Sutro Heights Corporation

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, records review and observation, R1 was able to leave the facility unassisted which poses an immediate health and safety risk to residents in care.

Based on observation, the licensee did not ensure that they had an order for R1 and R2's full bed rails, 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 in LPA observed powdered bleach in resident restroom left unsecured and accessible which poses an immediate health, safety or personal rights risk to persons in care.

Update reappraisal at required intervals

Based on record review, the licensee did not comply with the section cited above in 3 out of 5 resident appraisals that were not signed or completed, which poses/posed a potential health, safety or personal rights risk to persons in care.

HEALTH AND SAFETY CODEEach RCFE... shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the... training requirements listed on page one of this report. This requirement was not met, as staff who handle medications--including giving pre-poured medications to clients--have not received required medications training. Licensee failed to ensure that required medications training is given to staff who handle clients' medications, which poses a potential health, safety or personal rights risk to clients in care.

Assist residents with self-administered medication

INCIDENTAL MEDICAL CAREThe licensee shall assist residents with self-administered medications as needed.This requirement was not met, as staff failed to obtain antibiotic prescribed to client #1 on 8/8/23 in a timely manner. Licensee failed to ensure that client received Rx medication when prescribed, which posed an immediate health, safety or personal rights risk to clients in care.

Maintain facility in clean, safe, sanitary condition

MAINTENANCE AND OPERATIONThe 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, as licensee failed to ensure that backyard and access to backyard are free of debris. This posed a potential health, safety or personal rights risk to clients in care.

CRIMINAL RECORD CLEARANCEAll 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 obtain a CA clearance or a criminal record exemption as required by the Department. This requirement is not met, as staff RC is working with clientsfor over 30 days and does not yet have criminal record clearance. He was fingerprinted but not yet clieared. Licensee failed to ensure that staff working with clients have criminal record clearance, which poses an immediate health, safety or personal rights risk.

Maintain separate complete record for each resident

87506(a) RESIDENT RECORDSThe 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 was not met, as facility had not maintained a file for client #2 during initial complaint visit on 9/13/23. Licensee failed to maintain a current record for client #2, who was admitted on 9/1/23, This posed an immediate health, safety, or personal rights risk to client in care.

Assist residents with self-administered medication

87465(a)(4) INCIDENTAL MEDICAL CAREThe licensee shall assist residents with self-administered medications as needed.This requirement was not met, as client #1 was not provided with Rx medications for first 3 days of admission on 8/31/23.Licensee failed to ensure that clients are given medications as prescribed by MD, which poses an immediate health, safety or personal rights risk to clients in care.

Maintain facility in clean, safe, sanitary condition

Based on observation of a side fence in the backyard that was in severe disrepair and leaning towards the facility, the licensee did not comply with the section cited above in 1 out of 1 backyard fences, which poses an immediate health, safety or personal rights risk to persons in care.

Maintain facilities for fire and panic safety

FIRE SAFETYAll facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement is not met, as a wall is erected between first 2 rooms. Fire clearance was approved for one large room. There is a window in one of the rooms, but not the room closest to the street. Licensee failed to ensure conformity with fire clearance, which poses an immediate health and safety risk to clients in care.

Passageways and stairways kept clear

PERSONAL ACCOMMODATIONS/SVCSAll outdoor and indoor passageways and stairways shall be kept free of obstruction.In the ground level passageway leading from street to backyard, there are boxes, filled plastic bags and tables obstructing free and clear exiting. In addition, overgrowth of plants limits the width of passageway to backyard. Licensee failed to ensure that passageway is free of obstruction, which poses an immediate health and safety risk to clients in care.

LIMITATIONS CAPACITY/AMBULATORY STATUSA licensee shall not operate a facility beyond the conditions and limitations specified on the license, including... Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents.This requirement is not met, as client #1 is non-ambulatory and resides in room on 2nd level. Licensee failed to adhere to limitations of ambulatory status, which poses an immediate health and safety risk to clients in care

PERSONAL ACCOMMODATIONS AND SERVICESIndividual privacy shall be provided in all toilet, bath and shower areas.This requirement is not met, as commode is in use in 2nd floor shared room of client #1. Licensee failed to ensure privacy when toiletting for clients in shared room, which poses a potential health, safety or personal rights risk to clients in care.

