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Inspection visit

complaint

DEVONSHIRE ELDERLY CARELicense 1976095007 citations on this visit
7 citations recorded

Inspector’s narrative

What the inspector wrote

Allegation #2 - Facility does not have sufficient staff to meet residents' needs. Upon arrival, designee Maria told LPA’s that she is currently the only staff providing care and supervision to all six (6) residents in care. She stated that another staff member would be back later today, as staff was at the hospital. LPAs were able to obtain staff’s phone number and staff member told LPA’s that they resigned and will no longer be coming back to the facility. Based on LPA’s ob servation and an interview conducted, this allegation is substantiated. Allegation #3 - Resident's records are not complete and/or missing. Allegation #4 - Resident's records are not adequately stored. At 9:45 a.m., LPAs began touring the facility. Upon touring the second floor of the home, residents’ records were observed to be stacked in a small bookshelf in a staff bedroom along with other personal belongings. LPAs observed five (5) resident records, four (4) of which pertained to residents who currently reside at the facility. LPAs asked the designee Maria for the records of the two (2) additional residents. Maria was unable to provide the records and stated the Administrator Farah has the knowledge of the whereabouts of the two (2) resident records. Based on LPAs observation and interview, these two allegations are substantiated. Allegation #5 - Medications are not locked at the facility . Upon touring the kitchen, LPAs observed two (2) medication storage bins accessible to residents in one of the kitchen cabinets. LPAs instructed the designee Maria to immediately lock the medications in the designated storage cabinet. Based on LPAs observation, this allegation is substantiated. Allegation #6 - Facility does not provide a safe and hazard free environment for residents. Allegation #7 - Facility is in disrepair. During the rest of the facility tour, LPAs observed a smoke alarm detector pulled out with no batteries and wires hanging out. LPAs observed a staff bedroom door to be broken and wood sticking out of the bottom of the door which could be dangerous to staff and residents. LPAs observed two (2) windows - one in the kitchen and one in the bathroom to be missing a screen. A kitchen cabinet door was broken, and it was placed off to the side. Based on the observations mentioned above, these allegations are substantiated. Allegation #8 - Residents have access to dangerous items. When LPAs continued the tour in the backyard, LPAs observed two (2) large pickaxes on the side of the facility. In the designated detached laundry room, there was various tools intended for construction or repairs. Based on LPAs observations this allegation is substantiated. Deficiencies were issued per CA code of Regulations Title 22. See 9099D's included with this report. Appeal rights issued. Report signed and delivered. Exit interview conducted.

Citations

10 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.

  • 87303(e)(2)Type A

    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.

  • 87311Type A

    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.

  • 87204(a)Type A

    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(a)Type B

    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(d)(2)Type B

    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)Type A

    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(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, 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.

  • 87506(c)(1)Type B

    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.

  • 87303(e)(5)Type B

    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.

  • 87705(f)(1)(2)Type A

    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.

FAQ · About this visit

Common questions about this visit

What happened during the March 16, 2022 inspection of DEVONSHIRE ELDERLY CARE?

This was a complaint inspection of DEVONSHIRE ELDERLY CARE on March 16, 2022. 7 citations were issued: 3 Type A (serious) and 4 Type B.

Were any citations issued to DEVONSHIRE ELDERLY CARE on March 16, 2022?

Yes, 7 citations were issued (3 Type A, 4 Type B). The first citation was for: "Based on water temperature measurement, the licensee did not comply with the section cited above which poses an immediat..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

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.