1/11/24. -at 2:00 p.m., staff (S3) has no LIC503 Health Screening & TB test result on file, Total hours of training on file is only 22 hours. -at 2:30 p.m., staff (S4) not fingerprint cleared and associated. -at 3:15 p.m., resident (R1) LIC602A Physician's Report is over a year old. No LIC625 Appraisal/Needs and Services Plan & doctor's order for half bed rails. -at 3:50 p.m., R2's half bed rails no doctor's order on file,, -at 4:05 p.m., no doctor's order on file for R3's half bed rails. -at 5:00 p.m., R1's 3 medications not recorded on LIC622 Centrally Stored Medication and Destruction Record, Dates filled of other medications incorrectly recorded. -at 5:35 p.m., R2 has 21 medications on facility's hand but there's only 18 on doctor's order, Facility is only giving only 11 medications of which one (muti vitamins) is given twice daily when order is only once daily. Medications received were not properly recorded on LIC622. -at 7:00 p.m., R3 has no LIC622 on file. Doctor's order for calcium carbonate-Vit D3 (600 mg-12.5 mcg(500 unit) but the medication on facility's hand os 600 mg-10 mg (400 unit).No doctor's order for half bedrails. -at 7:05 p.m., no doctor's for R4's half bed rails. ....continued on 809C (pge 3) Page 3 Administrator submitted on this day the following updated/current documents: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. $3M Liability Insurance certificate Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $500.00 civil penalty is assessed for staff not fingerprint cleared. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in additional civil penalties. Deficiencies and plan and proof of corrections were discussed with the administrator and licensee. Exit interview conducted. Appeal Rights, LIC421BG Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.

Citations

16 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87309(a)Type A

    Ensure hazardous items are locked and not unattended

    Based on observation, the licensee did not comply with the section cited above which pose an immediate health, safety and/or personal rights risk to persons in care. LPA observed the following: knives in unlocked kitchen cabinet; scissors and pizza cutter in drawers without lock; Lysol, Windex, Barbasol in cabinet without lock in the ensuite bathroom; peritoneal cleansers and ointments, lighter, scissors in one of the residents rooms; peritnoeal cleaner in the common bathroom

  • 87303(f)(3)Type B

    Ensure outdoor waste containers are cleanable

    Based on observation, the licensee did not comply with the section cited above in trash can without lid which poses a potential health and/or personal rights risk to persons in care.

  • 87412(a)(11)Type B

    Include required health screening documents

    Based on record review, the licensee did not comply with the section cited above in S3 has not having LIC503 Health Screening & TB test on file which pose a potential health and/or personal rights risk to persons in care.

  • 1569.625(b)(1)Type B

    Based on record review, the licensee did not comply with the section cited above in S3 only having total of 22 hours training ofn file which poses a potential health, safety and/or personal rights risk to persons in care.

  • 1569.695(c)Type B

    Based on record review, the licensee did not comply with the section cited above in for not conducting drills at least every quater which poses a potential safety risk to persons in care.

  • 87303(e)(2)Type A

    Provide resident hot water for personal care

    Based on observation, the licensee did not comply with the section cited above in hot water at 125.1 degrees Fahrenheit.which poses an immediate health, safety and/or personal rights risks to persons in care.

  • 87355(e)Type A

    Address and clearance obligations before facility work

    Based on record review, the licensee did not comply with the section cited above in S4 not fingerprint cleared and associated to the facility which poses an immediate safety and/or personal rights risk to persons in care.A $500.00 civil penalty is assessed.

  • 87465(a)(4)Type A

    Assist residents with self-administered medication

    Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

  • 87465(c)(2)Type A

    Give PRN medication by physician order

    Based on record review, the licensee did not comply with the section cited above in staff administering R2's multi vitamins twice daily when doctor's order is once daily; Doctor's order for R3's calcium carbonate-Vit D3 (600 mg-12.5 mcg(500 unit) but the medication on facility's hand os 600 mg-10 mg (400 unit).which poses an immediate health and/or personal rights risk to persons in care.

  • 87465(e)Type A

    Require physician order and label for PRN medication

    Based on observation and record review)], the licensee did not comply with the section cited above in having 21 medications on hand for R2 but order on file is only for 18.count which poses an immediate health and/or personal rights risk to persons in care.

  • 87465(h)(1)(C)Type A

    Central store medicines that create safety hazards

    Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

  • 87465(h)(2)Type A

    Store centrally held medications in locked secure place

    Based on observation, the licensee did not comply with the section cited above in cabinets with residents' medications unlocked which poses an immediate health, safety or personal rights risk to persons in care.

  • 87506(a)Type B

    Maintain separate complete record for each resident

    Based on records review, the licensee did not comply with the section cited above for the following which poses a potential personal rights risk to persons in care: R1's 3 medications not recorded & other medications not proeprly recorded on LIC622; R2's medications not properly recorded on LIC622.

  • 87608(a)(3)Type B

    Maintain physician order documentation in resident record

    Based on record review, the licensee did not comply with the section cited above for not having doctor's orders for R1,R2, R3 and R4's half bed rails which poses a potential health, safety and/or personal rights risk to persons in care.

  • 87705(c)(5)Type B

    Based on record review, the licensee did not comply with the section cited above in R1's LIC602A over a year old & no LIC625 on file which pose a potential health and/or personal rights risk to persons in care.

  • 87705(f)(2)Type A

    Fire approval and staff access to unlock systems

    Based on observation, he licensee did not comply with the section cited above in Aleve, Glucosamine. Bengay in one of the resident's rooms which poses an immediate health, safety or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the March 23, 2024 inspection of ABOVE & BEYOND RCFE, INC.?

This was an inspection of ABOVE & BEYOND RCFE, INC. on March 23, 2024. 16 citations were issued: 9 Type A (serious) and 7 Type B.

Were any citations issued to ABOVE & BEYOND RCFE, INC. on March 23, 2024?

Yes, 16 citations were issued (9 Type A, 7 Type B). The first citation was for: "Based on observation, the licensee did not comply with the section cited above which pose an immediate health, safety a..."

What type of inspection was this?

This was an inspection. Inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.