Incidental medical and dental care services

INCIDENTAL MEDICAL CARE(h)(6) A record of centrally stored Rx medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started & expiration, prescription number and instructions: This requirement is not met, as there is no Centrally Stored Medication Records for staff #1 and #2. Licensee failed to ensure that CSMR is maintained for clients' medications, which poses a potential health, safety or personal rights risk to clients.

Provide signal systems for large or multi-floor facilities

MAINTENANCE AND OPERATIONFacilities shall have signal systems which shall meet the following criteria:...having separate floors or buildings shall have a signal system which shall operate from each resident's living unit, transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff, identify the specific resident living unit. This requirement is not met, as 3 out of 5 rooms on ground floor and 4 out of 5 rooms on 2nd floor do not have call system. Licensee failed to ensure that emergency call system is installed, which poses an immediate health & safety risk to clients 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,.. This requirment is not met as evidenced by facility did not ensure R1's room was ventilated, facility failed to get R1 up from the bed so R1 could enjoy fresh air and sunshine outside of R1's room; faciliy did not ensure R1 had cleaned and

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities..(a) In addition to the rights listed in Section 87468.1,..(5) To be served food of the quality and quantity necessary to meet their nutritional needs. This requirement is not met as evidenced by facility severed R1 cold meals which poses a potential risk for resident 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... This requirment is not met as evidenced by facility staff failed to complete R1's ADL log which poses a potential risk for resident in care.

Facility must safeguard entrusted cash and valuables

87217 Safeguards for Resident Cash, Personal Property, and Valuables..(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables This requirement has not been met as evidenced by facility mistakenly handed R1's personal wheelchair to a equipment company when they came to pick up equipment for another resident which posed a potential risk for resident in care.

Facility personnel sufficiency and competence

87411 Personnel Requirements - General..a) Facility personnel shall at all times be sufficient..and competent to provide the services necessary to meet resident needs...This requirement is not met as evidenced by facility staff was not trained on how to use a hoyer lift resulted R1 not getting out of bed for many months which posed a potential risk for resident in care.

Acceptance obligations tied to pre-admission appraisal needs

87464 Basic Services..(d) 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 is not met as evidenced by facility staff failed to provide R1 ADL care during bed bathes which poses a potential risk for resident in care.

Right to access and copy personal medical records

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,..(19) To have prompt access to review all of their records ... This requirement is not met as evidenced by R1 requested to review R1's inventory list, however, it was not provided which poses a potential risk for resident in care.

Store centrally held medications in locked secure place

87465 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 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 is not met as evidenced by during the 10-day complaint visit, LPA Han observed the medication storage in the kitchen was not locked and there were no staff present which poses an immediately risk to resident in care.

87468.2 Additional Personal Rights of Residents...(5)To be served food of the quality and quantity necessary to meet their nutritional needs. This requirment is not met as evidenced by residents are experiencing being served cold meals which poses a potential health risk to residents in care.

Acceptance obligations tied to pre-admission appraisal needs

87464 Basic Services..(d) 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 as identified .. This requirement is not met as the facility did not assist resident with showers for many weeks as scheduled which poses an immediately health risk to resident in care.

87468.1 Personal Rights of Residents in All Facilities..a) Residents in all residential care facilities for the elderly shall ...(2) To be accorded safe, healthful and comfortable accommodations,... This requirement is not met as evidenced by S1 and home health staff acknowledged that they have observed pest crawling on R1's lower extremity and on the bed which poses an immediately health risk for resident in care.

Maintain facility in clean, safe, sanitary condition

Based on observation, and interview, the licensee did not comply with the section cited above as the facility failed to ensure resident's room is cleaned, safe and sanitary which poses an immediate health, safety or personal rights risk to persons in care.

