Indian Summer Place

Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 5 residents are being medication without the physician's orders which poses an immediate health, safety or personal rights risk to persons in care.

Based on interview, the licensee did not comply with the section cited in that the facility could not provide proof of the liability insurance which poses a potential health, safety rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the centrally stored medication list with medication names and dosages was not udpated for (6) of (6) residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as (2) of (6) resident files were not available for LPA review which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as facility was unable to provide LPA proof of liability insurance during the visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as Administrator Samantha Alex has an expired certificate and has not submitted packet for renewal 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 as LPA toured facility on both Initial and subsequent visits and Complaint poster was not posted anywhere inside 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 in one client bathroom measured at 127.2 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as during initial and subsequent visits residents beds were either missing the required mattress pad or sheets, 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 as LPA observed knives to be stored in unlocked pantry and medication cabinet was unlocked within the unlocked kitchen, which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review and conversation with Administrator, the licensee did not comply with the section cited above as Administrator currently does not have a valid Administrator Certificate or required trainings, which poses 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 as Administrator could not furnish proof of Infection Control Plan during time of visits, 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 as LPA observed cleaning solutions in an unlocked cabinet under client bathroom sink, which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as LPA tested water temperature in both client restrooms, one restroom measured at 128.6 and the other at 129.5, which poses an immediate health, safety or personal rights risk to persons in care.

87303 Maintenance and Operation(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 requirement is not met as evidence by: 2 live small insects (roaches) were observed crawling in between R1's facility file. Facility was previously cited on 10/3/22 for same violation.

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 is not met as evidenced by: 3 of 4 Residents interviewed indicate Staff #3 works in the facility and 2 of 2 Staff interviewed verified Staff #3 works at the facility. Record review indicate Staff #3 does not have a criminal record clearance and not associated to the facility.

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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Interviews with 4 of 4 Residents indicate Staff #2 is working in the facility. Interviews with 2 of 2 Staff also verified Staff #2 is working in the facility. Record review indicate Staff #2 has a criminal record clearance but is not associated to the facility.

Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited abovewhich 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 which poses/posed a potential health, safety or personal rights risk to persons in care.

This is a continuation of the 87211(above). This standard is not met as evidence by: LPA was unable to obtain any special incidents for R-7 or R-8. Per staff interviews, R-8 indicated R-8 hit R-7 and staff interviewed all Residents. Per Staff interviews, no residents witnessed R-8 hitting R-7. Per file review, staff only had a written note on R-7's and R-8's file and was not reported to Licensing but was reported Long Term Care Ombudsman (LTCO). Per staff interviews, staff were under the impression that LTCO cross reports to Licensing

87211 Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but no limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.

Based on record review, the licensee did not comply with the section cited above for Staff #1 who does not have clearance nor associated to the facility and does not which poses an immediate health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in that the water temperature was measured at 134.2 degree F which poses an immediate health and safety risk to persons in care.