Green Merrylands

Based on observation the licensee did not comply with the section cited above maintenance and operation, which poses an immediate health, safety or personal rights risk to persons in care.

(a) 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.(1) Floor surfaces in bath, laundry and kitchen and facility areas shall be maintained in a clean, sanitary, and odorless condition. Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that floor surfaces in bath, and facility areas shall be maintained in a clean, sanitary, and odorless condition. which poses a potential health, safety or personal rights risk to persons in care.

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. 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: Facility staff failed to seek a higher level of care for R1’s pressure injurie[s] which multiplied while in care. The facility staff failed to inquire, assess the number, and seriousness of the pressure ulcers to determine if the level of care being provided to R1 was adequate, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.

Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that teh movable bin used for storing solid wastes does not have cover which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) and Staff #4 (S4) completed the required dementia training annually which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 and Staff #4 completed the required postural supports, restricted conditions or health services, and hospice care training which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the container used for storage of solid waste is in good repair which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's an activity program that address the needs and limitations of residents with dementia and include large motor activities and perceptual and sensory stimulation which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview and record review, the licensee did not comply with the section cited above by denying LPA Brown access to the Administrator Office during the facility Inspection which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the facility has a complete supply of first aid kit which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the facility has a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Resident #3 (R3) medications were given per R3 physicians's order as evidenced of one (1) of R3's medication was given to R3 but per Medication Administration Records (MAR) review, it does not show that R3's medication was given per physician's direction. Also, LPA Brown observed one (1) of R3's medication was not given to R3 due to no refill available at the facility since 08/03/2024, two (2) of R3's medication were not given to R3 due to no refill at the facility since 08/04/2024 and one (1) medication was not given to R3 due to no refill at the facility since 08/06/2024. This incidents poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the facility has an Administrator during normal working hours as required which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) and Staff #4 (S4) complete the required Residential Care for the Elderly (RCFE) 40 hours of training which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) and Staff #4 (S4) at the facility completed the required dementia training which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that nightlights are maintained in hallways and passages to nonprivate bathrooms which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the outdoor passageway is kept free of obstruction which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview and record review, the licensee did not comply with the section cited aboveby not ensuring that one (1) screwdriver and two (2) gallons of laundry detergent in the laundry room, are locked and not accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview, record review, the licensee did not comply with the section cited above by not having the required on the job training and/or related experience in the job for Staff #2 (S2), Staff #3 (S3) and Staff #4 (S4) which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview and record review, the licensee did not comply with the section cited above by not developing the required Infection Control Plan for the Facility which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Resident #2 (R2) and Resident #3 (R3) Admission Agreement were signed by the facility representativewhich poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing Resident #2 (R2), Resident #3 (R3) and Resident #4 (R4) to have half bed rail and not ensuring that they have written order from their physician indicating the need for half bed rail for mobilitywhich poses a potential health, safety or personal rights risk to persons in care.

Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing Resident #1 (R1) to have full bed rail but per records review, R1 is not on hospice and exception report submitted to licensing for approval for full bed rail which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's a staff scheduled to work the night shift, awake and on duty as required for facility with dementia residents which poses an immediate health, safety or personal rights risk to persons in care.

HSC 1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having an Administrator present during working hours at the facility which pose potential health, safety and personal rights risks to residents in care.

HSC 1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having an Administrator present during working hours at the facility which pose potential health, safety and personal rights risks to residents in care.

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: (1) Obtain a California clearance... This requirement is not met as evidenced by: Based on observation and interview, the Licensee did not comply with the section cited above by not obtaining Staff #5 (S5) criminal record clearance before allowing S5 to work at the facility on 02/20/2024 which pose immediate health, safety and personal rights risk to residents in care.

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...(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observation, interviews and records review, the Licensee did not comply with the section cited above by not updating R3, R4 and R5 Medication Adminisitration Record (MAR) after dispensing R3, R4 and R5 medications per their physician's order which pose immediate health, safety and personal rights risks to residents in care.

87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having Resident #1 (R1) record at the facility which poses potential health, safety and personal rights risks to resident in care.

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by allowing Resident #2 (R2) to have full bed rail at the facility which pose potential health, safety and personal rights risks to resident in care.

87224 Eviction Procedures (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 … Licensee did not meet this requirement as evidenced by: Based on interviews, record review and observations, the Licensee refused to accept R1 back to the facility upon hospital discharge. This posed a potential Health, Safety or Personal Rights risk to residents in care.

87309 Storage Space (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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. Based on observation, interview and records review, the LIcensee did not comply with the section cited above by not locking the one (1) knife at the kitchen cabinet making it accessible to residents in care which pose immediate health, safety and personal rights risks to residents in care.

