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Inspection visit

Non-compliance follow-up

BETSY'S II RCFELicense 49680205213 citations on this visit
13 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analysts (LPAs) Christi Coppo and Robert Frank arrived unannounced to conduct a Non-compliance and was greeted by Administrator Luningning Alicdan. On of 7/31/2024 licensee agreed to be on a Non-Compliance plan. The areas of concern were identified as: · Administrator Duties and Plan of Operation · Staff Training · Resident and staff records · Resident Care and Personal Rights · Insufficient Staffing · Failure to clear deficiencies timely · Medication Management · Failure to follow through with TSP Licensee was to ensure the following: · Follow through with responding to and participating with the Technical Support Program · Ensure compliance with areas including, but not limited to, staff training records, maintaining staff and resident records and pre-pouring of medication. · Ensuring personal rights of residents in care and ensuring resident needs are met. Continued on 809-C... Continued from 809... Today, LPAs conducted the Non-Compliance inspection. Licensee found to be in compliance as pertains to responding to and participating with the Technical Support Program. LPAs reviewed records pertaining to compliance with areas including staff training records, maintaining staff and resident records, and pre-pouring of medication. Staff members S1, S2 and S3 did not required hours of training on file (deficiency cited, see 809D ). S3, S4, and S5 did not have Health Screens on file ( deficiency cited, see 809D ).R1, R2, R3, R4, and R5 all did not have current appraisals on file ( deficiency cited, see 809D ). LPAs conducted interviews and made observations pertaining to Admin's ensuring of personal rights of residents in care and ensuring resident needs are met. Prescription and PRN medications were observed to be unsecured in the following rooms 10, 8, and 9. LPAs also observed there were unsecured medications and sharps (lancets), as well as sharps disposal container, in the cabinet next to the dining room table (deficiency cited, see 809D ). LPAs observed prescription medication had its label partially removed in R3's room number four (4) ( deficiency cited, see 809D ). LPAs observed golf ball sized bruised knot on R4's left hand side forehead. R4 reported that they fell and hit their head but that it doesn't hurt. Admin advised that R4's POA decided R4 did not need to go to the hospital. LPAs advised Admin that facility must call EMS and let them determine if the resident needs to have medical attention, if the resident then refuses that is their right but the EMS must be called first. LPAs also advised that an Incident Report must be submitted for any incident which threatens the welfare, safety or health of any resident, R3 reported to LPAs that two [2] times since New Year's Eve the Admin had to call 911 to help them with breathing issues. However, per LPAs' observation, no Incident report was submitted reporting the emergency services for R3. Admin could not produce an Incident report for either R3 or R4 ( deficiency cited, see 809D ) LPAs observed an oxygen tank in storage closet that was not secured to the wall or in an oxygen cradle ( deficiency cited, see 809(D ). LPAs observed that the hot water was both below and above the Title 22 regulation of being between 105 and 120 degrees F in room seven (7) and one (1) ( deficiency cited, see 809D ). Continued from 809-C LPAs observed door to laundry room from facility unlocked; LPAs observed unsecured cleaning products in metal cabinet found unlocked in laundry room ( deficiency cited, see 809D ). In the laundry room LPAs observed a large container of eggs on a shelf that were left unrefrigerated ( deficiency cited, see 809D ). LPAs observed an open can of cat food that was moldy in room three (3). LPA's observed an HVAC intake vent in the front hallway that was covered in dust/dirt and a grease like substance. LPAs observed many small unsealed or tied trash bags full of soiled incontinence briefs in laundry room with eggs ( deficiency cited, see 809D ). LPAs observed an extremely strong urine odor in room five (5) and odor in room two [2B] ( deficiency cited, see 809D ). LPAs observed S6 to be providing care to residents. S6 has fingerprint clearance and is associates to the facility; however there is no file on premises for S6. Admin explained S6 is their family member and is now living here. LPAs advised that all staff providing care to residents must have training, Health Screen and TB clearance on file as well as First Aid/CPR. Admin provided LIC500 to LPAs which indicated Admin is scheduled Monday-Friday 1pm-3pm and Monday-Friday 7pm-7am. LPAs advised that Admin duties must performed on business days within business hours such that they 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. Admin advised LPAs that they are very close to closing escrow with a buyer for the facility. LPAs advised residents will need a 60 day notice and it will need to be submitted to CCL as soon as issued. Admin to contact LPA for further instructions on required items for change of facility ownership. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given. .

