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Inspection visit

Complaint

CYECREST GUEST HOMELicense 3060057214 citations on this visit
4 citations recorded

Inspector’s narrative

What the inspector wrote

On 4/8/21 Staff #1(S1) left employment at the facility, leaving Staff #2(S2) as the only caregiver. Both staff indicated they were not strong enough to remove R1 from bed on their own and S2 described R1 as bedridden during S1’s absence. This indicated that R1 was not removed from bed from 4/8/21 until R1 left the facility on 5/30/21. S1 also stated that there was usually only one staff member at the facility prior to S1 leaving on 4/8/21. R1 was removed from the facility on 5/30/21 by family. Family were present during R1’s diaper change. Family observed an open wound on R1’s lower back/buttock area with a foul odor. S2 stated that she had noted a red rash. R1 did not receive any examination for the pressure injury while in care at the facility. The wound was diagnosed as infected and a Stage III pressure injury by R1’s Primary Care Physician and the Department’s Clinical Consultant’s. Based upon the Department’s investigation, it is clear that R1 had not been removed/transferred from bed for the time period 4/8/21 through 5/30/21 and possibly longer. As a result, R1 developed a Stage III pressure injury on R1’s coccyx that became infected as evidenced by the foul odor and medical assessment. This is a prohibited health condition that the facility was not approved to care for. In addition, R1’s family was never notified of R1’s wound nor the fact that R1 was completely bedridden, and there was no change of condition documented. The preponderance of evidence standard has been met and the above allegations are substantiated. See attached LIC9099D for cited deficiencies per California Code of Regulations, (Title 22, Division 6, Chapter 8). An exit interview was conducted and a copy of this report and appeal rights were provided to Licensee Tin Le.

Citations

6 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.

  • 87411(a)Type A

    Facility personnel sufficiency and competence

    Personnel Requirements-GeneralFacility 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 evidenced by: R1 was bedridden and Licensee failed to have enough staff to remove him from bed. This is an immediate Health and Safety risk to resident's in care.

  • 87625(b)(3)(7)Type A

    Managed Incontinence-The licensee shall be responsible for ensuring that incontinent residents are kept clean and dry and the condition of the skin exposed to urine and stool is evaluated regularly to ensure that skin breakdown is not occurring. This requirement was not met as evidenced by: Staff could not move R1 and failed to ensure that R1 was kept clean and dry. R1 developed skin breakdown. This was evidenced by the Infection and foul odor of the Stage III pressure injury. This is a immediate health and safety risk.

  • 87202(a(2)Type A

    Fire Clearance-Prior to accepting or retaining nonambulatory and/or bedridden resident's, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by city or county fire department.This requirement was not met as evidencesd by: Resident #1 was bedridden and the Licensee did not have an approved bedridden fire clearance. This is an immediate Health and Safety risk to residents in care.

  • 87203Type A

    Maintain facilities for fire and panic safety

    Fire Safety-All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement was not met as evidenced by: During visit, LPA observed the back door exits to be tied shut and a chair and recliner pushed up against the doors. This is a Health and Safety and Personal Rights risk to residents in care.

  • 87464(d)Type A

    Acceptance obligations tied to pre-admission appraisal needs

    Basic Services- A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs either directly or through outside resources.This requirement was not met as evidenced by: R1's ADL's could not be met by staff as staff were limited and R1 was bedridden. The Licensee failed to hire more staff to meet R1's needs and failed to notify R1's doctor and/or outside resources of his wound and bedridden status. R1 was not receiving home health or hospice services. This is an immediate health and safety risk.

  • 87615(a)Type A

    Prohibited Health Conditions- Persons who have a Stage 3 and 4 pressure injury shall not be admitted or retained in a residential care facility for the elderly.This requirement was not met as evidenced by: R1 was not removed from bed from 4/8/21 until R1 left the facility on 5/30/21. R1 developed a Stage III pressure injury while in care. R1 was not receiving hospice services. This is an immediate Health and Safety/Personal Rights risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the October 5, 2021 inspection of CYECREST GUEST HOME?

This was a complaint inspection of CYECREST GUEST HOME on October 5, 2021. 4 citations were issued: 4 Type A (serious).

Were any citations issued to CYECREST GUEST HOME on October 5, 2021?

Yes, 4 citations were issued (4 Type A, 0 Type B). The first citation was for: "Personnel Requirements-GeneralFacility personnel shall at all times be sufficient in numbers, and competent to provide t..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

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.