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Inspection visit

Routine inspection

WESTBOROUGH MANOR 6License 4156008488 citations on this visit
8 citations recorded

Inspector’s narrative

What the inspector wrote

On August 21, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregiver, Linda Mondejar and explained the purpose of today's visit. The Licensees, Anthony and Sheila Diaz arrived and assisted with the inspection. Upon entrance, LPA observed PPE supplies and disinfectants on the floor by some of the resident's rooms and the facility staff stated that a few residents tested positive for COVID-19. According to the Licensees, this was not reported to CCL and Local Public Health. LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. The outdoor passageways were cleared. 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. 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 111-114 degrees Fahrenheit. Fire extinguishers were checked. During tour of the garage, LPA observed a mattress, a medication bottle, a toaster, etc and staff stated that it is an area for staff to take breaks. A review of (6) resident files was conducted and noted on the LIC 858. A review of (3) staff files was conducted and noted on the LIC 859. The following documents were requested submitted to CCL by 8/22/24: - Liability Insurance, Administrator Certification and LIC 500 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 Licensees. A copy of this report and the appeal rights were provided.

Citations

8 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.

  • 87307(a)Type B

    Living accommodations aligned with facility function

    Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above LPA observed staff living/rest area in the garage as which poses/posed a potential health, safety or personal rights risk to persons in care.

  • 87611(d)Type B

    Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above 5 out of 6 residents did not a reappraisal 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 did not have any documentation of the emergency drills which poses an immediate 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 4 out of 6 residents have bedrails 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.

  • 1569.618(c)(3)Type A

    Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 3 out of 3 staff did not have a current CPR and first aid training which poses an immediate health, safety or personal rights risk to persons in care.

  • 1569.625(b)(2)Type A

    Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above 3 out of 3 staff did not have any training from 2023 to present which poses an immediate health, safety or personal rights risk to persons in care.

  • 87211(a)(2)Type A

    Report serious outbreaks and major accidents

    Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 4 out 6 residents tested positive for COVID-19 and the facility did not reported to CCL and LPH 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 resident did not have a copy of the pre-admission appraisal 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 21, 2024 inspection of WESTBOROUGH MANOR 6?

This was an inspection of WESTBOROUGH MANOR 6 on August 21, 2024. 8 citations were issued: 6 Type A (serious) and 2 Type B.

Were any citations issued to WESTBOROUGH MANOR 6 on August 21, 2024?

Yes, 8 citations were issued (6 Type A, 2 Type B). The first citation was for: "Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above LPA obser..."

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.