The Residence at Dean Llc

Request a transfer of criminal record clearance

Based on observation and record review, the licensee did not comply with the section cited above as 1 (one) staff (Staff #1 - S1) does have criminal record clearance, but was not associated to this facility and has been working at this location for at least 2 (two) months, which poses an immediate health, safety or personal rights risk to persons in care.

Notification to department after hospice care starts

Based on record review, the licensee did not comply with the section cited above as Resident #2 (R2) was admitted to the facility on 04/01/2025 and was admitted to hospice care on the same date, but no notification was received at CCL indicating a resident is receiving hospice services, which poses a potential health, safety or personal rights risk to persons in care.

Maintain physician order documentation in resident record

Based on record review, the licensee did not comply with the section cited above in 2 (two) of 2 (two) residents have half bedrails on their beds and neither resident had written physician's orders indicating the need for bed rails which poses a potential personal rights risk to persons in care.

Certified administrator requirements and substitute coverage

Based on observation and interview the licensee did not comply with the section cited above as the administrator is scheduled to be present M-F 09:00AM-01:00PM, however has not been present at any time when LPA has visited the facility, which poses a potential health, safety or personal rights risk to persons in care.

Maintain required personnel records for staff

Based on record review, the licensee did not comply with the section cited above as Administrator's file is not complete and/or present at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Require physician order and label for PRN medication

Based on observation and record review, the licensee did not comply with the section cited above as Resident #1 (R1) had over the counter medications and no prescription orders for these medications, which poses a potential health and safety risk to persons in care.

Keep prescriptions in original containers

Based on observation, the licensee did not comply with the section cited above in 2 (two) of 2 (two) residents' medications observed were prepared in advance for 9 (nine) days and stored in weekly medication boxes, which poses an immediate health and safety risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above in as the 1 (one) overnight staff, who is scheduled to work 7 (seven) days a week does not have CPR or first aid training, which poses a potential health, safety or personal rights risk to persons in care.

Maintain fire clearance before retaining specified persons

Based on observation and record review, the licensee did not comply with the section cited above as the fire clearance does not include a converted garage/staff room, and the facility fire extinguisher has not been serviced annually, which poses an immediate health and safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as Administrator is not present in the facility and no other staff files reviewed had annual medication training (last training was initial training in 2022 or 2023,) which poses an immediate health and safety risk to persons in care.

87217 Safeguards for Resident Cash, Personal Property, and Valuables (j) Upon the death of a resident, all cash resources, personal property, and valuables of that resident shall immediately be safeguarded.This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as R1 did not have a record of any items brought into the facility, nor were items safeguarded or documented upon R1's death, which posed a potential personal rights risk to persons in care.

Report specified resident events within seven days

87211 Reporting Requirements (a) (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...if any; and disposition of the case.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the above cited section, as no incident or death reports from the date of licensure to the present time have been received at CCLand there were at least 2 (two) deaths and a fall incident, which poses a potential safety risk to persons in care.

87507 Admission Agreements (g) (5) (A) Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the above cited section, as the facility's Admission Agreement states residents on hospice care will not receive a refund, which is not allowed per regulation and poses a potential personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on LPA's observation, the licensee did not comply with the section cited above in three out of three areas of concern - bathroom, kitchen, laundry cabinets left unlocked with cleaning detergents/chemicals accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.

Address and clearance obligations before facility work

Based on record review, the licensee did not comply with the section cited above in one out of seven staff; S1 does not have a criminal record clearance, which poses an immediate health, safety or personal rights risk to persons in care.

Include required health screening documents

Based on record review, the licensee did not comply with the section cited above in one out of seven staff who did not have a health screening on file, which poses a potential health, safety or personal rights risk to persons in care.

Maintain admission agreement and appraisal

Based on record review, the licensee did not comply with the section cited above as one out of four residents (R1) were missing a pre-admission apprasaisal and four residents were missing their appraisal/needs and services plan which poses a potential health and safety risk to persons in care.

Based on interview and record review the licensee did not comply with the section cited above as quarterly disaster drills were not documented for any shift which poses a potential health and safety risk to persons in care.