Serenity Care Villa - Sagewood

Facility personnel sufficiency and competence

Personnel Requirements – General. (a) 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 evidenced by: Based on interviews and record reviews, a staff member was not available for an intervention necessary to prevent an escalated altercation between two residents. This posed a potential health, safety, and resident rights risk to residents in care.

Right to access and copy personal medical records

87468.2 Additional personal rights of residents in privately owned facilities. (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19) To have prompt access to review all of their records and to purchase photocopies of their records…This requirement was not met as evidenced by: Based on interview and record review, R1 requested documents on two occasions, and no evidence existed to prove R1 received all documents. This posed a potential health, safety, and resident rights risk to residents in care.

Night Supervision. (a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m.…(1) In facilities caring for less than sixteen (16) residents, there shall be a qualified person on call on the premises. This requirement was not met as evidence by: Based on interviews and record reviews, facility did not schedule a necessary on-call staff member to cover the hours of 11pm and 7am to meet resident needs. This posed a potential health, safety, and resident rights risk to residents in care.

Grounds for eviction listed for residents

"(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5)." This requirement was not met as evidenced by: Based on record review and interviews, two unlawful eviction notices were served to a resident, which poses a potential health, safety, and/or personal rights risk.

Dignity in personal relationships

"(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons." This requirement was not met as evidenced by: Based on interviews, a resident was not treated with respect by a staff member, which poses an immediate health, safety, and/or personal rights risk.

Request a transfer of criminal record clearance

"(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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c)..."This requirement is not met as evidenced by: Based on observation, record review, and interview, S1 was working in this facility for at least five days without criminal record clearance association to this facility, which poses an immediate health, safety, and/or personal rights risk.

Request a transfer of criminal record clearance

Based on LIS review, the licensee did not ensure staff members were associated and cleared to work at this facility, which poses an immediate health, safety or personal rights risk to persons in care.

Dignity in personal relationships

"(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons."This requirement was not met as evidenced by: Based on interviews, R1 was not treated with respect or dignity by S1, which poses an immediate health, safety, and/or personal rights risk.

Ensure hazardous items are locked and not unattended

"Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients."This requirement was not met as evidenced by: Based on observation, cleaning solutions were left unlocked and accessible without supervision, which poses an immediate health and safety risk.

Facility personnel sufficiency and competence

"Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services."This requirement was not met as evidenced by: Based on observation, no staff were present in the facility on the morning of 12/22/23, which poses an immediate health and safety risk.

Maintain facility in clean, safe, sanitary condition

"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 was not met as evidenced by: Based on observation, a glass light fixture was broken and was not repaired. The fixture was within arms reach and posed an immediate health and safety risk due to risk of residents cutting themselves on the broken glass.

Require fire clearance before non-temporary bedridden admission

Care of Bedridden Residents: To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). This requirement was not met as evidenced by LPAs review of resident records which indicates the facility has a fire clearance for 6 non-ambulatory residents but do not have a fire clearance for a bedridden resident. LPA observed the LIC 602 for 1 resident which indicates the resident is bedridden and staff interviewed confirmed resident is unable to rotate or reposition without assistance which poses an immediate health, safety and personal rights risk to residents in care.

Maintain required personnel records for staff

The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee...This requirement was not met as evidenced by LPAs review of staff record where LPA observed one staff records only contained COVID vaccinations and hours of training which poses a potential health, safety and personal rights risk to residents in care.

Obtain baseline medical assessment before resident admission

Medical Assessment: Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement was not met as evidenced by LPAs review or resident records which revealed 2 of 6 residents do not have a current medical assessment on file which poses an immediate health, safety and personal rights risk to