Paradise Gardens

Certified administrator requirements and substitute coverage

All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility…This requirement was not met as evidenced by:Based on observations and interviews, the Licensee did not comply with section 87405(a) when the Administrator was unable to complete administrative duties due to performing caregiving duties… which is a potential health and safety risk to residents in care.

Maintain facility in clean, safe, sanitary condition

Based on observation, the licensee did not comply with the section cited above in the kitchen refrigerator, freezer, and the oven were either broken or completely inoperable which poses/posed a potential health, safety or personal rights risk to persons in care.

Request a transfer of criminal record clearance

Based on record review, the licensee did not comply with the section cited above in one out of one staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Document required significant condition changes

Based on records reviewed, the licensee did not comply with the section cited above in no reappraisals have been completed which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in one out of 6 resident status changed and was not documented which poses/posed a potential health, safety or personal rights risk to persons in care.

Record annual routine visit documentation

Based on record review, the licensee did not comply with the section cited above in 4 out of 6 resident files which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain separate complete record for each resident

Based on record review, the licensee did not comply with the section cited above in 6 out of 6 resident files which poses/posed a potential health, safety or personal rights risk to persons in care.

Include medical assessment and special precautions

Based on records reviewed, the licensee did not comply with the section cited above in 4 out of 6 resident files which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on records review, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Facility must keep complete hospice care plan on file

Based on records review, the licensee did not comply with the section cited above in one out of one residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in staff files reflecting training for dementia care which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on records review, the licensee did not comply with the section cited above in one out of one which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on records review, the licensee did not comply with the section cited above in one out of two persons which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on records reviewed, the licensee did not comply with the section cited above in 6 out of 8 staff files which poses/posed a potential health, safety or personal rights risk to persons in care.

Must complete individual written admission agreements

Based on record review, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

§1569.312 Basic services requirements: Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement was not met as evidenced by: Based on interviews and record reviews, the licensee did not ensure all residents were provided care and supervision when R1 was able to exit the facility without staff knowledge, which posess an immediate health and safety risk to persons in care.

Onsite food stock levels for nonperishables and perishables

Based on observation, the licensee did not comply with the section cited above when the facility did not have a supply of nonperishable foods for 7 days, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interviews, the licensee did not comply with the section cited above when the facility did not have a device with internet access for residents in care, which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on observation, the licensee did not comply with the section cited above when the following items were in need of repair: chair and ottoman in the living; exit door in the dining area, light bulb and faucet in the bathroom between bedroom 3 and 4, and the door track in bedroom 5. which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above when the facility did not have a planned activity schedule in the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above when medications for R3 were not refrigerated which poses/posed a potential health, safety or personal rights risk to persons in care.

Safe, healthful, comfortable accommodations

Based on observation, the licensee did not comply with the section cited above when a camera with audio was installed in bedroom 5, which poses an immediate health, safety or personal rights risk to persons in care.

RCFE complaint poster posting requirements

Based on observation, the licensee did not comply with the section cited above when the facility did not have the correct size complaint poster and the poster was not placed in the entryway, which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain separate complete record for each resident

Based on record review, the licensee did not comply with the section cited above when 6 out of 6 residents did not have a complete record, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above when 4 out of 6 residents have double-sided admission agreements, which poses/posed a potential health, safety or personal rights risk to persons in care.

Diet quality and preparation in safe healthful manner

(a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared, and served in a safe and healthful manner... this requirement was not met as evidenced by Based on observation and interviews, the facility did not comply with section 87555 when the facility accepted and used food donations that were past the best buy date, which is a potential health and safety risk to persons in care.

Store centrally held medications in locked secure place

87465(h)The following requirements shall apply to medications which are centrally stored: (2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication... this requirement was not met as evidenced by: Based on observation, the facility did not comply with section 87465 when medication was found to be accessible to persons other than employees in the refrigerator in the garage, which is an potential health and safety risk to persons in care.

(b) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 10 hours of training within the first four weeks of employment and four hours annually thereafter… This requirement was not met as evidenced by: Based on record review, the licensee did not ensure that all staff members received annual training. Record reviews revealed that 5 out of 9 staff did not have updated medication training which is a potential health and safety risk to persons in care.

Complete admission suitability appraisal

Based on record review, the licensee did not comply with the section cited above in out of 4 out of 6 persons who did not have appraisal of his/her individual service needs which poses a potential health, safety or personal rights risk to persons in care.