Ebadat Residential Care Home # 5

Personal Rights (a)(8)(C):Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to...(8)Not to be placed in any restraining device.Postural supports may be used under the following conditions:(C) Postural supports shall be fastened or tied in a manner which permits quick release by the client. This requirement is not met as evidenced by: Based on inspection and observation,(See continuation on next column, under Plan of Correction)

Health Related Services(k)(1):The following requirements shall apply to medications which are centrally stored(1)Medication shall be kept in a safe and locked place that isnot accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observation, medications are found accessible in a brown observed on top of an office table (against the wall on the left facing the street) in the main dining room which belongs. (See continuation on next column, under Plan of Correction)

Based on interview and observation, the licensee did not comply with the section cited above in wherein the hot water temperature in the bathroom was measured at 158 degrees F which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review the licensee did not comply with the section cited above in wherein 2 residents appraisal/needs and serices plan did not include the need for full length bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on interview, record review and observation the licensee did not comply with the section cited wherein 2 resident beds contains full length bed rails without a physician's order for the full length beds and approval from the Department which poses an immediate health, safety or personal rights risk to persons in care.

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department orThis requirement is not met as evidenced by: Based on interview, record review and observation the licensee did not ensure staff (S1) obtained a fingerprint clearance from the Department prior to working in the facility which poses an immediate health, safety, and personal rights risk to persons in care.

(a) Prior to admission of a resident with a restricted health condition, the licensee shall: (1) Communicate with all other persons who provide care to that resident to ensure consistency of care for the condition. This requirement is not met as evidenced by: Based on interview, record review, and observation the licensee did not ensure to immediately communicate with the appropriate agencies responsible for R1’s care to ensure a restricted health condition care plan was in place upon being notified of R1's restricted health condition which poses an immediate health, safety and personal rights risk to persons in care.

Based on observation, interview and record review the licensee did not ensure resident's appraisal/needs and services plan and IPP was updated annually which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review the licensee did not ensure staff were provided an additional 20 hours of annual training on the topics listed in this section which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and record review the licensee did not ensure staff were provided a quarterly emergency drill which poses/posed a potential health, safety or personal rights risk to persons in care.

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observation and interview the licensee did not ensure the centrally stored medication cabinet was locked and inaccessible to residents in care which poses an immediate health, safety, and personal rights risk to persons in care.

(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. Based on observation, interview, and record review 3 out of 3 residents are utilizing full length bed rails during the night without prior approval from the Department and physician's orders on file which poses an immediate health, safety, and personal rights risk to persons in care.

(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: This requirement was not met as evidenced by: Based on interview, observation, and record review the garage is not approved to be a bedroom when LPA observed staff (S1) sleeping in the garage which poses an immediate health, safety, and personal rights risk to persons in care.