Citations

13 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 1569.625(b)(2)Type A

    §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 not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that S1, S2 and S3 did not required hours of training on file, which poses an immediate health, safety or personal rights risk to persons in care.

  • 87211(a)(1)Type B

    87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency ...(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 of any of the events specified in (A) through (D) below... This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that licensee did not submit to CCL an Incident Report for R3 or R4 after they experienced incidents that required one be submitted, which poses a potential health, safety or personal rights risk to persons in care.

  • 87303(a)Type A

    87303 Maintenance and Operation(a)The facility shall be clean, safe, sanitary and in good repair at all times...This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPAs observed intake vent in front hallway covered in dust/dirt and a grease like substance, which poses an immeidate health, safety or personal rights risk to persons in care.

  • 87303(e)(2)Type A

    87303 Maintenance and Operation (e)Water supplies and plumbing fixtures shall be maintained...(2)Faucets used by residents...shall deliver hot water...of not less than 105 degree F and not more than 120 degree F. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in thatwhich poses an immeidate health, safety or personal rights risk to persons in care.

  • 87303(f)Type B

    87303 Maintenance and Operation(f)All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPAs observed unsealed/ tied trash bags full of soiled incontinence briefs in laundry room with eggs, which poses an potential health, safety or personal rights risk to persons in care.

  • 87309(a)Type A

    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 not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that door to laundry room from facility unlocked; LPAs observed unsecured cleaning products in metal cabinet found unlocked in laundry room, which poses an immediate health, safety or personal rights risk to persons in care.

  • 87411(f)Type B

    87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health...Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test...This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that S3, S4, and S5 did not have Health Screens on file, which poses a potential health, safety or personal rights risk to persons in care.

  • 87463(a)Type B

    87463 Reappraisals (a) The pre-admission appraisal...shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first...For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that R1, R2, R3, R4, and R5 all did not have current appraisals on file,which poses a potential health, safety or personal rights risk to persons in care.

  • 87465(h)(2)Type A

    87465 Incidental Medical and Dental 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... This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that prescription and PRN medications were accessible to residents in rooms 10, 8, 9, and in dining and laundry room, which poses a potential health, safety or personal rights risk to persons in care.

  • 87465(h)(4)Type B

    87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored:(4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that R3's prescription medication had it's label partially removed, which poses a potential health, safety or personal rights risk to persons in care.

  • 87555(b)(23)Type B

    87555 General Food Service Requirements(b) The following food service requirements shall apply:(23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation large container of eggs left on a shelf unrefrigerated in laundry room, which poses a potential health, safety or personal rights risk to persons in care.

  • 87618(b)(3)(E)Type B

    87618 Oxygen Administration ...the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation oxygen tank in storage closet not secured to wall or in cradle, which poses a potential health, safety or personal rights risk to persons in care.

  • 87625(b)(3)Type B

    87625 Managed Incontinence(b)...the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPAs observed an extremely strong urine odor in room five (5) and odor in room two [2B], which poses a potential health, safety or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the April 24, 2025 inspection of BETSY'S II RCFE?

This was a other inspection of BETSY'S II RCFE on April 24, 2025. 13 citations were issued: 5 Type A (serious) and 8 Type B.

Were any citations issued to BETSY'S II RCFE on April 24, 2025?

Yes, 13 citations were issued (5 Type A, 8 Type B). The first citation was for: "§1569.625 Staff training; legislative findings; contents (b)(2) In addition to paragraph (1), training requirements sha..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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