The Westchester Home on Spruce

Obtain required California clearance or exemption

(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: (2) Obtain a California clearance or a criminal record exemption as required by the Department or** This was not met as evidenced byS1 has been present in the facility and not fingerprint cleared

Resident record must include minimum required items

Based on record review, the licensee did not comply with the section cited above in 5 out of 5 resident files are missing doucments 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 care plans on file for all residents state residents should have 1:1 staffing, 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 all staff files reviewed did not contained training regulations as mandated, 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. During last facility visit on 3/28/25, Administrator on record was not present and LPA was informed that she had been absent from facility and had moved out of state to attend school. which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain and operate facility under definitive plan

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

Arrange appropriate medical and dental care

Based on interview and record review, the licensee did not comply with the section cited above R1 should be receiving Physical therapy and has not attended scheduled appointments since initial examination, which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain records of centrally stored medication dosages

Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 5 residents Medication reviewed and observed that 3 out of 5 residents did not receive medications due to medication not being refilled, which poses an immediate health, safety or personal rights risk to persons in care.

Maintain fire clearance before retaining specified persons

Based on observation, the licensee did not comply with the section cited above kitchen observed to have a locked wrought iron gate making kitchen inaccessible to residents. The wrought iron gate was not in place, when facility received fire clearance. Designated fire exit from backyard observed to be locked at time of inspection, which poses an immediate health, safety or personal rights risk to persons in care.

Keep prescriptions in original containers

87465(h)(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.This requirement was not met as evidenced by: Based on observation, LPA checked R1’s medication with Administrator present. LPA observed in R1’s Furosemide 20 mg medication bottle, 5 capsule that were different size stored in with the Furosemide tablets which poses an immediate health, safety or personal rights risk to persons in care.

Record centrally stored prescriptions and refill data

87465(h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year.This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, there are no Centrally Stored Medication Record (Lic 622) on file for all four residents, which poses/ posed a potential health, safety, or personal rights risk for the person in care.

Give PRN medication by physician order

87465(c)(2) Once ordered by the physician the medication is given according to the physician's directions.This requirement was not met as evidenced by: Based on observation, records reviewed, and interview conducted, residents’ medications were checked, and medications were observed not administered as directed by physician by staff, which poses an immediate health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above. LPA observed med (Medication) cart was unlocked and accessible; and a bottle of toilet cleaner was observed accessible and stored in cabinet under bathroom sink in first hall bathroom, which poses an immediate health, safety or personal rights risk to persons in care.

Request transfer of criminal record exemption

Based on observation, interview, and record review, the licensee did not comply with the section cited above. S1 has been working in the facility since 3/27/23, was present during the inspection, and does not have a completed request for transfer of criminal record exemption, which poses an immediate health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above. LPA observed two paint cans accessible in the unlocked first hall bathroom cabinet, which poses an immediate health, safety or personal rights risk to persons in care.

Request a transfer of criminal record clearance

Based on observation, interview, and record review, the licensee did not comply with the section cited above. S3 has been working in the facility since 4/22/22, was present in the facility during inspection, and does not have a completed request for transfer of criminal record clearance, which poses an immediate health, safety or personal rights risk to persons in care.