Alta Loma Gardens Residential Care #1

Based on observation, interview, and record review, the licensee did not comply with the section cited above by not ensuring the facility maintained Liability Insurance which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in 1 out of 3 bathrooms by ensuring that all disinfectants were locked and stored and inaccessible to residents which posed a potential health, safety or personal rights risk to persons in care.

87468.1(a)Residents in all residential care facilities.. all of the following personal rights(3)To be free from punishment, humiliation, intimidation, abuse..punitive nature, such as withholding.. interfering with daily living functions..sleeping, or elimination. Based on interviews, the licensee did not comply with the section cited above by not ensuring sufficient amount of staff are available to assist with residents needs. Also, staff was encouraging residents to go to there rooms at 5:30 PM.

87506(a)licensee shall ensure that a separate, complete, and current record is maintained for each resident...location..available to facility staff and to licensing agency staff. Based on interviews, and records review, the licensee did not comply with the section cited above due to facility staff not having access to residents complete files.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 4 staff records, by not ensure a backgroung clearance was completed and current 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 ensure the facility is conducting quarterly fire and emergency drill 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 in 3 out of 4 personnel records by not ensuring health screening, training records,TB test, job description, and application are in the personnel files 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 in 2 out of 3 resident in care by not ensuring each resident have a current physician report, and needs and service plan on file, 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 in 3 out of 3 resident MARS by not ensuring the record was accurate, medication are log, staff are signing and dated when medication is issued which poses an immediate health, safety or personal rights risk to persons in care.

87755(c) The licensing agency shall have the.. audit...resident or..facility..demand during normal business..requirements in Sections 87412(f), 87506(d), and 87508(b). This requirement is not met as evidenced by: Based on observation, and interviews the administrator did not comply with the section cited above by not maintaining personnel records and having them accessible for LPAs review which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA Delgado's observation and interview on April 3, 2024, the licensee did not comply with the section cited above in which LPA and Administrator found the medication door unlocked which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA Delgado's observation and interview on April 3, 2024, the licensee did not comply with the section cited above in which Bedroom #4 there was no lamp which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in the diaster drills was requested to be reviewed and was unable to be provided by staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA Delgado's and Administrator observation and interview on April 3, 2024, the licensee did not comply with the section cited above in which the cabinet for sharps was unlocked which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observations and review of records the licensee did not comply with the section cited above by not being able to produce any records for staff or residents. During the visit, staff did not have access to records. Administrator not available for contact to request such records; which poses a potential health, safety or personal rights risk to persons in care.

(b) In addition... the licensee shall be responsible for the following:(2) Ensuring that incontinent residents are checked...including during the night.This requirment was not met as evidenced by: Based on records review and intervie wit was round that R3 was not being changed after 5pm, and changed again until 5am. This is a potential health, saftey or personal rights risk to residents in care.

(i) Prescription medications...which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years...This requirment was not met as evidenced by: R1's medication which had not been disposed of and kept in the facility garage during the time of the visit.

Plan of Operation - A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). This requirement was not met as evidenced by:Resident 1 has a diagnosis of Dementia. This poses a potential health and safety risk to residents in care.

Resident Records - Each resident’s record shall contain at least the following information...This requirement was not met as evidenced by: Records received by LPA for Resident 1 are missing admissions agreement, hospice notes, incomplete functional assessment, and appraisal. This poses a potential health and safety risk to residents in care.

Inspection Authority of the Licensing Agency:(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b). This requirement was not met as evidenced by:LPA was not able to review any records requested for complaint# 18-AS-20211223163003.

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 as specified in Section 87355(c) or This requirement was not met as evidenced by:LPA Bueno confirmed that S1 has a person number but is not associated to this facility. This poses an immediate health and safety risk to residents in care.

Based on staff interview and record review, the licensee did not comply with the section cited above as LPA confirmed on Guardian that Staff 1 was not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.

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 and well-being of residents, employees and visitors. This requirement was not met by: Based on observatons, the Licensee did not comply with the above regulation with one area of the facility. LPA Colvin observed a 4-5 foot area of concrete in the driveway which was cracked and uneven, with height differences of approximately 2 inches. This is a potential safety risk to residents & visitors

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 as specified in Section 87355(c) This requirement was not met by: Based on record review and observation, the Licensee did not comply with the above requirement with one staff. LPA Colvin observed that S1 did not have their criminal record clearanced transferred to the facility. This is an immediate safety risk for all residents.

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 $742. This is a potential safety risk for all residents, as the license may be revoked.

Alterations to Existing Building or New Facilitie: (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidenced by" Based on observations and record review, the Licensee did not comply with the above regulation with one room of the facility. LPA Colvin observed the master bedroom to have two new walls installed to seperate the room. CCL was not notified of the construction. This is a potential safety risk to residents in care.

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 as specified in Section 87355(c) This requirement was not met by: Based on record review and observation, the Licensee did not comply with the above requirement with at least one staff. LPA Colvin observed that S2 did not have their criminal record clearanced transferred to the facility. This is an immediate safety risk for all residents.

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 or a criminal record exemption as required by the Department This requirement was not met by: Based on record review and observation, the Licensee did not comply with this requirement with at least one staff. LPA Colvin observed that S1 does not have a valid criminal record clearance and requires an exemption. This is an immediate safety risk to residents.

Resident Records: (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying... This requirement is not met as evidenced by: Based on observations and interviews, the Licensee failed to submit/provide resident records for inspection by Licensing Agency on at least three occasions (9/4/20, 9/16/20, and 9/25/20). This is an immediate health risk & personal rights risk to all residents due to impeding Licensing's investigations.

Personnel Records: (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement was not met as evidenced by: Based on observations and interviews, the Licensee failed to previously submit/provide resident records for inspection by Licensing Agency, and records were unavailable during today's visit. This is an immediate health risk & personal rights risk to all residents due to impeding Licensing's investigations.