Santa Fe Home Care Ii

Maintain and operate facility under definitive plan

Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety and personal rights risk to persons in care.The facility's current plan of operation does not match what is on file with CCLD received on 10/12/2015. The facility did not follow its medication policy (medication refills) for R2. It indicates medications are never allowed to run out unless directed to by the physician (obtain this direction in writing).

Submit and maintain current mailing address

(e) All individuals subject to a criminal record review... shall prior to working... in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above for one staff which poses an immediate safety risk to persons in care. LPA did not observe staff #1 (S1) having a criminal background clearance nor association to the facility. S1 worked in the facility on 08/22/24.

87405(b)(2) Administrator - Qualifications and Duties. (b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (2)Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by:Based on interview and observation the Licensee/Administrator failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited, which poses a potential health and safety risk to residents in care.

Submit and maintain current mailing address

(e) All individuals subject to a criminal record review... shall prior to working... in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above for one staff which poses an immediate safety risk to persons in care. LPA did not observe staff #5 (S5) having a criminal background clearance nor association to the facility. S5 worked in the facility on 08/07/24 and 08/08/24

Mark taps at high-temperature threshold

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in one bathroom which poses an immediate safety risk to persons in care. LPA Cloyd measured the water temparture at 142.8 degrees F.

Include hazardous health condition records

Based on record review the licensee did not comply with the section cited above for one staff member which poses a potential health risk to persons in care. On 08/07/24, LPA Cloyd did not observe a health screening report (LIC 503) with TB results for Staff #5.

Based on interview and record review, the licensee did not comply with the section cited above for one out of two residents which poses a potential health and safety or personal rights risk. On 08/07/24, LPA Cloyd did not observe a restricted health care plan for Resident #1 (R1) injections. LPA saw needles during medication review. Both Home Health Nurse and Staff stated that they assist with injections.

Maintain facility in clean, safe, sanitary condition

(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 interview and observation, the licensee did not comply with the section cited above which poses a potential safety and personal rights risk to persons in care. LPA observed the facility being remodeled and under construction.

Eviction report must be filed within five days

(f) A written report of any eviction shall be sent to the licensing agency within five (5) days.This requirement is not met as evidenced by: Based on interview and observation, the licensee did not comply with the section cited above for Resident #1 (R1) which poses a potential personal rights risk to persons in care. Licensing did not receive notice from the facility regarding R1's permanent move.

87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident’s physician as a medical necessity shall be provided.This was not met based on: LPA reviewed physician’s orders for R1, R2, and R5, and found they required a special diet of low sodium, low carbohydrates, and low sugar and during interviews with R2 and R5 stated they are served item that do not meet the modified diet prescribed by physician. This poses a health and safety risk to residents in care.

Incidental medical and dental care services

87465Incidental Medical and Dental Care (c) if the resident’s physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) a record of each dose is maintained in the resident’s record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident’s response. This was not met based on: Record review of Resident R1s Physicians report and Centrally stored medications has 2 PNR medications and there is no documentation of R1 receiving thier PRN. This poses a health and safety risk to residents in care.

Based on observation and record review, the licensee did not comply with the section cited above, it was observed during file review that R1 does not have a recent TB test on file, which poses a potential health, safety or personal rights risk to persons in care.

Obtain baseline medical assessment before resident admission

Based on observation and record review, the licensee did not comply with the section cited above, it was observed during file review that R1 does not have a Physicians Report on file, which poses a potential health, safety or personal rights risk to persons in care.

87412 Personnel Records (e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked.This requirement is not met as evidence by: Based on observation and interview, Licensee failed to provide personnel report LIC 500 during visits. Uncertain of adequate staff coverage. This poses a potential health and safety risk to 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 evidence by: Based on observation and interview, Licensee failed to provide resident records for (R1) hospice records and Medicaiton Administration Record during visits. This poses a potential health and safety risk to residents in care.

87405 Administrator - Qualifications and Duties (b) The administrator of a facility.. shall have the responsibility and authority to carry out the policies... (1) Knowledge of the requirements for providing care and supervision... (2) Knowledge of and ability to conform to the applicable laws, rules, and regulations This requirement was not met as evidenced by: Based on observation record and interviews, the Administrator failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited. This violation poses/posed a potential health, safety, or personal rights risk to persons in care.

Safe, healthful, comfortable accommodations

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on interviews, the licensee did not comply with this section. Staff assisted with medications for residents without knowledge of documenting PRN or prescribed medications. Residents are not provided a safe environment. This a potential health, safety or personal rights risks to persons in care.

