Pacaldo Llc

Requirement for building permit before construction

87305 Alterations to Existing Building or New Facilities(a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by based on observation, record review andinterview, one of the room on the lower level is not included on the facility sketch and accoridng to the facility staff, it was occuped by facility staff and the facility was not able to provide any documents to proof that it was permitted which posed a potential risk for residents in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as S2 did not have required training records in the personnel file which poses an immediate health, safety or personal rights risk to persons in care.

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

Ensure hazardous items are locked and not unattended

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed sharps stored in the kitchen dish rack are locked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.

Request a transfer of criminal record clearance

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as S1 and S2 are transferred from the sister facility, however, the criminal records were not transferred to this facility which poses an immediate health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the administrator did not ensure all the required documents are completed prior to R2 admission, all the required documents are completed for S1 and S2's personnel files, and the files are available at the facility for inspection which poses an immediate health, safety or personal rights risk to persons in care.

Perform a pre-admission resident appraisal

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as R1's pre-admission evaluation was incomplete as it was not signed by the resident and/or the responsible party; R2 was admitted on 5/12/2025 without a pre-admission evaluation which poses an immediate health, safety or personal rights risk to persons in care.

Obtain baseline medical assessment before resident admission

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as R2 was admitted on 5/11/2025 and there was no medical assessment in the file which poses an immediate health, safety or personal rights risk to persons in care.

Record findings for communicable tuberculosis conditions

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as R2 was admitted on 5/12/2025 and there is no communicable TB status in the file which poses an immediate health, safety or personal rights risk to persons in care.

Maintain separate complete record for each resident

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility did not have complete, and current record for R2 which poses an immediate health, safety or personal rights risk to persons in care.

Maintain admission agreement and appraisal

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above the facility did not have an admission agreement for R1 and R2 completed during the inspection which poses an immediate health, safety or personal rights risk to persons in care.

Maintain physician order documentation in resident record

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as R1 and R2 have bedrails without a written order which poses an immediate health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed there is no TB/chest X-ray status in S1's file which poses an immediate health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

87303 Maintenance and Operation..(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by several nails protruding from the wooden floor slabs and a few cracked wooden slabs which poses an immediately health risk for residents in care.