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Inspection visit

Follow-up

HEAVENLY CASTLE CARE INCLicense 1572092664 citations on this visit
4 citations recorded

Inspector’s narrative

What the inspector wrote

On 3/7/2024 Licensing Program Analysts (LPAs) B. Miranda and S. Doucette arrived to the facility unannounced to conduct a case management visit. LPAs introduced themselves and explained the reason for the visit. LPAs were allowed entry into the facility and Administrator (AD) Hasmik Nshanyan was contacted via phone. AD stated they were on their way and would arrive in about 45 minutes. LPAs observed facility to be clean, clutter & odor free. LPAs requested resident files to review while waiting for AD to arrive. Staff told LPAs to wait for AD. Due to staff not complying with LPAs requests to review resident records deficiency was cited. LPAs observed R1 & R2 in room 1. R1 has full bed rails on bed. LPAs reviewed R1's chart which did not indicate resident was on hospice and did not have a doctor's order on file for full bed rails. Due to facility not having proper documentation for full bed rails deficiency was cited. Resident records were reviewed. During the review R3's centrally stored log was not current and up to date. After reviewing R3's Oxycodone medication and AD conducting a medication count the start date did not match the medication count deficiencies were cited All deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8, are being cited on the attached LIC 809D . Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Hasmik Nshanyan.

Citations

6 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87465(a)(4)Type A

    87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self administered medications as needed.This requirement is not met as evidenced by: Based on observation, interviews, and records reviewed the licensee failed to log centrally stored medication indicated medication started on Monday 4/4/24 and after the count indicated the start date was 3/6/24. There was no verifiable date the medication started and the count of R3's Oxycodone was incorrect.

  • 87465(a)(6)Type A

    87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.This requirement is not met as evidenced by: Based on observation, interviews, and records reviewed the licensee failed to properly log R3's narcotic medication Oxycodone.This poses an immediate health, safety, or personal rights risk to residents in care.

  • 87506(a)Type B

    87506 Resident Records(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.This requirement is not met as evidenced by: Based on observation, interviews, and records reviewed the licensee failed to provide resident records when LPA’s requested. Staff was asked for resident files to review and told LPAs to wait for the administrator.This poses a potential health, safety, or personal rights risk to the residents in care.

  • 87608(a)(5)(B)Type A

    87608 Postural Supports(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.This requirement is not met as evidenced by: Based on observation, interviews, and records reviewed the licensee failed to obtain proper documentation for R1 to have full bed rails on the bed.This poses an immediate health, safety, or personal rights risk to residents in care.

    Read full inspector narrative
  • 87411(d)(3)Type B

    Personnel Requirements - General87411 (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement was not met as evidenced by Licensee did not ensure staff is able to communicate with LPA or residents which poses a potential health safety and or personal rights risk to residents in care.

  • 87507(g)(3)(B)1.Type B

    87507 Admission Agreements (g) Admission agreements shall specify the following: (3) Payment provisions, including the following: (B) Rate for additional items and services, including 1. A comprehensive description of and the corresponding fee schedule for all additional items and services not included in the fees for basic services shall be listed. This requirement was not met as evidenced by: Licensee provided a service without completed receipts or a signed agreement between Licensee and resident which poses a potential health safety and or personal rights risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the March 7, 2024 inspection of HEAVENLY CASTLE CARE INC?

This was a other inspection of HEAVENLY CASTLE CARE INC on March 7, 2024. 4 citations were issued: 3 Type A (serious) and 1 Type B.

Were any citations issued to HEAVENLY CASTLE CARE INC on March 7, 2024?

Yes, 4 citations were issued (3 Type A, 1 Type B). The first citation was for: "87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each fac..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.