Devonshire Elderly Care

87303 (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. Thisrequirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not comply with the section cited above in one area that showed there was water damage, leaks to the ceiling which poses a Potential Health, Safety or Personal Rights risks to persons in care.

(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement is not met as evidenced by Based on the observation and record review the licensee did not comply with the section cited above in handling of 1 out 5 resident's property which poses a potential health, safety or personal rights risk to persons in care.

(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 evidenced by: Based on the observation and record review the licensee did not comply with the section cited above in one out of one area of mold/mildew which poses an immediate health, safety or personal rights risk to persons in care.

87458(b)(1)-The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis/secondary diagnosis,...results of an examination for communicable tuberculosis, other diseases...This requirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not ensure one (1) out of six (6) residents to have their Physican's Report and tuberculosis paperwork which poses a Potential Health, Safety or Personal Rights risks to persons in care.

Criminal Clearance 87355(e)(1) 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: Licensee failed to obtain criminal clearance/background association for an indvidual that is currently working as a staff which poses an Immediate Health, Safety or Personal Rights risks to persons in care.

87303 (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. Thisrequirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not ensure four (4) out of four (4) damages at the facility to be in repaired at all times which poses a Potential Health, Safety or Personal Rights risks to persons in care.

87411(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.Thisrequirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not ensure one (1) out of five (5) staff had a health screening which poses a Potential Health, Safety or Personal Rights risks to persons in care.

Prior to construction or alterations, all facilities shall obtain a building permit.This requirement is not met as evidenced by: Based on the observation and record review the licensee did not comply with the section cited above in one out of one area of contruction-removal of a garage and new construction which poses an immediate health, safety or personal rights risk to persons in care.

Criminal Clearance 87355(e)(1) 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: Licensee failed to obtain criminal clearance/background for the individual that is living in one (1) of the three (3) living areas attached to the above facility which poses an Immediate Health, Safety or Personal Rights risks to persons in care.

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:This requirement is not met as evidenced by: Based on the observation and record review, the licensee did not comply with the section cited above in regards to the garage being converted into three (3) living areas which poses an immediate health, safety or personal rights risk to persons in care.

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:This requirement is not met as evidenced by: Based on the observation, interview and record review, the licensee did not comply with the section cited above in submitting an application for the conversion of the garage into three (3) separate living units which poses/posed an immediate health, safety or personal rights risk to persons in care.

87211 (a)(1)(A)Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports... including, but not 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 requirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not ensure resident reports to be submitted to CCLD from the above facility involving multiple incidents which poses an Immediate Health, Safety or Personal Rights risks to persons in care.

87309 Storage Space (a) Disinfectants, cleaning solutions…and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on LPA Spaeth’s and LPM Agard’s observations, a kitchen knife was left on the kitchen counter which poses 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 out of one objects which poses an immediate health, safety or personal rights risk to persons in care.

Based on the record review, the licensee did not comply with the section cited above in two out of three persons which poses an immediate health, safety or personal rights risk to persons in care.

87405 Administrator - Qualifications and Duties. (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person...This requirement is not met as evidenced by: Based on document review & observation, the Administrator didn’t comply with section cited above. On three separate visits, the Administrator was not present a sufficient number of hours to permit adequate attention to the management and administration of the facility resulting in multiple deficiencies & compliance issues. This an poses an immediate health and safety risk to residents in care.

87555(b)(28) General Food Service Requirements All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.This requirement is not met as evidenced by: Based on food inspection conducted by Ombudsman on 3/10/22 it was observed that the facility kept expired eggs and rice without an appropriate cover in the refrigerator. Moreover on 3/16/22, LPAs observed 3 refrigerators with crumbs, stains and liquid spills from frozen meat. This poses a potential health and safety risk to the residents in care.

Based on water temperature measurement, 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 above which poses an immediate health, safety or personal rights risk to persons in care.

87705 (f)(1)(2) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement is not met as evidenced by: Based on LPAs observations, the Administrator did not ensure that medications, tools, and cleaning supplies were inaccesible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care due to dementia residents in care.

87204(a) Limitations-Capacity and Ambulatory Status. A licensee shall not operate a facility beyond the conditions and limitations specified on the license including the maximum number of persons who may receive services at any one time.This requirement is not met as evidenced by: Based on LPAs observation on an annual visit on 3/10/22, the licensee did not comply with the section cited above as 7 residents were living at this facility 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 evidenced by: Based on LPA observation during the annual conducted concurrently today, bathrooms were observed to be unsanitary, one bedroom had a strong urine smell, and the refrigerators were contaminated with old food spills including old packaged meat liquids.This poses a potential health, safety or personal rights risk to persons in care.