87506 Resident Records(a)The licensee shall ensure...a current record is maintained for each resident in the facility.. readily available to facility staff and to licensing agency staff..(b) Each resident’s record shall contain.. (15)The admission agreement..This requirement is not met as evidenced by: the facility did not have resident #1 (R1)'s admission agreement in the facility which poses a potential health risk to residents in care.

§1569.652 Termination of admission agreement upon death of resident;...(c) A refund of any fees paid in advance....within 15 days after the personal property is removed. This requirement is not met as evidence by: In January 2022, R1 stayed at the facility for a few days and the responsible party paid for the entire month but the facility has yet refunded the unused portion of the payment to the RP poses a potential risk to person(s) in care.

Provide copies of signed agreements and amendments

87507 Admission Agreements..(e) The licensee shall provide a copy of the signed and dated current admission agreement,..to the resident or the resident's representative, The requirment is not met as evidenced by: The facility did not provide a copy R1's admission agreement to R1's responsible party despite R1's responsible party's requests which poses a potential risk to person(s) in care.

87413 Personnel - Operations (a) In each facility:(2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. The requirement is not met as evidenced by: staff #1 (S1) yelled at residents during care and supervision which poses an immediate health risks to residents in care.

§1569.80 Care and services decision making; meeting; written record a) A resident of a residential care facility for the elderly, or the resident's representative, or both, shall have the right to participate in decision making regarding the care and services to be provided to the resident. This requirement is not met as evidenced by: R1 is satisfied with services that was provided by the home health visiting nurse. However the facility pressured R1 discontinuing the services from this visting nurse which posed an immediately health risks to resident in care.

87457 Pre-Admission Appraisal - General(c)Prior to admission a determination of the prospective resident's suitability for admission shall be completed..(3) The prospective resident, or his/her responsible person,...shall be involved in the development of the appraisal. This requirement is not met as evidenced by R1 and R2's appraisal needs/service plans were not signed indicating it's reviewed and agreed by the residents and/or their responsible parties which poses a potential health risk to residents in care.

Update reappraisal at required intervals

87463 Reappraisals(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 is not met as evidenced by: during the 10-day initial complaint visit, LPA observed R1 and R2 have half bed rails up by the head of their beds, however, the need of utilzing this device was not reflected in their appraisal needs which poses a potential health risk to residents in care

Maintain physician order documentation in resident record

87608 Postural Supports (a) Based on the individual's preadmission appraisal, Postural supports may be used under the following conditions.(3) A written order from a physician indicating the need for the postural support... This requirement is not met as evidence by: R1 and R2 have half bed rails by the head of the bed and there was no written order from their physician which poses a potential health risks to residents in care.

Right to personal privacy in daily care

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1,...(1) To have a reasonable level of personal privacy in accommodations... This requirement is not met as evidenced by: The facility moved and displaced resident #1's personal belongings from R1's room without R1's presence, and consent which poses a potential health risks for resident in care.

Personal rights of residents in all facilities

PERSONAL RIGHTS OF RESIDENT IN ALL FACILITIES:(a) Residents in all residential care facilities..shall have following personal rights:(2)To be accorded... healthful and comfortable accommodations..and equipment. This requirement was not met as evidenced by: LPA Han observed a strong, and pungent smell in the lower level which was caused by the cleaning solution and according the resident, the smell was strong and unpleasant which posed potential health and safety risks to resident in care.

Maintain separate complete record for each resident

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 records review and interview, the Administrator did not ensure Resident 1's (R1) appraisal and service plan reflect the current health statues and needs including but not limiting incontinence care and dietary needs which poses an potential Health and Safety risk to persons in care.

Facility maintenance and healthful environment

PERSONAL ACCOMMODATIONS AND SERVICES(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met: Based on observation and interview, LPA observed the following during the inspection: A resident (R1)'s room has sawdust on top of the baseboard, one of the windows is cracked and had a spider web, laundry room sink has a brush that was placed on top of a gray dust and hair. The washer has hair and black dust under the cover on the right corner