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need .. medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist...(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by: Based on interviews, the licensee did not comply with this section. Licensee did not have evidence to show proof that prescribed medications or PRN for (R1,R3 & R4) were administered PCP orders. This poses an immediate health, safety or personal rights risks to persons in care.

Maintain facility in clean, safe, sanitary condition

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: Based on observation, the licensee did not comply with this section. LPA observed ants, pest droppings, dead pest inside the refrigerator and the outside perimeter of the appliance. This poses a potentieal health, safety or personal rights risks to persons in care.

87555 General Food Service Requirements (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. (28) All food shall be protected against contamination...This requirement is not met as evidence: Based on observation, LPA identified unsafe practices of food items not stored properly in refridgerator and pantry free from contamination, harmful bacteria, viruses, parasites, or chemical substances. This poses a potential health, safety and/or personal rights risks to persons in care.

Food quality controls and rejected damaged goods

87555 General Food Service Requirements (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.This requirement is not met as evidence by: Based on observation, the licensee did not comply with this section. LPA observed (10) food items that had expired dates. This poses a potentieal health, safety or personal rights risks to persons in care.

87506 Resident Records(c) All information and records obtained from or regarding residents shall be confidential. During the complaint visit on 5/3/2023 at 9:52 am, LPA observed residents’ confidential files including R1’s file were not locked and accessible. LPA advised S2 to keep and lock all confidential files. At 10:38 am, LPA observed R1’s confidential file folder was still accessible and not moved to a locked storage. This poses a potential health, safety and/or personal rights risk to residents in care.

87555 General Food Service Requireme(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. During LPA’s complaint visit on 5/3/2023 at 10:06 am, LPA checked and observed several bags of bread and chips were open and not sealed. LPA observed a bowl of meat, a glass container of gelatin and a soy sauce with sliced onions in the refrigerator uncovered. LPA also observed uncovered bowl of rice soup, chips and salsa near the stove oven. This poses a potential health, safety and/or personal rights risk to residents in care.

Freedom to leave and not be locked in

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This was not met as evidenced by: At around 10:23 am, LPA Montoya observed the right side gate is locked with a padlock. This poses a potential health, safety, and/or personal rights risk to residents in care.

Living accommodations aligned with facility function

(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. Based on observation and interview, there is no sufficient lighting in bedrooms #2 and #3.

(f) 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 was not met as evidenced by: Based on record review, observation and interviews, the licensee failed to ensure items that could constitute a danger to residents with dementia are inaccessible. Around 10:02 am, LPA observed two pairs of scissors and a knife on a dish drying rack in the kitchen and the drawer for sharp items was kept open and accessible. LPA observed a shovel in the backyard next to a storage shed; Around 10:20 am, LPA observed the cabinet for storing cleaning suppplies (Cloralen, etc ) was open and accessible. Around 10:25 am, LPA observed a trowel and a large black rake in the backyard next to the sliding door. Around 11:45 am, LPA observed lysol, laundry soap and fabric softener in the laundry room were accessible. This poses an immediate health, safety and/or personal rights risk to residents in care with dementia.

Keep bath, laundry and kitchen floors clean

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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This was not met as evidenced by: Based on LPA Montoya’s observations during a tour of the inside and outside grounds of the facility on 4/11/2023, kitchen floor is dirty, the bottom of the dishwasher had molded water and smelled malodorous, the laundry floor was covered with water leak, the ground of the right side of the facility is covered with molded water and white powder across the walkway. This poses a potential health, safety and/or personal rights risk to residents in care.

Food quality controls and rejected damaged goods

87555 General Food Service Requirements(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This was not met as evidenced by: Based on LPA Montoya’s observations during a tour of the inside and outside grounds of the facility on 4/11/2023, facility has expired food. LPA observed the following expired food: Chicken Bolgna – expired on 2/7/2023; a bag of wheat bread – expired on March 1, 2023; a bag of white bread – expired on March 18, 2023; a bag of garden salad – expired on April 7, 2023, and lettuce looks saggy. This poses a potential health, safety and/or personal rights risk to residents in care.

87555 General Food Service Requirements (b) The following food service requirements shall apply:(30) All utensils used for eating and drinking and in preparation of food and drink, shall be cleaned and sanitized after each usage.(31) Dishes and utensils shall be disinfected:(B) In facilities not using mechanical means, by an alternative comparable method approved by the licensing agency or by the local health department, such as the addition of a sanitation agent to the final rinse water. LPA observed about five white plates stored in the cabinet are still wet and one of them has food residue on the edges of the plate. LPA observed the dishwasher is not in good repair. R4 stated sometimes plates, cups and utensils are left overnight in the sink unwashed. This poses a potential health, safety and/or personal rights risk to residents in care.

