Carlton Plaza of Davis

Clean linen quantity and hygiene supplies

Clean linen quantity and hygiene supplies

Clean linen quantity and hygiene supplies

87608 Postural Supports (a)...Postural supports may be used under the following conditions. (1) ....used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc.This requirement not met by licensee as evidenced by: LPA observation of bench and postural support used as a restraint, which poses a potential health, safety or personal rights risk to persons in care.

Facility personnel sufficiency and competence

87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by: Based on incident report and interview, facility failed to maintain line of sight, which was a lack of supervision to R1 resulting in an elopement. The absence of supervision is an immediate risk to the Health, Safety and Rights of resident in care.

Facility personnel sufficiency and competence

87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to meet resident needs.....for the provision of adequate services. This requirement was not met as evidenced by: Based on interviews and record review,LPA observed Call Light logs from January 20, 20253 through February 19, 2025 in which residents would push the call buttons and the response times were exceeding over 60+ minutes. This is a potential health, safety and personal rights risk to the residents in care.

Health and Safety Code section 1569.2(b):(b) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement was not met as evidenced by: Based on interviews, staff ignored company policy of using 2-person assist when care plan called for a 2-person assist and worked independently, not waiting for assistance.

Facility personnel sufficiency and competence

87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidence by: Based on incident report and interview, facility failed to provide supervision to R1 resulting in an elopement. The absence of supervision is an immediate risk to the Health, Safety and Rights of resident in care.

Report serious outbreaks and major accidents

87211 (a)A written report shall be submitted to the licensing agency...within seven days of the occurrence of.. (2)Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidenced by: Based on reporting records Licensee did not report outbreak within the required 24 hours.

(a) Residents…shall have…the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff…sufficient in number… **Based on records reviewed & interviews facility didn't comply w/reg above when R1 accessed patio unsupervised, fell, and sustained injury which posed an immediate risk to the health and safety of residents in care.**Immediate civil penalty of $500.00 was issued today for serious bodily injury.

Reporting requirements

87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency such reports as the Department may require...:(1)A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events specified... This report shall include the resident's name, age, sex and date of admission; date d disposition of the case.(B)Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement is not met as evidenced by: **Based on records reviewed which indicate that Incident Report was not sent in timely manner which poses a possible threat to the health and safety of residents in care.

Maintain facility in clean, safe, sanitary condition

87303 Maintenance and Operation:(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors… This requirement has not been met as evidenced by: Based on repair records lighting in patio area of Memory Care went unrepaired and contributed to the fall and injury of R1. This posed an immediate risk to the health and safety of the resident.

Clean linen quantity and hygiene supplies

87307 Personal Accommodations andServices (a)(3)(a)...Living accommodations..The following provisions shall apply:(3) Equipment... personal care and maintenance...each resident...provide the following.. (C)Clean linen, including... bottom bed sheets,...The linen shall be in good repair. This requirement has not been met as evidence by:Based on photos, observation, Licensee failed to provide the resident required bottom bed sheet in 2 out of 2 days which poses a potential health, safety, and personal rights risk to clients in care.

87470 Infection Control Requirements(b) (2)All staff...providing direct care to resident who has a communicable disease shall wear appropriate... PPE ...(B)PPE shall be...discarded in the nearest... receptacle with... immediately upon completing a task.This requirement has not been met as evidence by: Based on photos, observation, interviews and record review Licensee did not follow mandated guidance of mitigation plan and failed to discard PPE in a tightly-lidded container as required which poses a potential health, safety, and personal rights risk to clients in care.