Community Care Licensing

Document Has Been Signed on 11/16/2023 06:17 PM - It Cannot Be Edited

FACILITY NAME:	FLINTWOOD CARE HOME		FACILITY NUMBER:	019200727
ADMINISTRATOR:	HOLT, JEAN		FACILITY TYPE:	740
ADDRESS:	36614 FLINTWOOD DRIVE		TELEPHONE:	(510) 742-5680
CITY:	NEWARK	STATE: CA	ZIP CODE:	94560
CAPACITY: 6		CENSUS: 2	DATE:	11/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Jean Holt		TIME COMPLETED:	04:30 PM

SUPERVISORS NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023

Link to Parent Document Below:

FACILITY NAME: FLINTWOOD CARE HOME	FACILITY NUMBER: 019200727
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2023

Type A

Section Cited

CCR

87202(a)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: 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 in admitting a bedridden resident without an approved bedridden fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/17/2023
	Plan of Correction
1 2 3 4	Administrator will: 1) notify local fire department regarding bedridden resident 2) will submit request for bedridden fire clearance to LPA by POC date

Type A

Section Cited

CCR

87204(a)

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. 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 in admitting a bedridden resident without an approved bedridden fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/17/2023
	Plan of Correction
1 2 3 4	Administrator will notify local fire department regarding the bedridden resident staying in a nonambulatory room. Administrator will submit request for bedridden fire clearance.

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023

Link to Parent Document Below:

FACILITY NAME: FLINTWOOD CARE HOME	FACILITY NUMBER: 019200727
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2023

Type A

Section Cited

CCR

87411(d)

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review, the licensee did not comply with the section cited above in not providing training to staff which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Administrator will provide staff with training and submit proof to CCL by POC date.

Type A

Section Cited

CCR

87613(a)(2)(B)

(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs. (B) Training shall be completed prior to the staff providing services to the resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review, the licensee did not comply with the section cited above in not having proof of training for resident with catheterwhich poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/29/2023
	Plan of Correction
1 2 3 4	By POC date, staff will undergo training on catheter management and submit proof to CCL.

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023

Link to Parent Document Below:

FACILITY NAME: FLINTWOOD CARE HOME	FACILITY NUMBER: 019200727
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2023

Type A

Section Cited

CCR

87411(c)(1)

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review conducted, the licensee did not comply with the section cited above in having Administrator and caregiver working with expired First aid and CPR which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/24/2023
	Plan of Correction
1 2 3 4	Administrator and staff will complete First aid and CPR training and submit proof to CCL by POC date.

Type A

Section Cited

HSC

1569.626(a)

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review, the licensee did not comply with the section cited above in having staff work without any training completed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Administrator will have staff complete all required trainings and submit proof to CCL.

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023

Link to Parent Document Below:

FACILITY NAME: FLINTWOOD CARE HOME	FACILITY NUMBER: 019200727
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2023

Type A

Section Cited

HSC

1569.69(a)(4)

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (4) The training shall cover all of the following areas: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review, the licensee did not comply with the section cited above in having staff work without required medication training which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Administrator will have staff complete medication training and submit proof to CCL.

Type A

Section Cited

HSC

1569.69(d)

(d) Each residential care facility for the elderly that provides employee training under this section shall use the training material and the accompanying examination that are developed by, or in consultation with, a licensed nurse, pharmacist, or physician. The licensed residential care facility for the elderly shall maintain the following documentation for each medical consultant used to develop the training: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review, the licensee did not comply with the section cited above in having staff work/manage medications without passing examination which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Staff will complete training and pass examination. Proof of passing exam will be submitted to CCL.

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023

Link to Parent Document Below:

FACILITY NAME: FLINTWOOD CARE HOME	FACILITY NUMBER: 019200727
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2023

Type A

Section Cited

CCR

87606(c)

(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and file review, the licensee did not comply with the section cited above in admitting a bedridden resident without an approved fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/17/2023
	Plan of Correction
1 2 3 4	Administrator will submit request for bedridden fire clearance by POC date.

Type A

Section Cited

CCR

87606(f)(1)

(f) To accept or retain a bedridden person, a facility shall ensure the following: (1) The facility's Plan of Operation includes a statement of how the facility intends to meet the overall health, safety and care needs of bedridden persons. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review, the licensee did not comply with the section cited above in not having plan of operation updated to meet the overall needs of bedridden resident which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Administrator will submit updated plan of operation to CCL by POC date.

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023

Link to Parent Document Below:

FACILITY NAME: FLINTWOOD CARE HOME	FACILITY NUMBER: 019200727
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2023

Type B

Section Cited

HSC

1569.153(d)

(d) A written resident personal property inventory is established upon admission and retained during the resident’s stay in the residential care facility for the elderly. Inventories shall be written in ink, witnessed by the facility and the resident or resident’s representative, and dated. A copy of the written inventory shall be provided to the resident or the person acting on the resident’s behalf. All additions to an inventory shall be made in ink, and shall be witnessed by the facility and the resident or resident’s representative, and dated. Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility at the written request of the resident, the resident’s family, a responsible party, or a person acting on behalf of a resident. The facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory. A copy of a current inventory shall be made available upon request to the resident, responsible party, or other authorized representative. The resident, resident’s family, or a responsible party may list those items which are not subject to addition or deletion from the inventory, such as personal clothing or laundry, which are subject to frequent removal from the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review, the licensee did not comply with the section cited above in not having SPV for one resident which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Administrator will get SPV completed and submit to CCL a copy of the completed form.

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023

Link to Parent Document Below:

FACILITY NAME: FLINTWOOD CARE HOME	FACILITY NUMBER: 019200727
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2023

Type B

Section Cited

CCR

87308(c)

(c) General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage. 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 in using the shower room as storage for wheelchair and other supplies which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/29/2023
	Plan of Correction
1 2 3 4	Administrator will clear the shower room and submit photo proof to CCL.

Type B

Section Cited

CCR

87412(a)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review conducted, the licensee did not comply with the section cited above in not having complete personnel records which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/29/2023
	Plan of Correction
1 2 3 4	Administrator will review all staff files and ensure records are complete. Administrator will send self-certification stating all staff records are complete.

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023

Link to Parent Document Below:

FACILITY NAME: FLINTWOOD CARE HOME	FACILITY NUMBER: 019200727
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2023

Type B

Section Cited

HSC

1569.267(d)

(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on file review conducted, the licensee did not comply with the section cited above in not having proof of staff training on residents' rights which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Staff will undergo training on Residents' Rights and submit proof to CCL.

Type B

Section Cited

CCR

87219(a)

(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: 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 in not providing activities to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/15/2023
	Plan of Correction
1 2 3 4	Administrator will submit to CCL calendar of activities and ensure activities are provided to residents.

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023

Link to Parent Document Below:

FACILITY NAME: FLINTWOOD CARE HOME	FACILITY NUMBER: 019200727
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/16/2023

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 file review, the licensee did not comply with the section cited above in not conducting drills every quarter which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/29/2023
	Plan of Correction
1 2 3 4	Administrator will complete all the required drill and make sure the proof of training are on file. Administrator will submit to CCL proof.

Type B

Section Cited

HSC

1569.695(e)(2)

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. 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 in not having Appraisal Needs and Services for one resident which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/29/2023
	Plan of Correction
1 2 3 4	Administrator wil complete needs and services plan for the resident and submit a copy to CCL by POC date.

SUPERVISOR'S NAME: Yvonne Flores-Larios LICENSING EVALUATOR NAME: Luisa Fontanilla LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023