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Inspection visit

Follow-up on corrections

GRACES HOMELicense 3060054704 citations on this visit
4 citations recorded

Inspector’s narrative

What the inspector wrote

On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purposes of conducting a case management deficiency in connection to the investigation completed under complaint control number: 22-AS-20221110131242. LPA Quiroz was greeted and granted entry into the facility by Administrator Ngoc "Nick" Mai and explained the reason for the visit. During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation. The investigation found the following: Hospital records confirm that R1’s responsible party informed hospital staff that R1 was not brought in by their caregiver due to caregiver having two other people to take care of. Facility was cited for lack of staffing on 2/07/2023 during a Case Management inspection by the Department. As of today’s date, the Plan of Correction has not been met. When interviewed regarding the fall, the Administrator reported they did not submit a written unusual incident report (UIR) to the Licensing Department as they didn’t think it was necessary as they believed R1 to be improving. The Administrator further reported they did not contact 9-1-1 as they believed the family would handle R1’s medical needs and that by contacting R1’s family, the Administrator believed he had met his Administrator duties. Following R1’s fall it was reported R1 was no longer able to walk. Hospital records from 11/09/2022 confirm R1 sustained a closed hip fracture. Despite the change in condition, no updated reappraisal was observed on file. In addition to the above noted incident, hospital records note R1 was hospitalized on 8/26/22 due to being hypotensive. While there, blood glucose levels for R1 were noted to be 244. The following is being cited per California Code of Regulations, Title 22 Division 6 Chapter 8. (SEE LIC 809-D Pages) An exit interview was conducted with Administrator and a copy of this report, confidential names list and appeal rights was provided at the time of exit.

Citations

5 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.

  • 87211(a)(1)(D)Type B

    87211(a)(1)(D) Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following…A written report…Any incident which threatens the welfare, safety or CONTINUED... health of any resident…This requirement is not met as evidence by: Licensee failed to submit a written report to the Licensing agency regarding R1’s unwitnessed fall in October of 2022 or hospitalization on 8/26/22. This poses a potential risk to residents in care.

  • 87405(d)Type A

    Required administrator qualifications listed in this subsection

    87405(d) Administrator- Qualification and Duties. The administrator shall have the qualifications specified…Knowledge of the requirements for providing care and supervision … and ability to conform to the applicable laws, rules and regulations. This CONTINUED... CONTINUE...requirement was not met as evidence by: Administrator failed to ensure the facility was properly staffed; failed to submit necessary written reports to licensing and failed to seek appropriate medical attention for R1. This poses an immediate risk to residents in care.

  • 87411(a)Type A

    Facility personnel sufficiency and competence

    87411(a) Personnel Requirements- General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…This requirement was not met as evidence by: The facility failed CONTINUED... CONTINUE...to seek immediate medical attention for R1 in part due to the caregiver needing to care for two other residents. The facility lacked sufficient staffing to be able to meet the resident’s need for immediate medical attention. This poses an immediate risk to residents in care.

  • 87463(c)Type B

    Document behavioral expression and related causes

    87463(c) Reappraisals. The licensee shall arrange a meeting … when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first. This requirement was not met as evidence by: Following R1’s fall the facility failed to CONTINUED... CONTINUE...complete a reappraisal despite R1 being unable to walk. R1 was able to walk with assistance prior to fall. This poses a potential risk to residents in care.

  • 87465(g)Type A

    Call 9-1-1 for imminent health threats

    87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health…This regulation was not met as evidence by: Resident was found on ground CONTINUED... CONTINUED...following an unwitnessed fall sometime in October of 2022. Despite reporting hip pain and being unable to walk, no medical attention was sought. R1 was transferred to the hospital approximately a month later and diagnosed with a hip fracture.

FAQ · About this visit

Common questions about this visit

What happened during the April 24, 2023 inspection of GRACES HOME?

This was an other inspection of GRACES HOME on April 24, 2023. 4 citations were issued: 2 Type A (serious) and 2 Type B.

Were any citations issued to GRACES HOME on April 24, 2023?

Yes, 4 citations were issued (2 Type A, 2 Type B). The first citation was for: "87211(a)(1)(D) Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Departmen..."

What type of inspection was this?

This was an 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.