Good Shepherd of Danville

(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b).This requirement was not met as evidence by: Based on observation and interview the above requirement was not met by Facility not having the requested records upon demand which poses an immedite health risk to residents in care.

Based on record review, the licensee did not comply with the section cited above in residents files being incomplete which poses a potential personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in S2 not being associated which poses an immediate safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in S2 not being trained prior to providing unsupervised care which poses a potential personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above by converting the garage without prior notice/ approval which poses a potential personal rights risk to persons in care.

(e) Water supplies... maintained as follows:(2) Faucets...temperature ...of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).This requirement was not as evidence by Based on observation the above requirement was not met by the shared bathrooms hot water measuring at 99.7 degrees F which poses an immedite health risk to residents in care.

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement was not met as evidence by: Based on interviews the facility did not comply with the section cited above by not having adequete staff to respond to residents needs in a timely manner which posed a potential health, and personal rights risk to persons in care.

(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3)To be free from punishment, humiliation, intimidation, abuse, …This requirement was not met as evidence by: Based on interviews the facility did not comply with the section cited above by speaking inappropriately to residents which posed a potential personal rights risk to persons in care.

(a)In addition … residents …shall have all of the following personal rights:(1)To have …personal privacy in… communications…and meetings of resident and family groups.This requirement was not met as evidence by: Based on interviews and observation the facility did not comply with the section cited above by not providing privacy to residents which posed a potential personal rights risk to persons in care.

(b)In addition … the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry … from incontinenceThis requirement was not met as evidence by: Based on interviews and record review the facility did not comply with the section cited above by not keeping R1 clean and dry from incontinence which posed a potential health , and personal rights risk to persons in care.

(a) Each licensee shall furnish... reports...to, the following:(1)A written report shall be submitted ...within seven days(D)Any incident which threatens the welfare,... of any resident.This requirement was not met as evidence by: Based on interviews, and record reviews, the facility did not comply with the section cited above by not reporting incidents to CCLD as required ehich posed a potential personal rights risk to persons in care.

(f) Basic services shall at a minimum include:(4)Personal assistance.. as indicated in the pre-admission appraisal, with ...bathing ...This requirement was not met as evidence by: Based on interviews, and record reviews, the facility did not comply with the section cited above by not providing resident with bathing as specified in their care plan which posed a potential personal rights risk to persons in care.

(a)Residents of residential care facilities for the elderly shall have all of the following rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons.This requirement was not met as evidence by: Based on interviews, and observation, the staff did not comply with the section cited above by speaking inappropriately to residents which posed a potential personal rights risk to persons in care.

(a) Residents... have all of the following rights: (6) To care, ...that meet their individual needs ... by staff that are...competency to meet their needs.This requirement was not met as evidence by: Based on interviews, record reviews, and observations the facility did not comply with the section cited above by not providing resident with competent care which resulted in pressure injuries which posed an immediate health, and personal rights risk to persons in care.

(a) All facilities shall maintain a fire clearance approved by the city, county, ..., or the State Fire Marshal: (2) Bedridden personsThis requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above in having two bedridden residents and one of the residents is in room 5 that is not cleared for bedridden which poses an immediate health, safety risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in having two bedridden residents and one of the residents is in room 5 that is not cleared for bedridden which poses an immediate health, safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in not having an updated emergency disaster plan which poses a potential safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in having knives unlocked which poses an immediate safety risk to persons in care.

Based on record review, licensee did not comply with the section cited above by not having staff fingerprint cleared which poses an immediate health and safety risk to the persons in care.

Based on observation, the licensee did not comply with the section cited above in having medications cabinet unlocked which poses an immediate safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above innot having done required disaster drills which poses a potential safety risk to persons in care.

Based on observatio, the licensee did not comply with the section cited above in having a cleaning solution out in residents bathrooms which poses an immediate health, and safety risk to persons in care.

(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5)This requirement is not met as evidence by: Based on record review and interview the licensee did not comply with the regulation above by issuing an eviction letter because the resident was unhappy with the service which posed a personal rights violation to person in care.

(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 regulation is not met as evidence by: Based on observation the dryer has an out of order sign and does not properly work. Staff has been hang drying clothes outside which poses a potental personal rights risk to persons in care

(a) Based on the individual's preadmission appraisal,... Postural supports may be used under the following conditions.(2) Postural supports shall... permits quick release by the resident.This regulation is not met as evidence by: Based on interview and photos R1 was restrained in bed by a strap that was tied to bedrails which posed a potential health and personal rights risk to person in care.

(f) Basic services shall at a minimum include:(3)Three nutritionally well-balanced meals...General Food Service Requirements.This requirement is not met as evidence by: Based on interviews and record review the licensee did not comply with the regulation above by not providing 3 balanced meals daily which posed a potential health risk to persons in care.

All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.This requirement is not met as evidence by: Administrator did not have training records readily available for review upon LPA's request

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...require such additional staff for the provision of adequate services.This requirement is not met as evidence by: Based on report of resident with previous elopement behavior eloping from facility the staff were not competent in how to address the behavior and prevent the resident from being missing for days.