Haven's House of Assisted Living

Based on observation, interview, and record review, the licensee did not comply with the section cited above facility Unable to provide proof of disaster drills being conducted which poses/posed a potential health, safety or personal rights risk to persons in care.

Reporting Requirements (a)Each licensee shall furnish ..., the following: (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... (B)Any serious injury as determined ... . This requirement was not met as evidenced by: Based on observations made, Licensee did not comply with the section cited above, Licensee failed to submit special incident report to the CCL as required which poses/posed a potential health, safety or personal rights risk to persons in care.

Additional Personal Rights of Residents...(a) In addition to the rights listed in ...: (20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict... This requirement was not met as evidenced by: Based on interviews and LPA observation of records, it was determined Facility refused to accept the resident (R1) back from the hospital. This poses an immediate health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental(h) The following requirements...:(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.This requirement was not met as evidenced by: Based on observations made, Licensee did not comply with the section cited above. LPAs observed multiple instances of resident medication being pre-poured over 24 hours in advance. This is a potential health and safety risk to residents in care.

87465 (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible a record of centrally stored prescription medications for each resident...: This requirement was not met as evidenced by: Based on observations made, Licensee didnot comply with the section cited above and did not ensure that there was a completed LIC622 or similar document with the all of the regulatory information required. This is a potential health and safety risk to residents in care.

Based on record review, interview and observation the licensee did not comply with the section cited above in [1} out of [4} staff which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in 4 out of 5 files did not have care plans or signatures for meetings which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observations, the licensee did not comply with the section cited above in items were found unsecured in kitchen, laundry room, bathroom and resident room which poses/posed a potential health, safety or personal rights risk to persons in care.

All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:This was not met as evidence by:** Based on record review and interview with Licensee, the facility did not comply with the section cited above in 1 out of 1 individuals (I1) without proof of background clearance or association to the facility, which poses an immediate health, safety or personal rights risk to persons in care.

87202(a): All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.(2) Bedridden personsThis requirement was not met as evidenced by: Based on a review of the STD 850 and an interview with an outside provider, facility retained a resident that was bedridden. Facility is currently Fire Clearance approved for 4 Non-Ambulatory residents which 0 can be bedridden. This is an immediate health, safety and personal rights risk to the resident(s) in care.

87459(a): The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited to:(4) Transferring, including the need for assistance in moving in and out of a bed or chair.This requirement was not met as evidenced by: Based on interviews that were conducted, resident was bedridden which requires a higher level of care for the resident that was in placement. Facility is licensed to retain 4 residents that are Non-Ambulatory which 0 can be bedridden. This is an immediate health, safety and personal rights risk to the resident(s) in care.

87506(a): The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.This requirement was not met as evidenced by: During the investigation, facility did not retain resident records which included the Medication Assessment Record (MAR) that documents medication administration. This is a potential health, safety and personal rights risk to the resident(s) in care.

87355 Criminal Record Clearance(a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review.(b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. This requirement was not met as evidenced by:During the opening of the complaint on March 14, 2023 at approximately 01:00 PM, LPA was greeted at the door by a Staff Member who was not background clearand associated to the facility

87468.1(a)(11): Personal Rights of Residents in All Facilities :To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidenced by:The auditory baby monitor was turned on. The receptor is kept in the live-in kitchen area, which can be heard by other facility staff, residents and visitors. This violation presents a potential Personal Rights violation.

87468.1(a)(1)-Personal Rights of Residents in All Facilities:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:LPA observed during the facility tour on September 13, 2022 that a baby monitor was inside the residents room, and was being used to monitor the resident's call for assistance.