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Inspection visit

Routine inspection (multi-day)

OAKHURST BOARD AND CARELicense 20720914216 citations on this visit
16 citations recorded

Inspector’s narrative

What the inspector wrote

On 9/25/2024 Licensing Program Analyst (LPA) B. Miranda arrived unannounced at the facility listed above to conduct a continuance of the Annual Inspection which was originally started on 9/20/24. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility. LPA met with staff Muang Saechao who stated they are in the process of becoming Administrator. Caregiver Heidy Campos was at the facility and the annual inspection was completed with her. LPA has been to the facility multiple times and current administrator Lucy Leang has not been at the facility. Interviews were conducted and some interviewees stated they did not know nor have they met the listed Administrator. Administrator was also not listed on the schedule Staff Maung Saechao provided. Current and valid administrator’s certificate was not provided. LPA did not observe documentation for emergency drills that were conducted at the facility. LPA observed medication to not be stored in original containers and to be stored in weekly pill planners. LPA reviewed a sample of files and R2’s file did not have current PRN form with correct medications. Residents with a DX of dementia should have a medical assessment and reappraisal completed annually, LPA reviewed sample files and found R1 to have their last medical assessment 9/21/2020. On 9/20/2024 LPA observed a cabinet in the dining area to be unlocked with medication accessible to residents. On 9/20/2024 & 9/25/2024 LPA observed exit auditory alarms to be turned off or not in working conditions. LPA reviewed a sample of resident’s centrally stored medication log which was not completed correctly for R1. LPA was not able to review liability insurance due to not being provided. LPA was not able to review staff file on 9/20/2024 due to not being at the facility. LPA reviewed staff files which did not have current training, some of the older training did not have the completed amount of time of training. Facility has residents with DX of dementia, LPA observed box cutter/razor in unlocked kitchen drawer, shed in the back of the facility unlocked with tools and other hazardous items, gardening items & cigarette butts left outside and accessible. LPA observed soiled toilet paper to be on the floor of the bathroom, trash can with no fitted lid, and brown markings on the back of the bathroom door. LPA observed one caregiver at the facility answering medication questions from family members, trying to conduct a tour, playing bingo with residents, give water to resident, make dinner, and tend to other resident needs. Caregiver was the only one on staff at the facility. Muang also stated the facility is short staffed. Exit interview was conducted and a copy of this report LIC809, LIC809C, LIC809Ds, and appeal rights were provided to Caregiver Heidy Campos

Citations

16 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.

  • 1569.605Type B

    Based on observation, interview, & record review, 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. Licensee/staff was not able to provide verification of current insurance.

  • 87412(a)(13)(B)1Type A

    Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA did not observe a current administrator's certificate. Correct background clearance was not file in staff files.

  • 1569.618(a)Type A

    Based on observation, interview, and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA have never observed the administrator Lucy Leang to be at the facility. There is no schedule indicating when the administrator is at the facility. LPA conducted multiple interviews, and the interviewees did not know who Lucy Leang was. Lucy's file with Administrator information is not current. Staff schedule did not show Lucy on schedule

  • 1569.625(b)(2)Type B

    Based on observation, interview, & record review, 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. LPA observed some of the staff training verification in the staff files did not have the amount of time spent on training.

  • 1569.695(b)Type B

    Based on observation, interview, & record review, 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. LPA is not observe documentation emergency drills to be conducted at the facility.

  • 87411(a)Type A

    Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed one caregiver at the facility answering medication questions to family members, trying to conduct a tour, playing bingo with residents, give water to resident, make dinner, and tend to other resident needs

  • 87412(c)Type B

    Based on observation, interview, & record review, 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. On 9/20/24 LPA was not able to review staff files due to not being at the facility. On 9/25/24 LPA was able to review staff files which did not have verification of current training.

  • 87412(g)Type B

    Based on observation, interview, & record review, 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. On 9/20/24 LPA was not able to review personnel records due to not being at the facility.

  • 87465(a)(6)Type A

    Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA reviewed a sample of resident's Centrally Stored Log which was not properly completed for R1

  • 87465(b)Type B

    Based on observation, interview, & record review, 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. LPA observed R2's records which has did not have updated PRN form with correct medication listed.

  • 87465(h)(2)Type A

    Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. 9/20/24 LPA observed a cabinet with resident's medications to be unlocked and accessible to residents

  • 87465(h)(5)Type A

    Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed resident's medications being kept in a weekly pill planner.

  • 87470(2)(A)(D)Type B

    Based on observation, interview, & record review, 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. LPA observed soiled toilet paper to be on the floor of the bathroom, trash can with no fitted lid, and brown markings on the back of the bathroom door.

  • 87705(c)(5)Type B

    Based on observation, interview, & record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA reviewed R1's records which has physician reported dated 9/21/2020.

  • 87705(f)(1)(2Type A

    Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed box cutter/razor in unlocked kitchen drawer, shed in the back of the facility unlocked with tools and other hazardous items, gardening items & cigarette butts left outside and accessible.

  • 87705(j)Type A

    Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. On 9/20/24 and 9/25/24 LPA observed auditory alarms on the exits to not be on or in working order.

FAQ · About this visit

Common questions about this visit

What happened during the September 25, 2024 inspection of OAKHURST BOARD AND CARE?

This was a other inspection of OAKHURST BOARD AND CARE on September 25, 2024. 16 citations were issued: 8 Type A (serious) and 8 Type B.

Were any citations issued to OAKHURST BOARD AND CARE on September 25, 2024?

Yes, 16 citations were issued (8 Type A, 8 Type B). The first citation was for: "Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/p..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

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.