Positive Directions #9

87405 Resident Record(b) Each resident’s record shall contain at least the following information: (8) Names, address, and telephone numbers of the resident’s representative, as defined in Section 87101(r), to be notified in case of accident, death, or other emergency. This requirement was not met as evidenced by LPAs observation of R1 files. Records obtained at the time of admission did not include the required information.

87455 Acceptance and Retention Limitations(c) No resident shall be accepted or retained if any of the following apply: (2) The resident requires 24-hour, skilled nursing or intermediate care as specified in Health and Safety Code Sections 1569.72(a) and (a)(1). This require was not met as evidenced by LPAs observation of R1's records facility obtained at the time of initial admission on 10/08/24 and readmission from hospital on 10/11/24. Based on interviews, R1 had conditions that facility was not aware of and the hospitalization records and death certificate are evidence of the medical conditions that were not disclosed or observed at the time of admission.R1 was not assessed at the time of admission on 10/08/24 and also readmission on 10/11/24. This poses an immediate risk to the health, safety and or personal rights of the residents in care.

87457 Pre-Admission Appraisal - General(a) Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions. (1) Sufficient information about the facility and its services shall be provided to enable all persons involved in the placement to make an informed decision regarding admission. This requirement was not met as evidenced by LPAs observation of Resident R1's file. No preadmission appraisal was observed in file or conducted prior to R1's admission. This poses an immediate risk to the health, safety and or personal rights of the residents in care.

87458 Medical Assessment(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement was not met as evidenced by LPAs observation of Resident R1s file. No medical assessment was obtained prior to admission not observed in file. This poses an immediate risk to the health, safety and or personal rights of the residents in care.

87459 Functional Capabilities(a) The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited to:(7) Physical condition, including:(F) Medical history and problems. This requirement was not met as evidenced by LPAs review of R1 file. There is no functional capabilities assessment completed addressing medical history and problems.

87463 Reappraisals(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. This requirement was not met as evidenced by LPAs observation of R1 and R2's file. 2 out of 2 residents in care did not have reassessments completed after hospitalization's and prior to readmission back into the facility after hospital visit. This poses an immediate risk to the health, safety and or personal rights of the residents in care.

87355 Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department:This requirement is not met as evidenced by: Based on file review; House Manager S1 is not associated with the facility.

87412 Personnel Records(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. (1) The licensee shall be permitted to retain such records in a central administrative location provided that they are readily available to the licensing agency at the facility as specified in Section 87412(f). This requirement was not met as evidenced by LPAs request for staff records on 10/15/24. Administrator stated staff files were at the office and would be sent via email to LPA. LPA received records on 10/30/24, 15 days after the request. This poses a potential risk to the health, safety and/or personal rights of the residents in care.

87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as evidenced by: LPA's observation of staff schedule and interviews with licensee, Staff S2 has not received a fingerprint clearance and has been working in the facility since 08/2022. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of resident's in care ** A Civil penalty in the amount of $500 is hereby assessed**

Prohibited Health Conditions (a)Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly (4) Staphylococcus aureus ("staph") infection or other serious infection.:This requirement was not met as evidenced by LPA's observation of records and interviews with staff, R1 was admitted to the hospital from the facility with severe sepsis. LPA's observation of records and interviews with Staff, R1 was admitted to the hospital from the facility with severe sepsis. If not corrected, the violation will have a direct and immediate risk to the health, safety, or personal rights of resident's in care.** A Civil penalty in the amount of $500 is hereby assessed**

No Deficiency cited. Form created in error. Facility reported incidents as required by Title 22.