Golden Moments Care Home Winding Way

Call 9-1-1 for imminent health threats

87465 Incidental Medical and Dental Care (g) 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 including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure to contact 9-1-1 timely following the fall and sustained injury of R3, which poses an immediate health, safety, and personal rights risk to the residents in care.

87415 Night Supervision (a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services and shall be available as indicated below to assist in caring for residents in the event of an emergency. (1) In facilities caring for less than sixteen (16) residents, there shall be a qualified person on call on the premises. This requirement is not met as evidenced by: Based on interviews conducted, observations, and records reviewed, the facility did not ensure that overnight staff were on-call to provide basic services to residents in care, which poses an immediate health, safety, and personal rights risk to the residents in care.

Regular observation and documentation of resident changes

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews conducted, observations, and records reviewed, the facility did not ensure to observe the residents for changes in condition and seek attention for unmet needs, which poses an immediate health, safety, and personal rights risk to the residents in care.

Assist residents with self-administered medication

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on LPA's observations, the facility did not ensure that medications were administered to residents as prescribed, which poses an immediate health, safety, and personal rights risk to the residents in care.

Food quality controls and rejected damaged goods

87555 General Food Service Requirements (b) The following food service requirements shall apply: (8) 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 is not met as evidenced by: Based on LPA's observations, the facility did not ensure that food items on the premises were of good quality, which poses a potential health, safety, and personal rights risk to the residents in care.

Maintain separate complete record for each resident

87506 Resident Records (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 observations and records reviewed, the facility did not ensure a complete and current record for each resident was maintained, which poses a potential health, safety, and personal rights risk to the residents in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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 of any of the events specified in (A) through (D) below. (...)(D) Any incident which threatens the welfare, safety or health of any resident (...). This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure to report unusual incidents in accordance with Title 22, which poses a potential health, safety, and personal rights risk to the residents in care.

Care and supervision as defined by statute and rules

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews conducted, observations, and records reviewed, the facility did not ensure to provide basic services to residents in need, which poses an immediate health, safety, and personal rights risk to the residents in care.

§1569.683 Eviction notices; reasons for eviction contents; service (a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident shall set forth in the notice to quit the reasons relied upon for the eviction, with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. In addition, the notice to quit shall include all of the following: (...) This requirement is not met as evidenced by: Based on observations and records reviewed, the facility did not ensure that 60-day notice issued to R1 complied with the Health and Safety code, which poses a potential heatlh, safety, and personal rights risk to the residents in care.

§1569.686 Licensee notification of specified events; department initiation of compliance plan, noncompliance conference, or other appropriate action; penalties; exception (a) A licensee shall notify the department, the State Long-Term Care Ombudsman, all residents, and, if applicable, their legal representatives, in writing, within two business days, and shall notify all applicants for potential residence, and, if applicable, their legal representatives, prior to admission, of any of the following events, or knowledge of the event: (5) A utility company has sent a notice of intent to terminate electricity, gas, or water service on the property within not more than 15 days of the notice. This requirement is not met as evidence by: Based on interviews conducted and records reviewed, the facility did not issue notices to all necessary parties regarding Final Notice that electric service was about to be turned off, which poses a potentional health, safety, and/or personal rights risks to the residents in care.

Record centrally stored prescriptions and refill data

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year (...). This requirement is not met as evidenced by: Based on LPA's observations and records reviewed, the facility did not ensure to maintain records of R1's centrally stored medications for at least one year, which poses a potential health, safety, and/or personal rights risk to the residents in care.

Financial plan and required reporting obligations

Financial plan and required reporting obligations

87213 Finances The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents (...). This requirement is not met as evidenced by: Based on interview conducted and records reviewed, the facility did not ensure to secure funds to meet operating costs for care of residents, which poses a potential health, safety, and/or personal rights risk to the residents in care.

§1569.652 Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, the facility did not ensure to issue a refund for advance fees paid to R1’s authorized representative upon the removal of R1’s property after they passed away, which poses a potential health, safety, and/or personal rights risk to the residents in care.

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, furnishings and equipment. This requirement is not met as evidenced by Based on interviews conducted and observations, the facility did not ensure to provide R1 with safe equipment to meet the resident's needs, including wearable diapers, which poses an immediate health, safety, and personal rights violation to the resident in care.

Facility personnel sufficiency and competence

87411 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 is not met as evidenced by: Based on interviews conducted, observations, and records reviewed, the facility did not ensure to schedule staff to meet the needs to resident (R1), which poses an immediate health, safety, and personal rights violation to the residents in care.

Complete admission suitability appraisal

87457 Pre-Admission Appraisal (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Based on interviews conducted or records reviewed, the facility did not ensure to complete a pre-admission appraisal for resident (R1), which poses an immediate health, safety, and personal rights violation to the residents in care.

87455 Acceptance and Retention Limitations (b) The following persons may be accepted or retained by the licensee: (8) Persons who are under 60 years of age whose needs are compatible with other residents in care, if they require the same amount of care and supervision as do the other residents in the facility. This requirement is not met as evidenced by: Based on interviews conducted, observations, and records reviewed, the facility did not ensure that resident (R1) had compatible needs with the other residents in care, which poses an immediate health, safety, and personal rights violation to the residents in care.

Dignity in personal relationships

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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews conducted and observations, the facility did not ensure to treat all residents with dignity and respect, which poses an immediate health, safety, and personal rights violation to the residents in care.

