Betsy's Residential Care Home

Maintenance and Operation 87303(a)(a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by: Based on LPA, licensee and S1 observation, the licensee did not comply with the section cited above in that water heater closet has rodent droppings present, rodent droppings also observed by LPA, licensee, and caregiver outside in the garage on the same side as the refrigerator; additionally, an insulin syringe was found on the floor in the garage, which poses a potential health, safety or personal rights risk to persons in care.

Incidental Medical and Dental Care Services 87465 (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Based on LPA and caregiver observation, the licensee did not comply with the section cited above in that there were pre-poured medications in kitchen drawer, which poses an immediate health, safety or personal rights risk to persons in care.

87411 Personnel Requirements - General (a) 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 by licensee as evidenced by: Based on LPA interview, facility does not currently have at least two [2] staff present on all shifts, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA record review, the licensee did not comply with the section cited above in that R1 did not have TB clearance on file, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA and caregier observation, the licensee did not comply with the section cited above in that water heater closet has rodent droppings present, rodent dropping also observed by LPA and caregiver outside in the garage on the same side as the refrigerator; additionally, an insulin syringe was found on the floor in the garage, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPA and caregiver observation and record review, the licensee did not comply with the section cited above in that the following errors were observed on the CSML for R1: Vitamin C should be administered 2 times per day but listed on CSML as only one, Aspirin present on current orders but not listed on CSML, Multivitamin with iron listed on current orders but not listed on CSML, Senna listed on current order as 17.2 but listed as 8.6mg on CSML, insulin dose listed as 75 units in the morning and 40 units in the evening. Entry for 75 units in the morning present on CSML but not the 40 units in the evening, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA and caregiver observation, the licensee did not comply with the section cited above in that there were pre-poured medications in kitchen drawer, which poses an immediate health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine...own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided ...(3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement not met by licensee as evidenced by: based on LPA and caregiver observation PRN outcomesvand entry dates of PRN adminsitration for R2 not documented, which poses a potential health, safety or personal rights risk to residents.

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement not met by licensee as evidenced by: based on LPA and caregiver observation, Calcium Citrate-Vitamin D3 315mg-5mcg not listed on the CSML for R1, which poses a potential health, safety or personal rights risk to residents.

87405(a) Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator. This requirement not met as evidenced by: Based on LPA and and licensee interview and record review, the licensee did not comply with the section cited above in that Administrator does not have an actively current Administrator certificate or Administrator, which poses an immediate health, safety or personal rights risk to residents

87405(a) Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator. This requirement not met as evidenced by: Administrator does not have an actively current Administrator certificate. This poses an immediate health, safety or personal rights risk to residents

§1569.625 Staff training; legislative findings; contents (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...This requirement is not met as evidenced by: Based on LPA and caregiver observations, the licensee did not comply with the section cited above in that S2 and S3 did not have the required number of training hours completed, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPAs and licensee observations, the licensee did not comply with the section cited above in that resident room 2 had commode full of waste and urine, with very strong odor filling the room. LPAs observed resident room 4 to have strong odor from urine as well which poses a potential health, safety or personal rights risk to persons in care.

Based on LPAs and licensee observations, the licensee did not comply with the section cited above in that Hallway floor outside of hall bathroom has water damages causing expansion of laminate flooring resulting in uneven walking surface. Floor bows inward under weight, which poses a potential health, safety or personal rights risk to persons in care.

Based on LPAs observation and record review, the licensee did not comply with the section cited above in that three (3) of five (5) staff (S1, S2, S3) did not have First Aid which poses an immediate health, safety or personal rights risk to persons in care.

87625(b)(2) Managed Incontinence (b) In addition to Section 87611...the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night This requirement is not met as evidenced by: Based on evidence obtained during investigation, the licensee did not comply with the section cited above in that licensee did not ensure incontinence needs were met per hospice care plan, which poses an immediate health, safety or personal rights risk to persons in care.

87465 (h) The following requirements shall apply to medications...centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees....This requirement is not met as evidenced by: Based on LPA observation the licensee did not comply with the section cited above in that med cart in living room was unlocked which poses an immediate health, safety or personal rights risk to persons in care.

HSC 1569.625 (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...This requirement is not met as evidenced by: Based on LPA record review, the licensee did not comply with the section cited above in that training records for staff not available, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.

