Stetson Court Living

Buildings and Grounds - The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. LPA Lund observed debris on the side of the facility and the emergency exit gate doesn’t have a latch and needs to be fixed.

Maintain fire clearance before retaining specified persons

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: . LPA Lund observed that there were three residents on hospice out of the six residents. All three residents are bedridden and get out of bed with out the help of staff.

Maintain fire clearance before retaining specified persons

Based on LPA interviewing staff, the licensee did not comply with the section cited above in staff have been sleeping in common areas on roll away beds. The facility sketch shows bedroom #3 as a staff room, but a resident is living in that room. which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA record review, the licensee did not comply with the section cited above in staff have been sleeping on roll away beds in common areas and facility sketch shows bedroom #3 as a staff room. A resident in living in #3 bedroom. which poses/posed a potential health, safety or personal rights risk to persons in care.

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:Based on observation the licensee did not comply with the section cited above as the fire extinguisher were last purchased on Januaryof 2022 which poses an immediate health, safety or personal rights risk to persons in care.

Care of Persons with Dementia. Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. LPA was able to determine the last disaster drill was conducted on 12/30/2021 this poses an immediate safety risk.

Care of Persons with DementiaLicensees who accept and retain residents with dementia shall ensure that each resident with dementia has an annual medical assessment and a reappraisal done at least annually. LPA observed that R1 diagnosed with dementia didn't have an updated LIC 602.

Buildings and Grounds - The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:LPA observed debris on the side of the house. This poses a potential safety risk to the residents in care.

Obtain required California clearance or exemption

87355(e)(2) Criminal Record Clearance. Prior to working, residing or volunteering in a licensed facility, all individuals subject to a criminal record review shall request a transfer of a criminal record clearance from another facility or Trustline.This requirement is not met as evidenced by: Based on LPA observation and record review licensee failed to ensure S1 obtained a criminal record clearance transfer prior to starting.

Care of Bedridden Residents. To accept or retain a bedridden person, a facility shall ensure the following: The facility's Plan of Operation includes a statement of how the facility intends to meet the overall health, safety and care needs of bedridden persons.This requirement is not met as evidenced by: Record review, interviews, and observation. Facility failed to obtain proper fire clearance for (R1). R1 is unable to turn or assist with ADLs This poses and immediate health and safety risk to residents in care.

Document behavioral expression and related causes

87463 Reappraisals. (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first This requirement is not met as evidenced by: Based on record review, the licensee failed to ensure that annual reappraisals were done for R1 last assessment was done in 2015, which poses a health risk to residents in care.

87412(b)(2) Personnel RecordsHealth screening documents as specified in Section 87411(e). This requirement is not met as evidenced by: oberservation and records review LPA obtained information that the health screening for staff S1 was not done.

Staff training in personal care activities

Personnel Requirements – General. All staff who assist residents with personal activities of daily living shall receive at least ten hours of initial training within the first four weeks of employment and at least four hours annually thereafter. S1 and S2 file is missing orientation documentation

80075(f) Health Related Services. Staff providing care and supervision shall receive first aid training from qualified agencies including but not limited to the American Red Cross.Expired First Aid and CPR for S3 proof in file.