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Inspection visit

Routine inspection

EMBRACING SENIORSLicense 5658024644 citations on this visit
4 citations recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Zabel Chochian conducted a Required annual visit to the above facility. Upon arrival LPA met with staff and reason for visit was explained. Staff contacted Administrator Joseph Trupiano by phone. Mr. Trupiano was informed that LPA will be conducting the Annual inspection today. Mr. Tupiano stated that he is unable to be at the facility today due to transportation issues and informed LPA that staff designated will assist LPA with the Annual visit and sign for the report. A tour of the physical plant was conducted with staff at approximately 12:15pm. LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following was noted: Smoke detectors and Carbon Monoxide detectors were tested and functioned properly during time of visit. Fire extinguishers were observed to be fully charged with service tag dated 9/13/2023. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects are stored in a locked drawer. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms . Sufficient amounts of supplies for personal hygiene observed. Common Areas : These included the living room and dining area; areas observed clean; furniture in good condition. Surrounding Grounds (Outdoors): There is a shaded area with proper furniture for outdoor use. No bodies of water on the premises. Staff files reviewed approximately 1pm observed to be complete with required documentation such as health screenings, updated first aid/CPR certifications, required annual training and all other pertinent documents required. Staff training records lack start time and information on what material was used for the training. Technical violation issued. (Continue to LIC809C) All resident files reviewed at approximately 1:45pm observed to be complete with required documentation such as admission agreements, updated physician reports, appraisals, and physicians orders for bed rails. Residents' needs and services plan reviewed observed three (3) out of four (4) plans on file were not signed by resident/resident responsible person. Discussed with Licensee, technical violation issued for this violation. Medications and medication records reviewed from approximately 1:45pm-3pm. Medications observed stored in locked cabinet. Centrally stored logs reviewed observed to be complete/accurate with medications on hand. One out of four residents medications and medication records reviewed revealed that R3 is taking PRN medication and it is indicated by the physician that R3 is unable to clearly communicated and clearly state symptoms for the PRN need. Staff do not have record of contacting physician before providing PRN medication. Tis was discussed with Licensee. Deficiency issued for this violation. Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. Today's reports and appeal rights were discussed with Licensee over the phone. Copy of report provided.

Citations

9 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.

  • 87211(a)(1)(B)Type B

    (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted...... within seven days of the occurrence of any of the events specified in.....(B) Any serious injury....while the resident is under facility supervision. This requirement is not met as evidenced by: Based on interviews and records review, licensee did not comply with the section cited above. No evidence or confirmation that the licensee submitted the 5/12/2023 SIR, dated 05/25/2023, to CCL. Licensee did not submit an SIR for R1’s fall , which posed a potential health and safety risk to residents in care.

  • 87465(a)(1)Type A

    (a) A plan for incidental medical and dental care shall be developed by facility. The plan shall encourage routine medical and dental care.... (1) The licensee shall arrange.....for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews and medical records, the licensee did not comply with the section cited above. The licensee did not seek medical attention when R1’s pressure injuries progressively worsened, which posed an immediate health and safety risk to residents in care.

  • 87615(a)(5)Type A

    (a) Persons who require health services for or have a health condition including, but not limited to, those specified....(5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities. This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. The licensee retained R1 who depended on others to perform all activities of daily living, which posed an immediate health and safety risk to residents in care.

  • 87632(d)(2)Type B

    (d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver....... (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally Ill resident.....This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. There is no evidence/confirmation that the licensee submitted a notification for R1’s 05/24/2023 initiation of hospice care services, which posed a potential health and safety risk to residents in care.

  • 1569.695(d)Type B

    Based on record review, the licensee did not comply with the section cited above. Facility emergency disaster plan was not reviewed/updated. This poses a potential health, safety or personal rights risk to persons in care.

  • 87465(d)(1)Type B

    Based on record review, the licensee did not comply with the section cited above. One (1) out of four (4) resident records reviewed observed with PRN medication on hand which was indicated by physician that R3 is unable to determine his/her own need for the PRN medication, and is unable to communicate his/her symptoms clearly. Licensee/staff do not have record of physician contact made prior to administering PRN medication. This poses a potential health, safety risk to persons in care.

  • 87465(d)(2)Type B

    Based on record review, the licensee did not comply with the section cited above. One (1) out of four (4) resident records reviewed observed with PRN medication on hand which was indicated by physician that R3 is unable to determine his/her own need for the PRN medication, and is unable to communicate his/her symptoms clearly. Licensee/staff do not have record of contacts made prior to administering PRN medication. This poses a potential health, safety risk to persons in care.

  • 87609(b)(4)Type B

    Based on interview and observation, the licensee did not comply with the section cited above. R1 is receiving home health services in the facility. No agreement between licensee and home health agency observed on file. This pose a potential health, safety or personal rights risk to persons in care.

  • 87468.2(a)(4)Type A

    (4)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 is not met as evidenced by: Based on medical records, photos, and interviews, licensee did not comply with the section cited. Staff did not provide the necessary care and supervision resulting in R1 sustaining pressure injuries and bruising while in care, which posed an immediate health and safety risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the March 27, 2024 inspection of EMBRACING SENIORS?

This was a inspection inspection of EMBRACING SENIORS on March 27, 2024. 4 citations were issued: 4 Type B.

Were any citations issued to EMBRACING SENIORS on March 27, 2024?

Yes, 4 citations were issued (0 Type A, 4 Type B). The first citation was for: "(a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted...... wit..."

What type of inspection was this?

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

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.