Golden Legacy Elderly Care Ii

Maintain separate complete record for each resident

Resident Records: Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This requirement was not met as evidenced by LPA review of resident records, R1 has an incomplete (blank) admissions agreement and no pre-placement appraisal which poses an immediate health, safety and personal rights risk to residents in care.

Food quality controls and rejected damaged goods

General Food Service Requirements: All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement was not met as evidenced by LPA observations of approximately 20 canned goods that had expired dates including 2024 and 2025 which poses an immediate health, safety and personal rights risk to residents in care.

Handle syringes and needles under bloodborne pathogen rules

Maintenance and Operation: Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens. This requirement was not met as evidenced by LPA observations and staff statements that used syringes are disposed of in old medication containers that do not meet requirements specified in regulations which poses an immediate health, safety and personal rights risk to residents in care.

Health screening and fitness requirements

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks...This requirement was not met as evidenced by: Based on record review the facility did n ot have a health screening for S1 which poses an immediate health, safety and/or personnel rights risk.

Conformance with applicable laws and regulations

87405(d)(2 If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform...This requirement was not met as evidenced by: Based on record review and interview, the licensee did not abide by the compliance plan and regulations which poses an immediate health, safety or personal rights risk to persons in care.

87355 Criminal Record Clearance(b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client..This requirement was not met as evidenced by: Based on record review S1 did not have a criminal record clearance with the facility which poses an immediate health, safety and/or personnel rights risk.

87412 Personnel Records(e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked.This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above because there is only 1 person scheduled 24 hours a day 7 days aweek which poses an immediate health, safety or personal rights risk to persons in care.

Certified administrator requirements and substitute coverage

Based on record review, the licensee did not comply with the section cited above the administrator is not scheduled a sufficient number of hours in the facility which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above where there was no bath mat in the bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.

Modified diets for medical necessity

Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation and interview, the licensee did not comply with the section cited above because there isonly 1 person scheduled 24 hours a day 7 days aweek which poses an immediate health, safety or personal rights risk to persons in care.

Include required health screening documents

Based on record review, the licensee did not comply with the section cited above in 1out of 6 staff members which poses an immediate health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above there were cleaning solutions and poisons in the unlocked garage which were accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Assist residents with self-administered medication

87465 Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self-administered medications as needed...This requirement was not met as evidenced by: Based on observation, record review, and interview S1 did not administer R5's inhaler which poses an immediate health, safety and/or personnel rights risk.

Store centrally held medications in locked secure place

"(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication." This requirement was not met as evidenced by: Based on observation, a resident was allowed access to medication, which poses an immediate health and safety risk.

87219 Planned Activitiesa) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: (4) Physical activities such as games, sports and exercise which develop and maintain strength, coordination and range of motion.This requirement was not met as evidenced by: Based on observation and interview Licensee does not provide planned activities or physical activities which poses an potential health, safety and/or personnel rights risk.

Provide assistance for residents medical needs

87465 Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility...This requirement was not met as evidenced by: Based on observation, record review, and interview the facility did not take R5 to R5's doctor appointments which poses an immediate health, safety and/or personnel rights risk.

Ensure hazardous items are locked and not unattended

"(a) 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, a resident was in posession of a knife, which poses an immediate health and safety risk.

Safe, healthful, comfortable accommodations

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations...This requirement was not met as evidenced by: Based on observation, record review, and interviews S1 and licensee did provide a comfortable living enviroment which poses an potential health, safety and/or personnel rights risk.

Allowing diabetic residents based on self-management ability

"(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional." This requirement was not met as evidenced by: Based on observation and interviews, a resident was not able to perform their own blood glucose testing or injections, and staff were not monitoring their ability to do so, which poses an immediate health, safety and/or personnel rights risk.

87628 Diabetes(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (4) Providing modified diets as prescribed by a resident's physician as specified in Section 87555(b)(7).This requirement was not met as evidenced by: Based on observation, record review, and interview S1 did not prepare meals for residents that according to the Physicians report need a diabetic diet and allowed R3 who is on a diabetic diet to have candy in their room which poses an immediate health, safety and/or personnel rights risk.

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...This requirement was not met as evidenced by: Based on observation, record review, and interview S1 did not have 40 hours total of training before starting employment with the facility which poses an potential health, safety and/or personnel rights risk.

Store centrally held medications in locked secure place

87465Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible ...This requirement was not met as evidenced by: Based on observation of LPA Williams and LPM Camilon-Lee medications were observed unlocked in night stand drawer which poses an immediate health, safety and/or personnel rights risk.

