Community Care Licensing

Document Has Been Signed on 01/27/2024 08:24 PM - It Cannot Be Edited

FACILITY NAME:	C & R HOME FOR THE ELDERLY		FACILITY NUMBER:	015600507
ADMINISTRATOR:	TEOFILO CRIS SANQUE		FACILITY TYPE:	740
ADDRESS:	34819 CLOVER STREET		TELEPHONE:	(510) 324-0627
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY: 6		CENSUS: 5	DATE:	01/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Precilla San Miguel/Licensee-Administrator		TIME COMPLETED:	08:30 PM

SUPERVISORS NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2024

FACILITY NAME: C & R HOME FOR THE ELDERLY	FACILITY NUMBER: 015600507
	VISIT DATE: 01/27/2024

Link to Parent Document Below:

FACILITY NAME: C & R HOME FOR THE ELDERLY	FACILITY NUMBER: 015600507
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2024

Type A

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for peritoneal cleanser in one of the resident's bedrooms and razor and ointment in the common bathroom, and staff bedroom with vitamins/sipplements unlocked which pose an immediate health, safety and/or personal rights risk to persons in care.
	POC Due Date: 01/28/2024
	Plan of Correction
1 2 3 4	Staff locked the items. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 1/28/24.

Type A

Section Cited

CCR

87465(h)(1)(C)

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for the following which pose immediate health and/or personal rights risks to persons in care: refrigeratorr in staff room where resident's medication are kept was unlocked; unlocked kitchen cabinet where other residents medication are kept
	POC Due Date: 01/29/2024
	Plan of Correction
1 2 3 4	Staff locked the room and cabinet. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 1/28/24.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2024

Link to Parent Document Below:

FACILITY NAME: C & R HOME FOR THE ELDERLY	FACILITY NUMBER: 015600507
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2024

Type A

Section Cited

CCR

87465(h)(2)

(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 responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above for unlocked central storage for medications which pose an immediate health, safety and/or personal rights risk to persons in care.
	POC Due Date: 01/28/2024
	Plan of Correction
1 2 3 4	Staff locked the storage. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 1/28/24.

Type A

Section Cited

CCR

87465(e)

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in resident (R2) has 8 medications with no doctor's order on file.which poses an immediate health and/or personal rights risk to persons in care.
	POC Due Date: 01/28/2024
	Plan of Correction
1 2 3 4	Administrator stated she'll obtain doctor's order. Copy to be submitted by 1/28/24.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2024

Link to Parent Document Below:

FACILITY NAME: C & R HOME FOR THE ELDERLY	FACILITY NUMBER: 015600507
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2024

Type B

Section Cited

CCR

87355(e)(3)

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above for S3 not associated to the facility which poses a potential safety and/or personal rights risk to persons in care.
	POC Due Date: 02/10/2024
	Plan of Correction
1 2 3 4	Administrator to have the staff associated and submit proof by 2/10/24.

Type B

Section Cited

HSC

1569.625(b)(2)

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review)], the licensee did not comply with the section cited above for staff (S2) not having the required 20 hours annual training on file which poses a potential health, safety and/or personal rights risk to persons in care.
	POC Due Date: 02/10/2024
	Plan of Correction
1 2 3 4	Administrator to have the staff complete the required training and submit proof by 2/10//24.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2024

Link to Parent Document Below:

FACILITY NAME: C & R HOME FOR THE ELDERLY	FACILITY NUMBER: 015600507
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2024

Type B

Section Cited

HSC

1569.319(a)

(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, the licensee did not comply with the section cited above for not having internet service poses a potential personal rights risk to persons in care.
	POC Due Date: 02/10/2024
	Plan of Correction
1 2 3 4	Administrator stated she'll have internet service. Proof to be submitted by 2/10/24.

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and reord review, the licensee did not comply with the section cited above for not conducting disaster drills as required which poses/posed a potential safety risk to persons in care.
	POC Due Date: 02/10/2024
	Plan of Correction
1 2 3 4	Administrator stated she'll have drills conducted. Proof to be submitted by 2/10/24.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2024

Link to Parent Document Below:

FACILITY NAME: C & R HOME FOR THE ELDERLY	FACILITY NUMBER: 015600507
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2024

Type B

Section Cited

CCR

87705(c)(6)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and recorda review, the licensee did not comply with the section cited above in residents' (R1, R2 & R3) LIC625 over a year old. which pose a potential health and/or personal rights risk to persons in care.
	POC Due Date: 02/10/2024
	Plan of Correction
1 2 3 4	Administrator stated she'll complete the appraisal. Self-certification to be submitted by 2/10/24.

Type B

Section Cited

CCR

87705(c)(5)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in residents (R1,R2, & R3) LIC602A over a year old .which pose a potential health and/or personal rights risk to persons in care
	POC Due Date: 02/10/2024
	Plan of Correction
1 2 3 4	Administrator to have doctor's appointment scheduled and update the LIC602As. Self-certification to be submitted by 2/10/24.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2024

Link to Parent Document Below:

FACILITY NAME: C & R HOME FOR THE ELDERLY	FACILITY NUMBER: 015600507
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2024

Type B

Section Cited

CCR

87411(f)

87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition .. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in S2 and S3 not having LIC503 Health Screening on file which poses a potential health risk to persons in care.
	POC Due Date: 02/10/2024
	Plan of Correction
1 2 3 4	Administrator to have the staff health screened and submiit copies of LIC503s by 2/10/24.

Type B

Section Cited

CCR

1569.625(b)(1)

§1569.625 Staff training; legislative findings; contents (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents....... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for S3 not having the required hours of training completed which poses a potential health, safety and/or personal rights risk to persons in care.
	POC Due Date: 02/10/2024
	Plan of Correction
1 2 3 4	Admimistrstor stated she'll have the training completed. Self-certification to be submitted by 2/10/24.

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2024

Link to Parent Document Below:

FACILITY NAME: C & R HOME FOR THE ELDERLY	FACILITY NUMBER: 015600507
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/27/2024

Type B

Section Cited

CCR

87506(a)

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above for R2's medications not properly records on LIC622 which poses a potentiial personal rights risk to persons in care
	POC Due Date: 02/10/2024
	Plan of Correction
1 2 3 4	Administrator to have the LIC622 corrected and submit self-certification by 2/10/24.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Bennett Fong LICENSING EVALUATOR NAME: Alicia Delmundo LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2024