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Inspection visit

Routine inspection

ALWAYS TLCLicense 41560080812 citations on this visit
12 citations recorded

Inspector’s narrative

What the inspector wrote

On August 6, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Adoracion "Doris" Mores and explained the purpose of today's visit. LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. The outdoor passageway was observe to be obstructed with a wooden fence and many medical devices. The facility has 6 residents and all of them are in private rooms. Furniture and furnishings were observed to be sufficient. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped with non-skid mats and grab bars. Facility exits are equipped with audible alarms. Comfortable temperature is maintained and lighting is sufficient for comfort. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time. Central storage for medications, sharps and chemicals were observed to be locked and inaccessible to residents in care. Hot water temperature in the kitchen and bathroom were measured at 108-119 degrees Fahrenheit. Fire extinguishers were checked. During tour of the facility, LPA observed a unit was built in the garage that was not indicated on the facility sketch and according to the San Mateo Consolidated Fire Department and Foster City Building Department, there is no records that a building permit as obtained. A review of (6) resident files was conducted and noted on the LIC 858. A review of (2) staff files was conducted and noted on the LIC 859. The following documents were requested submitted to CCL by 8/13/24: - Liability Insurance and Administrator Certification. Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. . This report is reviewed and discussed with the caregiver. A copy of this report and the appeal rights were provided.

Citations

12 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 1569.625(b)(2)Type B

    Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 1 staff did not have any training records for 2023 and 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 1569.695(c)Type A

    Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility was not able to provide any documents that emergency drills were completed accordingly which poses an immediate health, safety or personal rights risk to persons in care.

  • 87202(a)Type A

    Maintain fire clearance before retaining specified persons

    Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed a unit was built in the garage and according to the San Mateo Consolidated Fire Department and Foster City Building permit, there was no records of a building permit was obtained which poses an immediate health, safety or personal rights risk to persons in care.

  • 87305(a)Type A

    Requirement for building permit before construction

    Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed a unit was built in the garage and according to the San Mateo Consolidated Fire Department and Foster City Building permit, there was no records of a building permit was obtained which poses an immediate health, safety or personal rights risk to persons in care.

  • 87307(d)(6)Type A

    Passageways and stairways kept clear

    Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above LPA observed outdoor passageway was blocked by the wooden fence and stored many medical devices and other objects which poses an immediate health, safety or personal rights risk to persons in care.

  • 87456(a)(2)Type A

    Perform a pre-admission resident appraisal

    Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 4 out of 6 residents did not have a pre-admission appraisal which poses an immediate health, safety or personal rights risk to persons in care.

  • 87456(a)(3)Type B

    Obtain and evaluate recent medical assessment

    Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed resident with diagnosis of dementia did not have a recent medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87458(a)Type A

    Obtain baseline medical assessment before resident admission

    Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 1 out of 6 resident did not have a completed medical assessment/LIC602 on file which poses an immediate health, safety or personal rights risk to persons in care.

  • 87470(b)(2)Type A

    Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed that there was no gowns available at the facility while caring for a resident who has a contagious disease which poses an immediate health, safety or personal rights risk to persons in care.

  • 87506(b)(17)(E)Type B

    Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 6 out of 6 residents did not have a copy of the reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87608(a)(3)Type A

    Maintain physician order documentation in resident record

    Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 2 out of 6 residents with bed rails by the head of the bed without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.

  • 87608(a)(5)(B)Type A

    Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 4 out of 6 residents have bed rails by the head and foot of the bed and according to the staff, these residents are not on hospice which poses an immediate health, safety or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the August 6, 2024 inspection of ALWAYS TLC?

This was an inspection of ALWAYS TLC on August 6, 2024. 12 citations were issued: 9 Type A (serious) and 3 Type B.

Were any citations issued to ALWAYS TLC on August 6, 2024?

Yes, 12 citations were issued (9 Type A, 3 Type B). The first citation was for: "Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA ob..."

What type of inspection was this?

This was an inspection. Inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.