Routine inspection (multi-day)·March 4, 2022

Citations

9 citations recorded^*CCLD

• 156.72Type B

  87212 Emergency Disaster Plan(a) Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available. This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by not having an Emergency Disaster Plan. Which poses a potential health and safety risk to residents. which poses a potential health and safety risk to residents.

• 87208(A)(7)Type B

  87208((A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended...7)Sketches, showing dimensions, of the following: This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by staff sleeping in the garage in a makeshift bedroom being used for accommodation. Which poses a potential health and safety risk to residents.

• 87211(a)(1)Type B

  87211 (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, ... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence,,, This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by not having a Mitigation Plan LIC 808. Which poses a potential health and safety risk to residents.

• 87303(a)Type B

  87303 Maintenance and Operation(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 was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by not providing a grab bar in the bathtub. having a hole in the ceiling from an upstairs bathroom leak in the shared bathroom. Using a screwdriver to operate the shower faucet in bedroom #1. Which poses a potential health and safety risk to residents.

• 87303(e)(2)Type A

  87303 (e) Water...shall be maintained as follows:(2) Faucets used by residents for personal care...Hot water temperature controls shall be maintained... temperature of not less than 105 degree F (41 degree C) and not more than 120 degree...This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by maintaining water temperature between 105 degree F and 120 degree F which poses an immediate health and safety risk to residents.

• 87506(b)(17)(A)(B)Type B

  87506(b) Each resident’s record shall contain at least the following ...(17)Documents and information required...(A)Section 87457, Pre-Admission Appraisal;(B)Section 87459, Functional Capabilities;(C) Section 87461, Mental Condition; (D)Section 87462, Social Factors This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by missing required documentation in residents files, Pre-placement Appraisal Needs and Services Plan, Identification and Emergency Information, Consent for Medical Treatment and Residents Rights. Which poses a potential health and safety risk to residents.

• 87606(f)(1)Type A

  87606(f)(1) (f) To accept or retain a bedridden person, a facility shall ensure the following: (1) The facility's Plan of Operation includes a statement of how the facility intends to meet the overall health, safety and care needs of bedridden persons. This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by accepting a bedridden resident with restricted health condition without fire clearance in room #1. Which poses an immediate health and safety risk to clients.

• 87621(b)(1)(B)Type A

  87621(b) In addition to Section 87611 the licensees shall be responsible... (1) Ensuring that ostomy care is provided by an appropriately...(B)There shall be written documentation by an appropriately skilled professional outlining...instruction...facility staff who have been instructed. This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by accepting a resident with a restricted health condition. Which poses an immediate health and safety risk to clients.

• 87705(f)(1)Type A

  (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s)..This requirement was not met as evidence by: Based on LPAs observation licensee did not comply with the section cited above by not maintaining a safe environment with unlocked rakes, shovel, paint, tree trimmer, 3 ladders, lawn mower and unlocked shed located in the back yard. which poses an immediate health and safety risk to residents.

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