Routine inspection·July 31, 2025

Citations

13 citations recorded^*CCLD

• 1569.695(b)Type B

  HEALTH & SAFETY CODEA facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement is not met, as there is no documentation that staff received training on responding to emergencies, which poses a potential health, safety or personal rights risk to clients in care.This deficiency was cited on 9/3/24 and proof of correction was not submitted.

• 1569.695(c)Type B

  HEALTH & SAFETY CODEA facility shall conduct a drill at least quarterly for each shift...type of emergency... shall vary. An actual evacuation...is not required... Documentation... shall include the date, the type of emergency covered...names of staff participating in the drill. This requirement is not met, as documentation of emergency drills does not clearly indicate what was done, which poses a potential health, safety or personal rights risk to clients in care.This deficiency was cited on 9/3/24 and proof of correction was not submitted.

• 87204(a)Type B

  Limit operations to licensed capacity

  LIMITATIONS - CAPACITY & AMBULATORY STATUSA licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. This requirement is not met, as client #1 is determined by MD to be bedridden, but facility is not licensed for bedridden clients. Licensee failed to ensure operation within limits of license, which poses a potential health, safety or personal rights risk to clients in care.

• 87405(a)Type B

  Certified administrator requirements and substitute coverage

  ADMIN QUALIFICATIONS DUTIESAll facilities shall have a qualified and currently certified administrator. This requirement is not met, as proof of a certified RCFE administrator is not available. Licensee failed to ensure there is a certified RCFE administrator, which poses a potential health, safety or personal rights risk to clients in care.

• 87411(c)(1)Type B

  First aid training requirements

  PERSONNEL REQUIREMENTSStaff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met, as 5 out of 6 staff do not have proof of current first aid training, which poses a potential health, safety or personal rights risk to clients in care.

• 87412(a)(1Type B

  PERSONNEL RECORDSThe licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain specific information. This requirement is not met, as staff records for 6 out of 6 files reviewed are missing job applications, health screenings, including TB test results, criminal record statements. Licensee failed to ensure required staff records are maintained, which poses a potential health, safety or personal rights risk to clients.This was observed on 9/3/24 and not corrected.

• 87457c)Type B

  PRE-ADMISSION APPRAISALPrior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance/Retention LimitS. This requirement is not met, as there is no signed appraisal on file for client #5, who was admitted 3 years ago. This poses a potential health, safety or personal rights risk to clients. This was cited on 9/3/24.

• 87463(a)Type B

  Update reappraisal at required intervals

  REAPPRAISALSThe pre-admission appraisal... shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition... and to keep the appraisal accurate. This requirement is not met as reappraisals for ALL clients are missing or dated more than 12 months ago. Licensee failed to ensure that annual reappraisals are done, which poses a potential health, safety or personal rights risk to clients.This deficiency was observed on 9/3/24 and proof of correction was not submitted.

• 87463(h)(1Type B

  REAPPRAISALSThe licensee shall request that all residents receive an annual routine visit with a licensed medical professional... every 12 months...Documentation.. shall be added to the resident's record...of a resident's refusal...shall be added to the resident's record. This requirement is not met, as MD assessments for 3 out of 6 client were done over 3 years ago or not maintained. Licensee failed to ensure annual MD assessments, which poses a potential health, safety or personal rights risk. NO MD report for C2, MD reports for C5 & C6 dated 2022. This deficiency observed 9/3/24.

• 87465(a)(8)Type B

  Maintain an approved first aid kit on-site

  INCIDENTAL MEDICAL CARE... a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be...approved by the American Red Cross, or shall contain at least... current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. This requirement is not met, as there is no first-aid manual available, which poses a potential health, safety or personal rights risk to clients in care.

• 87506(a)Type B

  Maintain separate complete record for each resident

  RESIDENT RECORDSEach resident’s record shall contain…Resident's legal name…Social Security number, Date of admission…Last known address, Birthdate, Religious preference, if any…Names, address, and telephone numbers of the resident’s representative … to be notified in case of emergency, Name, address, phone number of physician and dentist to be called in an emergency. This requirement is not met, as there is no emergency informatiion maintained for 3 out of 6 clients, which poses a potential health, safety or personal rights risk. No emergency info for C1, C2, C4

• 87608(a)(3)Type B

  Maintain physician order documentation in resident record

  POSTURAL SUPPORTSA written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.This requirement is not met, as there are no MD orders maintained for 4 out of 6 clients who have half bed rails. Licensee failed to maintain MD orders for use of half bed rails, which poses a potential health, safety or personal rights risk to clients in care.This deficiency was cited on 9/3/24 and proof of correction was not submitted.

• 87611(b)(1)(2)(3)Type B

  GENL REQUIREMNTS HEALTH COND.The licensee shall complete & maintain a current, written record of care... that includes, but is not limited to... Documentation from the physician of... Stability of the medical condition, Medical condition which requires incidental medical services, Method of intervention...skilled professional...who will perform the procedure if the resident needs assistance; names...phone number of...skilled professionals providing services, Emergency contacts. Client #4 has gall bladder stoma & there is no information about care or condition.