87307 Personal Accommodations and Services (d) (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.This requirement is not met as evidenced by: Based on LPA observation during the annual conducted concurrently today, two window screens are in disrepair, facility has large cracks in walls, kitchen cabinets are in disrepair, one fire alarm detector is in disrepair, staff bedroom door is broken, staff bedroom wall has a hole, and outlet covers are missing and have exposed wires in one of the bedrooms. This poses a potential health, safety or personal rights risk to persons in care.

87411(a) Personnel Requirements-General. Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs.This requirement is not met as evidenced by: Based on LPA observation and interviews, the licensee failed to provide sufficient staff for residents in care. There was one (1) staff member for six (6) residents in care.

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, interview and record review, the Administrator failed to provide two (2) out of sixe (6) resident records. This poses a potential health, safety or personal rights risk to persons in care.

78506(c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.This requirement is not met as evidenced by: Based on observation, the Administrator did not ensure that resident records remain confidential as they were located in a shared bookshelf in one of the bedrooms. This poses 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.

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

Based on LPA observations the licensee did not comply with the section cited above as 7 residents were observed living at this facility which poses an immediate health, safety or personal rights risk to persons in care.Civil Penalties 1548(c) Notwithstanding Section 1534, the department shall assess an immediate civil penalty of five hundred dollars and a one hundred dollar ($100) per day per violation for any of the following serious violations: (1) (A) Fire clearance violations, including, but not limited to, over capacity.

Based on LPA observations, the licensee did not comply with the section cited above by allowing someone to rent and live in the converted garage which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA Avetisyan's observation, the licensee did not comply with the section cited above by not having the required emergency agency contact information posted at the facility which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA Avetisyan's observation, the licensee did not comply with the section cited above by not providing all staff who are working with COVID-19 positive residents with fit testing for N95 respirators which poses a potential health, safety and personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not obtaining PRN authorization letters for 3 out of 3 residents which poses a potential health, safety or personal rights risk to persons in care.

Based on interview with administrator and record review, the licensee did not comply with the section cited above by not keeping/updating centrally stored medication and destruction log for 3 out of 3 resident which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA Avetisyan's observation, the licensee did not comply with the section cited above by not ensuring Routine symptom screening (+/- temperature and symptom check) has been initiated at entry for all staff, residents, and visitors. 2) Not documenting daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents in order to track spread and why facility took certain steps to prevent and mitigate spread in the facility which poses a potential health, safety and personal rights risk to persons in care.

Based on facility application review and pre-licensing report review the licensee did not comply with the section cited above admitting and retaiing a resident diagnosed with Dementia prior to obtaining an approved dementia plan of operation which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA Avetisyan's observation, the licensee did not comply with the section cited above by not ensuring staff have received training on infection prevention, symptoms, transmission and PPE use by an individual trained in infection control which poses a potential health, safety and personal rights risk to persons in care.

Based on LPA Avetisyan's observation, the licensee did not comply with the section cited above by not ensuring that Facility has an adequate 30-day supply of PPE (e.g., facemasks, respirators, gowns, gloves, and eye protection such as face shield or goggles) and a list including items on hand or indicating where such items will be acquired and when

Based on record review, the licensee did not comply with the section cited above by not inlcuding required addendums to the admission agreements for 3 out of 3 residents which poses a potential health, safety or personal rights risk to persons in care.

Based on observations made the licensee did not comply with the section cited above by not having resiednts rights and all other required postings posted at the facility which poses a potential health, safety or personal rights risk to persons in care.

Based on record review and interview with the administrator the licensee did not comply with the section cited above by not obtaining a medical assessment for 1 out of 3 residents which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not obtaining a TB for 1 out of 3 residents upon admission to the facility which poses an immediate health, safety or personal rights risk to persons in care.

Except as provided in approved continuing care agreements, no licensee or employee of a facility shall:accept any general or special power of attorney for any such person;This requirement is not met as evidenced by: Licensee did not ensure that any facility staff should not be appointed as POA of any resident. LPA record review and interview with administrator and staff revealed that S1 was appointed as the POA of a resident. This poses a potential personal rights to the residents in care.