Obtain required California clearance or exemption

"(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...(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)..."This requirement was not met as evidenced by: Based on observation, record review, and interview S1 was not associated with the facility which poses an immediate health, safety and/or personnel rights risk.

Maintain required personnel records for staff

"87412 Personnel Records(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information..."This requirement was not met as evidenced by: Based on record review, S1 did not have a completed personnel record which poses a potential health, safety, and/or personnel rights risk.

Limit operations to licensed capacity

"A licensee shall not operate a facility beyond the conditions and limitations specified on the license..." This requirement was not met as evidenced by: Based on interview and observation, two backyard studios were being used for habitation, despite not being approved for use by the fire department, code enforcement, and this facility's license.

Maintain facility in clean, safe, sanitary condition

"(a) The facility shall be clean, safe, sanitary and in good repair at all times..." This requirement was not met as evidenced by: Based on observation, dried feces and toilet paper were left on a backyard patio, which poses an immediate health and safety risk.

Address and clearance obligations before facility work

Based on interviews, the licensee did not comply with the section cited above in licensee's mom is not fingerprint cleared and has been staying in workshop in the backyard which poses an immediate health, safety or personal rights risk to persons in care.

Maintain fire clearance before retaining specified persons

Based on LPA observation, the licensee did not comply with the section cited above in workshop in backyard does not have fire clearance and individuals have been living there which poses an immediate health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on LPA observation, the licensee did not comply with the section cited above in there were two bottles of bleach, two bottles of detergent, and a gallon of bug spray on old washing machine near back fence which poses an immediate health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on LPA observation, the licensee did not comply with the section cited above in tree branches, two washing machines, two dryers, two refrigerators, and old lumber was piled in backyard which poses/posed a potential health, safety or personal rights risk to persons in care.

Requirement for building permit before construction

Based on LPA observation, the licensee did not comply with the section cited above in workshop has been used for living quarters which poses/posed a potential health, safety or personal rights risk to persons in care.

Update reappraisal at required intervals

87463(a) Reappraisals: The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. This requirement was not met as evidence by: based on file review, the Licensee did not ensure to complete a reappraisal for R1 which includes hoyer lift need. This posed a potential health safety risk to R1.

Acceptance obligations tied to pre-admission appraisal needs

87464(d) 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... This requirement was not met as evidence by: Based on observation, interviews, and file review, the Licensee did not ensure the were able to meet R1's transfer needs. This posed a potential health and safety risk to R1.

Assist residents with self-administered medication

87465(a)(4)Incidental Medical and Dental Care...A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidence by: Based on observation and file review, the Licensee did not ensure to assist R1 and R2 with their self administered medication as needed. This posed a potential health and safety risk to R1 and R2.

Record centrally stored prescriptions and refill data

Incidental Medical and Dental Care 87465(h)(6) The following requirements shall apply to medications which are centrally stored:The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident...This requirement was not met as evidence by Based on observation and file review, the Licensee did not ensure R1 had a current MAR. This posed a potential health and safety risk to R1.

Update reappraisal at required intervals

Reappraisals 87463(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate... This requirement was not met as evidence by. Based on observation, R1's appraisal was not updated to reflect R1's physical health status change. This posed a potential health and safety risk to R1.

87555(b)(2) General Food Service Requirements:The following food service requirements shall apply:Where meal service within a facility is elective, arrangements shall be made to assure availability of an adequate daily food intake for all residents... this requirement was not met as evidence by: Based on observation, the Licensee did not ensure R1 was provided adequate daily food intake during BF. This posed a potential health and safety risk to R1

Require physician order and label for PRN medication

Based on observation and file review, the Licensee did not ensure resident 3 had a PRN doctors order for their Acetaminophen 500 MG. This posed a potential health and safety risk to resident 3

Maintain facilities for fire and panic safety

Based on observation resident 3 was residing in a non-designated resident room.

Label and preserve medicine compliance standards

Based on observation and file review, resident 3's Medication bottle label was altered. The doctors administration order information was altered with a black marker.

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 requirement was not met as evidence by: Based on interviews and record reviews The Licensee did not ensure R2 received timely medical attention after their fall. This posed an immediate health and safety risk to R2.

Care and supervision as defined by statute and rules

87464(f)(1) Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by: Based on interviews and file reviews, the Licensee did not ensure resident 1 was supervised and provided care at all times on 10/22 and 10/24. which led to R1 eloping from facility. This posed an immediate health and safety risk to residents in care.

Right to sufficient care and qualified staff

Additional Personal Rights of Residents in Privately Operated Facilities 87468.2(a)(4). To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met by evidence by: Based on file reviews and interviews, the Licensee did not ensure R2 was provided care and supervision which resulted in a fall.