Hennelly House

I§1569.625(b)(2)Staff training - in addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This regulation has not been met as evidenced by: Based on file reviews conducted, 1 of 3 staff does not have current annual training of 20 hours. S1 last training is indicated back in 2022. This poses a potential health and safety risk to residents in care.

§1569.695(c)Emergency Plans - A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This regulation has not been met as evidenced by: Based on file reviews and speaking to staff, the facility does not have a diaster drill log and has not conducted a drill within the last 3 months. This poses a potential health and safety risk to residents and staff in care.

First aid training requirements

87411(c)(1) Personnel Requirements - General - Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This regulation has not been met as evidenced by: Based on staff files reviewed, 3 of 3 staff do not have current first aid or CPR cards. 2 of 3 expired in March of 2026, and 1 of 3 has an expired card as of 2020. This poses a potential health and safety risk to residents in care.

Annual routine visit with medical professional

87463(h) Reappraisals - The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This regulation has not been met as evidenced by: Based on file reviews, 3 of 5 residents have not had a recorded annual visit. R1, R4, and R5 have physician's reports that are older than one year with a diagnosis of dementia. This poses an immediate health and safety risk to the residents in care.

87406(g) Administrator Certification Requirements - (g) Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements. This regulation has not been met as evidenced by: Based on record reviews conducted, administrator certificate for S1 has expired as of 07/26/2019. This poses a potential health and safety risk to residents in care.

87705(c)(5) Care of Persons with Dementia - (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: 5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This regulation has not been met as evidenced by: Based on records reviewed on 2 of 4 resident files, LPA observed that R1 and R2 both are diagnosed with dementia and do not have current medical assessments. R1's physicians report is dated 10/12/2020 and R2's physicians report is dated 06/10/2022. This can pose an immediate health and safety risk to resident's in care.