Follow-up on corrections·December 13, 2023

Citations

3 citations recorded^*CCLD

• 87405(d)(1)(2)Type B

  87405 Administrator - Qualifications and Duties(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.This requirement was not met as evidenced by: On 12/12/2023, LPA Lourdes Montoya observed during records review that R1's Appraisal/Needs and Services Plan dated 7/1/2021 is identical to R1's Appraisal/Needs and Services Plan dated 1/21/2023. LPA observed the typed written date (7/1/2021) was erased with a white out and the date was changed with a hand written date (1/21/2023). Two staff (S1-S2) acknowledged that the appraisal dated 7/21/2021 is a photo copy of the appraisal dated 1/21/2023. S3 on the other hand argued that since R1 did not have any medical change, a photo copy of R1's 2021 appraisal is acceptable to make R1's appraisal current. This poses a potential health, safety and/or personal right risk to persons in care.

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• 87506(a)Type B

  Maintain separate complete record for each resident

  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 was not met as evidenced by: On 12/12/2023, LPA interviewed two staff (S1-S2). Interviews with S1 and S2 revealed they assumed the resident records are maintained completely and accurately. LPA reviewed records of five out of five residents (R1-R5). LPA’s records review revealed resident records are not maintained completely and accurately. This poses a potential health, safety, and/or personal rights risk to persons in care.

• 87705(c)(4)(A)Type B

  87705 Care of Persons with Dementia(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.This requirement was not met as evidenced by: On 12/12/2023, LPA interviewed two staff (S1-S2). Interviews with S1 and S2 revealed there are two caregivers providing care and supervision to five residents during day shift from 7:00 AM through 7:00 PM. S1 and S2 stated an awake staff is placed to work overtime at nght from 7:00 PM - 7:00 AM when any residents pose a restless behavior. Based on interview with S1 and S2 and LPA's records review, it was revealed that four residents (R1, R2, R4 & R5) need close supervision due to their medical conditions, however S1 and S2 stated there are no on-duty awake staff during night shift unless needed. This poses a potential health, safety, and/or personal rights risk to persons in care.

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