87208 Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation.This requirement was not met by licensee as evidenced by: Per agreement during office meeting with licensee on 3/29/2024, licensee was to review and submit facility's Plan of Operation. Licensee has not submitted Plan of Operation to CCL, which poses a potential health, safety or personal rights risk to persons in care.

87303(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens. This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that syringe for insulin was found accessible, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.

87412 (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening...This requirement is not met as evidenced by: Based on LPA record review, the licensee did not comply with the section cited above in that staff (S1) did not have health screen, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year... This requirement was not met by licensee as evidenced by: Based on LPA observation the Physician's Report for new resident R1 was not signed by a physician. Per LPA interview with licensee, the unsigned Physician's report is the only one retained by facility for R1, which poses/posed a potential health, safety or personal rights risk to persons in care.

87465 (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Based on: LPA observation, the licensee did not comply with the section cited above as unlocked drawer in kitchen contained pre-poured medication. Due to Licensee’s failure to respond to and work with CCL's TSP to correct identified concerns, deficiencies are being re-cited.

87555(b) The following food service requirements shall apply: (23) All readily perishable foods...capable of supporting... growth of micro-organisms...shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that a bowl of cooked pasta left out overnight, which posed a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.

87555(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that opened food items in refrigerator were not covered or labeled, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.

87705 (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that kitchen drawer containing sharp knives not locked, which poses/posed a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.

87705 (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication... cleaning supplies and disinfectants. This requirement was not met by licensee as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that the hallway closet containing toxins was unlocked and accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.

Based onLPA and Licensee observation, the licensee did not comply with the section cited above in that a bowl of cooked pasta left out overnight and during the day previous at room temperature, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA interview with Licensee, the licensee did not comply with the section cited above in that facility has one resident (R1) that is bedridden but facility does not have bedridden fire clearance and could not produce proof of notification to fire deptartment, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA record review, the licensee did not comply with the section cited above in [1] out of [3] residents. Resident R1 has a physician report dated 2022 but nothing current which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA record review, the licensee did not comply with the section cited above in [1] out of [3] residents. Resident R1 did not have a current appraisal on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA and Licensee observation, the licensee did not comply with the section cited above in that kitchen drawer containing sharp knives not locked, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA and Licensee observation, the licensee did not comply with the section cited above in that a 64 ounce jug of bleach was accessible in the hallway shower which conained approximately 4 ounces remaining in the jug. Unlocked hallway closet had toxins accessible including acetone and disinfectants, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA and Licnsee observation the licensee did not comply with the section cited above because: med cart in living room to be unlocked, all medication accessible to residents, unlocked drawer in kitchen contained: prescription Tramodal, unwrapped syringe, and pre-poured medication in dishes, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA record review, the licensee did not comply with the section cited above in [1] out of [2t] staff (S1) did not have health screen, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA and Licensee observation, the licensee did not comply with the section cited above in that the drywall/sheet rock is missing from around shower spigot and pipe(s) exposed in resident's shower (R3) in room #1 which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA and Licensee observation, the licensee did not comply with the section cited above in that trash bins in residents rooms are not covered. Trash bin in resident room (R2) contained soiled brief for at least 2 days, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA and Licensee observation, the licensee did not comply with the section cited above in that syringe for insulin was found accessible in unlocked kitchen drawer. Syringe was unwrapped from packaging and possibly used, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA and Licensee observation, the licensee did not comply with the section cited above in that a plastic container on side of house was filled with brown liquid and old tools covered in orange and brown spots, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA observation and Licensee record review, the licensee did not comply with the section cited above in that facility has not conducted quarterly disaster drill since 2020, as documented in disaster drill paperwork. which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA record review, the licensee did not comply with the section cited above in [2] out of [2 ]staff (S1 and S2) which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA and Licensee observation, the licensee did not comply with the section cited above as LPA and Licensee observed unlocked drawer in kitchen to contain pre-poured medication in dishes. LPA and Licensee observed pillboxes in living room stacked on chair by the computer which contained medications, to be accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA and Licensee observation, the licensee did not comply with the section cited above in that opened food items in refrigerator were not covered or labeled including a cake, half of a tomato, bowl of red substance, and a cup of brown liquid, which poses/posed a potential health, safety or personal rights risk to persons in care.