87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having Resident #1 (R1) record at the facility which poses potential health, safety and personal rights risks to resident in care.

HSC 1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having an Administrator present during working hours at the facility which pose potential health, safety and personal rights risks to residents in care.

87303 Maintenance and Operation (a) 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...This requirement is not met as evidenced by: Based on observation and interview, the Licensee did not comply with the section cited above by not having the kitchen cabinet and laundry cabinet in good repair which pose potential health, safety and personal rights risks to residents in care.

87309 Storage Space (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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. Based on observation, interview and records review, the LIcensee did not comply with the section cited above by not locking the one (1) knife at the kitchen cabinet making it accessible to residents in care which pose immediate health, safety and personal rights risks to residents in care.

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: (1) Obtain a California clearance... This requirement is not met as evidenced by: Based on observation and interview, the Licensee did not comply with the section cited above by not obtaining Staff #4 (S4) criminal record clearance before allowing S4 to work at the facility on 01/06/2024 which pose immediate health, safety and personal rights risk to residents in care.

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) Request a transfer of a criminal record clearance... This requirement is not met as evidenced by: Based on observation and interview, the Licensee did not comply with the section cited above by not transferring Staff #3 (S3) criminal record clearance to the facility before allowing S3 to work at the facility on 01/09/2024 which poses potential health, safety and personal rights risk to residents in care.

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...(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observation, interviews and records review, the Licensee did not comply with the section cited above by not updating R3, R4 and R5 Medication Adminisitration Record (MAR) after dispensing R3, R4 and R5 medications per their physician's order which pose immediate health, safety and personal rights risks to residents in care.

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by allowing Resident #2 (R2) to have full bed rail at the facility which pose potential health, safety and personal rights risks to resident in care.

87224 Eviction Procedures (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 … Licensee did not meet this requirement as evidenced by: Based on interviews, record review and observations, the Licensee refused to accept R1 back to the facility upon hospital discharge. This posed a potential Health, Safety or Personal Rights risk to residents in care.

1569.267(d) Resident's Bill of Rights(d)The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented. This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above evidenced by not providing poses a potential health, safety or personal rights risk to persons in care.

1569.618(b)Administration and management of residential care facilities; substituted qualifications; employee scheduling.(b).one ..manager..designated substitute qualifications.. responsible designated substitute shall meet..This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above evidenced by not having a designated substitute which poses an immediate Health, Safety or personal rights risk to persons in care.

1569.618(c)(3) Administration and management of residential care facilities; substituted qualifications; employee scheduling (c) The facility shall employ..:(3) Ensure that at least one staff member who has (CPR)on the premises at all times..This requirement is not met as evidenced by: Based on observation, interview and reecord review the licensee did not comply with the section cited above by not having at least one staff member on premises at all times who is certified CPR.

1569.69 (3) Employees assisting residents with self-administration of medication; training requirements(3) An employee shall be required for hands-on shadowing training. resident in the self-administration of medications... This requirement is not met as evidenced: Based on observation,interview and recrod review the licensee did not comply with the section cited above by not having medication training for staff, which poses a potential health and safety risk to persons in care

87208(a)Plan of Operation(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing.. the license application..This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above evidenced by not providing a copy of facility Plan Of Operation which poses a potential health, safety or personal rights risk to persons in care.

87303(a) Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times... the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above by having bathroom cabin broken and not in good repair which poses a potential health, safety or personal rights risk to persons in care.

87411(d) Personnel Requirements - General(d)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 evidenced by: Based on observation, interview and record review the licensee did not comply with the section cited above evidenced by not providing dementia training and initial training which poses a potential health, safety or personal rights risk to persons in care.

Personnel Requirements - General (d) All personnel shall be given on the job training.. (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement is not met as evidenced by: Based on obeservation,interview and record review, the licensee did not comply with the section cited above by not having staff being able to adequately communicate with residents due to lanaguage barrier which poses an immediate Health, Safety or personal rights risk to persons in

87411 Personnel Requirements...(g)prior to employment or initial presence in the facility, all employees and volunteers...shall:(1) Obtain a California clearance...as required by law..This requirement is not met as evidenced by: The Licensee did not obtain a criminal record clearance for Staff #3 (S3) prior to S3 beginning employment or initial presence in the facility. Which poses an immediate health and safety risk to residents in care.

