Varenita of Westlake

Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1...residents...shall have all of the following personal rights: (8) To be free from...financial exploitation...This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as S1 financially exploited R1 which posed an immediate health, safety, or personal rights risk to R1.

Based on record review, the licensee did not comply with the section cited above as fire extinguishers were not serviced within the last 12 months which poses a potential health, safety or personal rights risk to persons in care.

87303 Maintenance and Operation(i) Facilities shall have signal systems which shall meet the following criteria:(1) All facilities licensed for 16 or more...shall have a signal system which shall:This requirement is not met as evidenced by: Based on interviews, the licensee did not comply as R1 was without a pendant for a period of time which posed a potential health, safety, and personal rights risk to person(s) in care.

Based on record review, the licensee did not comply with the section cited above in that six (6) of six (6) staff were missing 40 hours initial and 20 hours annual training which poses a potential health, safety and personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in that cleaning solutions and scissors were stored accessible to residents with dementia which poses a potential health and safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that three (3) out of six (6) staff did not have First Aid training which poses a potential health and safety rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that two (2) staff members did not have a transfer of criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.

87468.1 Personal Rights of Residents in All Facilities.(a) Residents in all RCFE..shall have all of the followingpersonal rights (11)To have their visitors, including ombudspersons and... permitted to visit privately during reasonable hours and without prior notice...This requirement is not met as evidenced by: Based on interviews review, the licensee did not comply with the section cited above, as one visitors were prevented from visiting R1, which poses a potential health, safety or personal rights risk to persons in care.

Based on record review and interviews, the licensee did not comply with the section cited above in five out of five staff files indicate staff did not complete annual required training which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review and interviews, the licensee did not comply with the section cited above in that one out of five staff files reviewed indicate that staff was not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, record review and interviews, the licensee did not comply with the section cited above in medications were found in resident's room and resident's LIC 602 indicates resident cannot store/administer medications which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review and interviews, the licensee did not comply with the section cited above in that One out of five staff files reviewed indicate staff do not have documentation showing negative TB tests which poses an immediate health, safety or personal rights risk to persons in care.

87355(e)(2) Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2) Request a transfer of a criminal record clearance…This requirement is not met as evidenced by: Based on interviews and observations, the licensee did not comply with the section cited above, as one individual (S1) have been working at the facility without a criminal record transfer, which poses an immediate health and safety risk to residents in care.

87307(e) Personal Accommodations and Services. Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools, or similar bodies of water...through fencing, covering or other means. This requirement is not met as evidenced by:Based on observation, the licensee did not comply with the section cited above as the facility had water fountains in the courtyard and in front of the building filled with standing water, which poses an immediate health and safety risk to persons in care.

87468.1(a)(2) Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement was not met as evidenced by: Based on observations and interview, the licensee did not comply with the section cited above, as staff and guests within the community were not wearing face masks in the facility, which poses a potential personal rights risk to residents in care.