Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
01/17/2025
Section Cited
CCR
87468.2(a)(4) | 1
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7 | 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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7 | Administrator stated they will provided a new schedule with staff that is able to communicate with residents in care. Schedule will be submitted to CCL by POC date. |
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14 | This requirement was not met as evidence by: LPA observation and interviews conducted. Observation of S1 and S2 utilizing a translation device to communicate with residents, visitors and other staff. | 8
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13
14 | |
Type B
01/17/2025
Section Cited
CCR
87211(a)(1)(D) | 1
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7 | 87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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 specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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7 | Administrator stated they will complete training with all staff on reporting requirements. In-service sign in sheet and training material will be provided to CCL by POC date. |
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14 | This requirement was not met as evidence by: interviews conducted and review of SIR’s. Interview with staff indicated an incident with R1 and R2 in a physical altercation. Review of SIR’s did not show the facility reported this incident to CCL or other appropriate parties. This poses a potential health, safety and or personal right risk to residents in care. | 8
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14 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
01/17/2025
Section Cited
HSC
1569.619(c)(2) | 1
2
3
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5
6
7 | 1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (2) Ensure the health, safety, comfort, and supervision of the residents.
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7 | Admnistrator stated they will provide all staff training on personal rights, monitoring residents and redirecting residents. 2 staff will be placed on the schedule at all times. In-service sign in sheet and training material will be provided to CCL by POC date. |
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14 | This requirement was not met as evidence by: interviews conducted. Interviews indicated staff did not prevent R2 from going into R1’s bedroom and physically attacking R1. This poses a potential health, safety and or personal rights risk to residents in care. | 8
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