87457 Pre-Admission Appraisal (a) Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions. (1) Sufficient information about the facility and its services shall be provided to enable all persons involved in the placement to make an informed decision regarding admission. This requirement is not met as evidenced by: Based on interviews conducted or records reviewed, the licensee did not provide sufficient information about the facility's services and staffing to resident (R1) to allow R1 to make an informed decision regarding admission, which poses an immediate health, safety, and personal rights violation to the residents in care.

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, furnishings and equipment. This requirement is not met as evidenced by: Based on LPA's observations and records reviewed, the facility did not ensure to provide R1 with necessary comfortable equipment to meet the resident's needs, which poses a potential health, safety, and personal rights violation to the resident in care.

Facility personnel sufficiency and competence

87411 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 is not met as evidenced by: Based on interviews conducted and observations, the facility did not ensure to have sufficient staff to meet the residents needs, which poses a potential health, safety, and personal rights violation to the residents in care.

Certified administrator requirements and substitute coverage

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. (...) This requirement is not met as evidenced by: Based on interviews conducted and observations, the facility did not ensure to have a certified administrator, which poses a potential health, safety, and personal rights violation to the residents in care.

Based on records reviewed, the facility did not ensure to complete and document quarterly drills in accordance with the Health and Safety Code, which poses a potential health, safety or personal rights risk to persons in care.

Maintain required personnel records for staff

Based on records reviewed, the facility did not ensure that personnel records were complete and maintained for 2 of 3 staff members, which poses a potential health, safety or personal rights risk to persons in care.

Based on records reviewed, the facility did not ensure that 2 of 3 staff received training per Health and Safety Code, which poses a potential health, safety or personal rights risk to persons in care.

§1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Based on LPA's observations, the facility did not ensure that one (1) staff member had CPR training on file, which poses an immediate health, safety or personal rights risk to persons in care.

First aid training requirements

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 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on LPA's observations, facility did not ensure that two (2) staff members had first aid training on file, which poses an immediate health, safety or personal rights risk to persons in care.

Submit fingerprints for state and federal searches

87355 Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted... (3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility. This requirement is not met as evidenced by: Based on LPA's observations, facility did not ensure that a criminal record clearance was obtained for two (2) staff members, which poses an immediate health, safety or personal rights risk to persons in care.

Allow licensing inspection and controlled record removal

87412 Personnel Records (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement is not met as evidenced by: Based on LPA's observations, facility did not ensure to make personnel records available to licensing agency to inspect, which poses an immediate health, safety or personal rights risk to persons in care.

Obtain required California clearance or exemption

87355 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: (2) Obtain a California clearance or a criminal record exemption as required by the Department (...). This requirement is not met as evidenced by: Based on records reviewed, facility did not ensure that a criminal record clearance was obtained for one (1) volunteer, which poses an immediate health, safety or personal rights risk to persons in care.

Maintain separate complete record for each resident

Based on LPA's observations and records reviewed, the facility did not ensure that resident records were complete, which poses a potential health, safety or personal rights risk to persons in care.

Assist residents with self-administered medication

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility (...) by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication count and records reviewed, the facility did not ensure that residents R2 and R4 were receiving medications as prescribed, which poses an immediate health, safety, and personal rights risk to residents in care.

87355 Criminal Record Clearance (j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file as required in Section 87412, Personnel Records. This requirement is not met as evidenced by: Based on records reviewed, facility did not ensure that a criminal record clearance was obtained for one (1) staff member, which poses an immediate health, safety or personal rights risk to persons in care.

Certified administrator requirements and substitute coverage

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. (...) This requirement is not met as evidenced by: Based on interviews, LPA's observation, and records reviewed, the facility did not ensure to assign an Administrator with an active Administrator certificate, which poses an potential health, safety, and personal rights risk to residents in care.

87507 Admission Agreements (g) Admission agreements shall specify the following: (5) Refund conditions. (E) Preadmission fees shall be refunded according to the following conditions: 1. A 100 percent refund of a preadmission fee shall be provided to an applicant or the applicant’s representative if: b. The licensee fails to provide full written disclosure of preadmission fee charges and refund conditions. This requirement is not met as evidenced by: Based on interviews conducted, the facility did not issue a refund to R1's representative for a preadmission fee after R1's representative chose not to move R1 into the facility, which poses a potential health, safety, and personal rights violation to the residents in care.

Maintain facilities for fire and panic safety

Based on LPA's observation, the facility did not ensure that fire extinguisher was serviced, which poses an immediate health, safety or personal rights risk to persons in care.

Based on interviews, LPA's observation, and records reviewed, the facility did not ensure to obtain an exception for a prohibited health condition before accepting and retaining a resident using a G-tube, 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's observations, the facility did not ensure that chemicals and disinfectants were locked and inaccessible to the residents in care, which poses an immediate health, safety or personal rights risk to persons in care.

§1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Based on records reviewed, facility did not ensure that there was at least one (1) staff member with CPR training on the premises at all times, which poses a potential health, safety, and personal rights risk to the residents in care.

§1569.625 Staff training; legislative findings; contents (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Based on records reviewed, facility did not ensure that staff were acquiring all required trainings per Health and Safety Code, which poses a potential health, safety, and personal rights risk to residents in care.

First aid training requirements

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 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on records reviewed, facility did not ensure that caregivers received first aid training by an agency such as American Red Cross, which poses a potential health, safety, and personal rights risk to the residents in care.