Coverage for absent regular staff members

87413 Personnel - Operations(a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This was not met as evidenced by: Based on LPA’ review of staff’s timesheets and interviews conducted, there is a lack of staffing in the facility. Since January 2023 to April 2023, there were days that facility had only one staff duringd day and night. There are currently five residents in the home of which three are diagnosed with dementia. One out three residents with dementia is ambulatory, two are non-ambulatory. R3 and R5 observed only one staff (S2) is present in the facility every day and some days, another staff comes to help S2. This poses a potential health, safety and/or personal rights risk to residents in care.

87506 Resident Records(c) All information and records obtained from or regarding residents shall be confidential. During LPA's visit on 4/11/2023 AND 4/14/2023, LPA observed all five residents' records (folders) are stored in an unlocked cabinet. This poses a potential personal rights, health or safety risk to residents in care.

Submit and maintain current mailing address

(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 was not met as evidenced by: Based on record review, observation and interviews, the licensee failed to ensure S1 is fingerprint clear prior to working. S1 started working as a caregiver in this facility on 4/4/2023. This poses an immediate health, safety and/or personal rights risk to residents in care.

Maintain facility in clean, safe, sanitary condition

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 was not met as evidenced by: Based on observations and interviews, the facility is in disrepair. The diswasher is broken and has malodorous smell, the back door is rotted, the floor in the laundry room is covered with water due to a leak, the outdoor patio is covered with dried leaves, the lock of the right side gate is not working properly and the kitchen floor and oven are dirty.

Notify agency before locking doors or gates

(f) 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). This was not met as evidenced by: Based on record review, observation and interviews, the licensee failed to ensure items that could constitute a danger to residents with dementia are stored inaccessible. LPA observed R1 who has dementia sitting at the back patio and a couple of shovels and a rake are accessible at the patio. LPA observed the cabinet under the sink where cleaning supplies such as bleaches, glass cleaner, etc. are stored is unlocked and accessible to residents with dementia.

Submit and maintain current mailing address

Based on LPA Montoya’s interview with the Administrator (S1) on 9/23/22, S3 started working on 9/23/22 without a background clearance. LPA Montoya and LPA Gibb observed S3 is working in the facility in blue scrub uniform. Based on review of S3’s timesheet, she began working on 9/14/2022 to date. On 9/27/22, LPA returned to the facility and observed S3 is working again without background clearance. The administrator failed to ensure S3 obtained a California background clearance prior to working or volunteering. This poses an immediate health, safety or personal rights risk to persons in care.

Based on observation and interview, record review, the licensee did not comply with the section cited above. The administrator (S1) stated S3 just started working on 9/23/2022 when asked by LPA Montoya. Based on LPA Montoya’s interview with two residents (R1 and R2), and review of S3’s timesheet, S3 began working at the facility on 9/14/2022 and continued to work until LPA's visit day. This poses an immediate health, safety or personal rights risk to persons in care.

Obtain baseline medical assessment before resident admission

Based on observation, interview and record review, the licensee did not comply with the section cited above. Resident #1 has no Physician’s Report on file. This poses a potential health, safety or personal rights risk to persons in care.

Keep prescriptions in original containers

Based on observation and interview, the licensee did not comply with the section cited above. Medication is dispensed to another container one week prior to administration per Staff 2. 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. The fireplace in the family room is not properly screened which poses a potential health, safety or personal rights risk to persons in care.

Conformance with applicable laws and regulations

Based on LPA Montoya’s interview with the Administrator (S1), S3 started working on 9/23/22 without a background clearance. LPA Montoya and LPA Gibss observed S3 is in the facility in blue scrub uniform. Based on review of S3’s timesheet, S3 worked on 9/14/22-9/18/22 and based on interview with R1 and R2, S3 continued to work on 9/19/22, 9/20/22 and 9/23/22. The administrator failed to ensure S3 obtained a California background clearance prior to working or volunteering which poses an immediate health, safety or personal rights risk to persons in care.

Provide resident hot water for personal care

Based on LPA's observations, the licensee did not comply with the section cited above. The water temperature in the common bathroom is 124.4 degree Fahrenheit and the water temperature in bedroom # 3 is 124.00 degree Fahrenheit. This poses an immediate health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on observation, the licensee did not comply with the section cited above. LPA Montoya and LPA Gibb observed three stove burners are not operable; the sliding door in the kitchen and the screen door are not in good repair; doorbell is broken off the wall; a missing kitchen cabinet; a fire extinguisher mounted in the laundry room was last serviced on 2/15/2018. This poses a potential health, safety or personal rights risk to persons in care.