California Home for the Adult Deaf (chad)

877211(a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence… This report shall include the resident's name, age, sex and date of admission; ... This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any… case.This requirement was not met as evidenced by:

Based on interview, record review, the licensee did not comply with the section cited above in one out of one which poses a potential health, safety or personal rights risk to persons in care.

Maintain admission agreement and appraisal

Based on interview, record review the licensee did not comply with the section cited above in four out of four residents which poses a potential health, safety or personal rights risk to persons in care.

Maintain required personnel records for staff

Based on interview, record review, the licensee did not comply with the section cited above in one out of one staff which poses a potential health, safety or personal rights risk to persons in care.

Maintain separate complete record for each resident

(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 evidenced by: Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 5 resident files requested which poses/posed a potential health, safety or personal rights risk to persons in care.

Allow licensing inspection and controlled record removal

Based on observation and record review, the licensee did not comply with the section cited above in seven out of seven staff files which poses an immediate health, safety or personal rights risk to persons in care.

Maintain separate complete record for each resident

Based on observation and record review, the licensee did not comply with the section cited above in 5 out of 5 resident files which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in one out of one staff schedule which poses an immediate health, safety or personal rights risk to persons in care.

Obtain and evaluate recent medical assessment

Based on observation and record review the licensee did not comply with the section cited above in five out of five resident files which poses an immediate health, safety or personal rights risk to persons in care.

Maintain physician order documentation in resident record

87608 Postural Supports (a) Based on the individual's... appraisal, the facility shall provide assistance and care… Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support.This requirement is not met as evidence by: Based on interviews and record review, the Licensee did not ensure R1 had a written order from Physician for pillows to be placed on the side of R1 while laying in bed to ensure R1 did not fall off. R1 is no longer a resident. This poses a poses a potential health, safety or personal rights risk to persons in care.

Staff training in personal care activities

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidence by: based on interview and record review the licensee did not comply by having S1 assist residents with personal activities of daily living without fulfilling the annual required hours of training which poses a potential health, safety or personal rights risk to persons in care.

Based on interview, the licensee did not comply with the section cited above with drill that was not documented or conducted within the required timeframe which poses a potential health, safety or personal rights risk to persons in care.

Health screening and fitness requirements

Based on interview, the licensee did not comply with the section cited above with (2) staff that did not have a documented or conducted health physcal before working at the facility which poses a potential health, safety or personal rights risk to persons in care.

Resident care and supervision skills

Personnel Requirements- General, (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This...shall provide knowledge of ...(3)Skill and knowledge required to provide necessary resident care...to...residents. This requirement was not met as evidenced by: The Licensee did not ensure all staff were trained to provide necessary care for residents. Based on interviews and records reviewed, there is no evidence that S1 was trained to provide R1 with assistance with their medical condition. This poses a potential health, safety, and personal rights

REPORTING REQUIREMENTS: (a) Each licensee shall furnish to the licensing..reports..(1)..report shall be submitted..This requirement was not being met as evidenced by: Based on LPA's review of Department records revealed that the Licensee did not submit a death report for R1. This poses a potential health and safety risk to residents in care.

Records available to licensing agency for inspection

RESIDENT RECORDS: (d)..All resident records shall be available to the licensing..This requirement was not being met as evidenced by: Based on LPA's review, staff could not provide resident records for R1, thus the Licensee did not comply with regulation. This poses a potential health and safety and personal rights risk to residents in care.

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: Based on interview, the licensee did not ensure the facility was maintained in conformity with the state fire marshall. Per Barrett, the facility accepted a 7th client into the home approximately 1 week ago. The facility only has a capacity for 6 residents. The facility is not in compliance with their approved fire clearance. This poses a potential threat to the safety of the residents in care.

Reporting Requirements: (a) Each licensee shall furnish...such reports...including...the following: (1) A written report shall be submitted...within seven days of...any of the events specified...(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met by: Based on record review, the Licensee did not comply with the above regulation with at least one resident. LPA Colvin observed that R1 went to the Emergency Room in March 2021 in regards to a fall, but no report was submitted to Licensing. This is an immediate personal rights violation of R1.

Facility maintenance and healthful environment

Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by: Based on observations, the Licensee did not comply with the above regulation with two areas of the facility. LPA Colvin observed cracks in the driveway making the ground unlevel by 1 inch as well as a hole in the walkway in the backyard. This is a potential safety risk for residents in care.

Right to sufficient care and qualified staff

Additional Personal Rights...in Privately Operated Facilities: (a) In addition to the rights listed...residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff...to meet their needs. This requirement was not met by: Based on record review, the Licensee did not comply with the above regulation with at least one resident. LPA Colvin observed that facility records instructed staff to cut R1's Carvedilol, though R1's medication bottles did not reflect this instruction. This was an immediate health risk for R1.

Fees for license or applications; use of revenues; collected; denial or forfeiture: (e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above regulation with the facility's licensing fees. LPA Colvin observed that the Licensee owes $1,236.50 and has been behind on licensing fees since 2019. This is a potential safety risk for all residents, as the license may be revoked.

Passageways and stairways kept clear

Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by: Based on observations, the Licensee did not comply with the above requirement with at least one walkway. LPA Colvin observed the walkway from the driveway to the front door to be over halfway obstructed by a pile of dirt and a hazard cone. This is a potential safety risk to all residents in care.

Right to accept or decline care or services

PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To receive or reject medical care or other services. This requirement was not met, as evidenced by: Based on records, the Licensee did not ensure R1 was permitted to reject medical care orother services. Copies of email correspondence between Barrett and R1's responsible party reveal Barrett required proof of COVID-19 vaccination prior to allowing R1 to return to the facility.