Terrace Gardens

Based on record review, the licensee did not comply with the section cited above by not ensuring that resident #1 (R1) has an updated physician report on file which poses a potential health, safety or personal rights risk to persons in care..

Based on interview, record review, the licensee did not comply with the section cited above by not ensuring that the facility has the tracking documentation of medication administered to resident #1, #2, #3 (R1, R2, R3) 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 did not ensure that the facility has the carbon monoxide detector 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 facility has the required liability insurance which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not ensuring that the facility has the required emergency/fire drill signed by the staff on file for review which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not ensuring that staff #1 (S1) does not have the health screening report on file which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not ensuring that resident #2 (R2) and resident #5 (R5) has the required physician's report on file. Licensee did not ensure that the residents has the required tuberculosis (TB) test and TB test result, which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not ensuring that the facility have an updated liability insurance.which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not ensuring that Staff #1 (S1) has an updated CPR/First Aid certification and Staff #2 (S2) have a CPR/First Aid certification on file, which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, record review, the licensee did not comply with the section cited above by not ensuring that the facility have the Infection Control Plan available for review at the time of visit, which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above by not ensuring that resident #4 (R4) have the admission agreement on file which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA observation of cameras in the bedrooms. This is a violation of the residents personal rights.

Based on the following: LPA observed two gates leading from the back yard with locking mechanisms which prevent exiting without a key. LPA observed that the key is maintained in a coded lock box on the side of a backyard shed with the key in it. LPA also observed in the garage an addition of walls and a door. Inside the addition is a bed, clothing and personal effects of caregivers. Administrator admits that they are using the place a a place to rest for the employees. This space is not part of the approved fire clearance as a caregiver room.

Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.This requirement is not met as evidenced by: As indicated on complaint number 56-AS-20220808090401, Resident 1 was found outside the facility and returned to this facility by a visitor.

If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. This requirement was not met as evidenced by:Administrator interview showed that Resident 1 is receiveing two nonprecription PRN medications. This poses a potential health and safety risk to residents in care.

The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement was not met as evidenced by:LPA and Staff 1 viewed one of two side gates secured and locked with padlock. This poses a potential safety risk to residents in care.

Personnel Records : (a) The licensee shall ensure...records are maintained on...each employee. Each personnel record shall contain...: (13) For employees...(B) Documentation of either a criminal record clearance or a criminal record exemption... This requirement was not met by: Based on record review and interview, the Licensee did not comply with the above regulation with one staff member (S2). Licensee was unable to provide LPA Colvin with proof of clearance or transfer in S2's personnel file. This is a potential safety risk to all residents in care.

Criminal Record Clearance: (e) All individuals ...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 observations and record review, the Licensee did not comply with the above regulation with one staff member (S2). LPA Colvin observed that S2 was present in the facility wihtout proof of background clearance. S2 is not associated to the facility. This is an immediate safety risk to residents in care.

Reporting Requirements: (a) Each licensee shall furnish to the licensing agency...the following:(1) A written report shall be submitted...within seven days...of any of the events specified ...(D) Any incident which threatens the welfare, safety or health of any resident... This was not met by: Based on record review, the Licensee did not comply with the above regulation with at least one incident. LPA Colvin observed that emergency services were called out to the facility on 6/8/20 but the facility never submitted an Incident Report to CCL. This was an immediate safety risk to all residents.

Additional Personal Rights of Residents in Privately Operated Facilities : (a) In addition to the rights listed...residents... ave all of the following personal rights:(1) To have...privacy in...medical treatment, personal care and assistance... This requirement was not met as evidenced by: Based on interviews, the Licensee did not comply with the above regulation with at least one resident (R1). Licensee stated that S1 took photos of R1 when paramedics responded to provide medical aid. Licensee does not have consent on file. This posed a potential personal rights violation to R1.