Carries Care Villa

87411 Personnel Requirements - General(d) All personnel shall be given on the job training ,,,skill in the following...(3) Skill and knowledge required to provide necessary resident care...This requirement is not met as evidenced by: Based on interview the licensee did not comply with the section cited above as S1 was not trained on proper use of the facility's Hoyer lift which poses a potential safety risk to clients in care.

87464 Basic Services(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement is not met as evidenced by: Based on observation, record review, and interviews the licensee did not comply with the section cited above as residents were left in soiled diapers and residents requests for assistance went unanswered for extended periods of time which posed a potential health or personal rights risk to persons in care.

87211 Reporting Requirements(a) Each licensee shall furnish...:(1) A written report shall be submitted to... licensing...within seven days of...(D) Any incident which threatens the welfare, safety or health of any resident...This requirement is not met as evidenced by: Based on record review and interview the licensee did not comply with the section cited above as an incident report was not submitted to licensing within the required timeframe which posed a potential health, safety, or personal rights risk to clients in care.

87309 Storage Space and Access(a) ... the licensee shall ensure that disinfectants, cleaning solutions...are in locked storage and are not left unattended if outside the locked storage.This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as the staff room was observed to be unlocked and contained unsecured cleaning supplies which posed an immediate safety risk to clients in care.

(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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) ...This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the above cited section as 2 staff were not associated to the facility which poses an immediate health, safety, and personal rights risk to persons in care.

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section as 4 residents did not have a hospice care plan on file whihc poses a potential health, safety, and personal rights risk to persons in care.

87412 Personnel Records(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as S2's file was missing from the facility which poses a potential health, safety, or personal rights risk to clients in care.

87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored:(6) The licensee shall be responsible for assuring that a record...is maintained...This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as R1's CSMDR was missing an accurate log of M1 which poses a potential health risk to clients in care.

87465 Incidental Medical and Dental...(a) A plan for incidental medical and dental care shall be developed...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, interview, and record review the licensee did not comply with the section cited above as R1's M1 medication was not administered as prescribed by their physician on at least 3 separate occasions with at minimum 7 pills missing which poses an immediate health risk to clients in care.

87411 Personnel Requirements - General(d) All personnel shall be given on the job training...(4) Knowledge required to safely assist with prescribed medications...This requirement is not met as evidenced by: Based on record review and interview the licensee did not comply with the section cited above as S1 admitted to dispensing medication to R1 without appropriate medication training which poses a potential health and safety risk to clients in care.

87705 Care of Persons with Dementia(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement...This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above as three auditory alarms were non-functional during the visit and one alarm was reported to be turned off when R1 eloped from the facility which poses a potential safety risk to clients in care.

§1569.312 Basic services requirementsEvery facility required to be licensed under this chapter shall provide at least the following basic services:(a) Care and supervision as defined in Section 1569.2.This requirement is not met as evidenced by: Based on interview the licensee did not comply with the section cited above as R1 eloped from the facility while under the care of staff and was found by law enforcement away from the facility approximately 30 minutes later which poses a potential safety risk to clients in care.

Based on record review, the licensee did not comply with the section cited above as three resident files were missing signed copies of The personal rights of residents which poses a potential personal rights risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above as two staff members who were providing assistance to residents without the supervision of the Administrator or Licensee Representative did not have a minimum of 20 hours of training prior to providing assistance 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 as the facility did not have record of the last completed emergency disaster drill which poses a potential safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as the resident bathroom toilet was observed to be missing a large portion of the ceramic on the water tank leaving a sharp edge exposed which poses a potential health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as two bedrooms had furniture and personal items cluttering the area where residents would traverse which poses/posed a potential safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as an under-sink storage in the resident bathroom contained cleaning chemicals and was unlocked which poses an immediate health and safety risk to persons in care.

Based on interview and record review, the licensee did not comply with the section cited above as one resident had a significant change in condition that was not reflected on their most up-to-date physicians report which poses a potential health to persons in care.

Based on observation, the licensee did not comply with the section cited above as the garage was observed to contain expired food items in the emergency food storage which poses a potential health risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as six residents had incomplete personal property inventory records which poses a potential personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as in two (2) out of three (3) residents diagnosed with dementia need updated annual medical assessments 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, as Resident #1 (R1) is bedridden and does not reside in the bedridden room, which poses an immediate health and safety risk to persons in care.

87468.2 (a)(20)(a) Personal Rights of Residents ... residents in privately operated residential care facilities for ... shall have all of the following personal rights:(20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents for ...regulations and shall comply... For purposes of this paragraph, "involuntary" means a transfer, discharge, or eviction that is initiated by the licensee...and which poses an immediate health and safety or personal rights risk. This requirement was not met as evidenced by: Based on the investigation and information obtained. The administrator refused resident back to facility at the time resident was discharged, which poses an immediate risk to persons in care.