Mission Villa

Maintain required personnel records for staff

Based on record review the licensee did not comply with the section cited above as LIC501 in Staff 1’s (S1’s) file was incomplete which poses a potential health, safety, or personal rights risk to residents in care.

Document required staff training and orientation

Based on record review the licensee did not comply with the section cited above as Licensee was unable to provide verification that staff trainings and/or orientations have been conducted and/or documented which poses a potential health and safety risk to residents in care.

Ensure hazardous items are locked and not unattended

87309 Storage Space and Access(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met by evidence of bleach and "tide-pods" being unsecured and in access to resident in care, which poses a potential risk to residents in care.

Report specified resident events within seven days

87211 Reporting Requirements.(a) (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...This requirement is not met as evidenced by: Based on interview conducted, the licensee did not comply with the section cited above as the licensee did not submit within seven (7) days a written report of suspected adult/elder abuse which poses an immediate health and safety risk to resident(s) in care.

Right to confidential records and approved disclosure

87468.2(a)(4)…Residents…shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when they did not ensure residents received proper oral hygiene assistance, which posed a potential risk to residents in care. health and personal rights.

1569.657(a) For any rate increase due to a change in the level of care of the resident, the licensee shall provide the resident and the resident’s representative…written notice of the rate increase within two business days after initially providing services at the new level of care. The notice shall include a detailed explanation of the additional services to be provided at the new level of care and an accompanying itemization of the charges. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section when they increased R1’s rate without justification, which posed a potential health, safety and personal rights risk to residents in care.

Obtain required California clearance or exemption

Based on interviews, the licensee did not comply with the section cited above as the licensee did not ensure that S1 was properly associated to the facility prior to working, residing and/or volunteering, which poses an immediate safety risk to persons in care.

Based on interview with Administrator, the licensee did not comply with the section cited above as the licensee was unable to provide First Aid/CPR training documents for facility staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain facilities for fire and panic safety

Based on observation and interviews conducted, the Licensee did not comply with the section cited above as four smoke alarms were observed to have no signals and/or extremely weak signals which poses an immediate health, safety or personal rights risk to persons in care.

Maintain facility in clean, safe, sanitary condition

Based on observation, the licensee did not comply with the section cited above as an electrical outlet was within reach of a resident's bed. Based on observation, soiled items in a kitchen sink were observed, and an unused washer and dryer were onplaced the west patio which poses an immediate health, safety or personal rights risk to persons in care.

Regular observation and documentation of resident changes

87466 Observation of the Resident. When changes such as…a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person… This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section when the licensee waited at least one (1) day to inform R1’s responsible person of a large bruise, which posed a potential health and safety risk to residents in care.

Prompt responses to resident communications

87468.1(a)(9) Personal Rights. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have communications to the licensee from their representatives answered promptly and appropriately. This requirement was not met as evidenced by:Based on interview and record review, the licensee did not comply with the above cited section when the licensee did not respond to RP1’s communications for over 3 days, which posed a potential health and safety risk to residents in care.

Arrange appropriate medical and dental care

Type B 87465(a)(1) Incidental Medical and Dental Care. The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section when they instructed family members to obtain medical attention for R1 instead of the facility staff arranging it, which posed a potential health and safety risk to residents in care.

Certified administrator requirements and substitute coverage

87405(a) Administrator – Qualifications and Duties. All facilities shall have a qualified and currently certified administrator…The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section when the designated administrator was not present a sufficient number of hours to manage the facility, which posed a potential health and safety risk to residents in care.

Facility personnel sufficiency and competence

87411(a) Personnel Requirements.Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section when staff fell asleep on shift or did not show up, which posed a potential health and safety risk to residents in care.

HSC §1569.69(b) Training Requirements:Each employee…who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the above cited section when 5 staff (S1, S2, S3, S4, licensee) did not have adequate training, which posed a potential health and safety risk to residents in care.