87413(a)(1) Personnel - Operations(a) In each facility:(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.This requirement is not met as evidenced by: Based on observation, interview and record review the licensee did not comply with the section cited above evidenced by not providing staff coverage when regular staff return from their country

87458(a) Medical Assessment(a)Prior to a person's acceptance as a resident, .. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.This requirement is not met as evidenced: Based on observation,interview and recrod review the licensee did not comply with the section cited above by not having three(3)physician reports, which poses a potiential health and safety risk to persons in care

87462 Social FactorsThe facility shall obtain sufficient information about each person's likes and dislikes and interests and activities..suggest the program of activities in which the individual may wish to participate. This requirement is not met as evidence by: Based on observation and interview the licensee did not comply with the section cited above evidenced by not obtaining information dislikes and likes activites which poses a potential health, safety or personal rights risk to persons in care.

87465(h)(2)Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in centrally stored medication.This requirement is not met as evidenced by: Based on observation, interview and record review the licnesee did not comply with the section cited above by having the centrally stored medication cabinet accessible to residents which poses an immediate Health, Safety or personal rights risk to persons in care.

87470(c) Infection Control Requirements(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.This requirement is not met as evidenced by Based on observation and interview the licensee did not comply with the section cited above evidenced by creating An Infection Control Plan which poses a potential health, safety or personal rights risk to persons in care.

87506(b)(15)Resident Records(b) Each resident’s record shall contain at least the following information:(15)The.. Admission Agreements and 87457, Pre-admission Appraisal... This requirement is not met as evidenced by: Based on observation,interview and recrod review the licensee did not comply with the section cited above by not having three(3) admission agreements, which poses a potiential health and safety risk to persons in care

87507(a) Admission Agreements(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement is not met as evidenced by: Based on observation,interview and recrod review the licensee did not comply with the section cited above by not having one(1) admission agreements, which poses a potiential health and safety risk to persons in care

87707(1) Training Requirements If Advertising Dementia Special Care, Programming And/Or Environments(1) Direct care staff shall complete six hours of orientation specific to the care of ..This requirement is not met as evidenced by: Based on observation,interview and record review the licensee did not comply with the section cited above evidenced by not providing dementia training and initial training which poses a potential health, safety or personal rights risk to persons in care.

1569.158(g)(2) Family councils(1) If a facility has a family council, the facility shall include.. members.. (2) If a facility does not have a family council, the facility shall provide, upon admission of a new resident, written representative of their right to form a family council. Based on observation and interview the licensee did not comply with the section cited above evidenced by not providing poses a potential health, safety or personal rights risk to persons in care.

1569.153(d)Theft and loss program; standards, property inventories and surrender of personal effects; secured areas(d) A written resident personal property inventory..This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above evidenced by not having residents' written inventory which poses a potential health, safety or personal rights risk to persons in care.

1569.618(a)Administration and management of residential care facilities; substituted qualifications; employee scheduling.(a)... operation of the facility when the administrator is temporarily absent from the facility. Based on observation and interview the licensee did not comply with the section cited above evidenced by not having administractor present during working hours which poses an immediate Health, Safety or personal rights risk to persons in care.

87609 Allowable Health Conditions and the Use of Home Health Agencies(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met:(2) The licensee provides the supporting care and supervision needed to meet the needs of the resident receiving home health care. Based on interview and document review, the licensee did not comply with the section cited above evidenced by not having a care plan to support a resident’s home health needs which poses an immediate health, safety, or personal rights risk to persons in care.

87628 Diabetes.(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. Based on interview and document review, the licensee did not comply with the section cited above evidenced by unskilled staff administering glucose testing to a resident which poses an immediate health, safety, or personal rights risk to persons in care.

87506 Resident Records. (c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. Based on interview and record review, the licensee did not comply with the section cited above evidenced by denying resident records to a resident’s legal conservator who is appointed for estate and person which poses a potential health, safety or personal rights risk to persons in care.

87156 Licensing Fees(a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. Based on interview, record review, and observation the licensee did not comply with the section cited above evidenced by a past due amount of $1,484.00 in licensing fees which poses a potential health, safety or personal rights risk to persons in care.

87355. Criminal Record Clearance. (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: Based on interview, observation, and record review, the licensee did not comply with the section cited above evidenced by not processing a criminal record transfer for S1. S1 has worked at the facility for three (3) years without being associated to the facility.

Based on observation, the licensee did not comply with the section cited above by not having a staff personnel record for S1 for licensing to review which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and records not available for LPA review, the licensee did not comply with the section cited above by not having proof of a current administrator which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above by allowing S2 to work in the facility without having a criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.

87468.2 ADDITIONAL PERSONAL RIGHTS OF RESIDENTS IN PRIVATELY OPERATED 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: (20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents for reasons other than those permitted by state law or regulations and shall comply with all eviction and relocation protections for residents.