Community Care Licensing

Document Has Been Signed on 03/19/2024 02:03 PM - It Cannot Be Edited

FACILITY NAME:	JEWEL HOMECARE 1		FACILITY NUMBER:	306005501
ADMINISTRATOR:	PAO, WESLEY		FACILITY TYPE:	740
ADDRESS:	5111 HAMER LN		TELEPHONE:	(424) 270-4452
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY: 6		CENSUS: 6	DATE:	03/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Nemecio Masone Wesley Pao		TIME COMPLETED:	02:20 PM

SUPERVISORS NAME: Armando J Lucero LICENSING EVALUATOR NAME: Claudia Gutierrez LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024

Link to Parent Document Below:

FACILITY NAME: JEWEL HOMECARE 1	FACILITY NUMBER: 306005501
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2024

Type A

Section Cited

CCR

87465(a)(6)

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, AD interview, and record review, the licensee did not comply with the section cited above in four out of four client records, as they do not contain a centrally stored medication record, which poses an immediate health, safety and personal rights risk to persons in care.
	POC Due Date: 03/20/2024
	Plan of Correction
1 2 3 4	AD stated they will maintain a record of centrally stored medication and keep it up to date. AD stated staff training will conducted to ensure records are accurately maintained. LPA will made an additional visit to ensure POC has been met.

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 and staff interview, the licensee did not comply with the section cited above as various prescription medications were observed on the kitchen counter, in an unlocked kitchen drawer and in an unlocked kitchen cabinet, which poses an immediate health, safety and personal rights risk to persons in care.
	POC Due Date: 03/20/2024
	Plan of Correction
1 2 3 4	AD stated all medication will be centrally stored and mainitained in a locked cabinet. Medication management training will be provided to staff. LPA will make an additional visit to ensure POC has been met.

SUPERVISOR'S NAME: Armando J Lucero LICENSING EVALUATOR NAME: Claudia Gutierrez LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024

Link to Parent Document Below:

FACILITY NAME: JEWEL HOMECARE 1	FACILITY NUMBER: 306005501
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2024

Type B

Section Cited

CCR

87303(e)(3)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. 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 two out of two bathroms taps which poses a potential safety risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	AD stated in lieu of warning signs, water temperature will be adjusted to be between 105 and 120. AD stated water temperature will be monitored on an ongoing basis to ensure temperature is maintained below 125. LPA will make an additional visit to ensure POC has been met.

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 observation, AD interview, and record review, the licensee did not comply with the section cited above as staff records indicate staff has not had training in the past two years, which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	AD stated staff training will be conducted immediately to meet regulation requirement. AD will provide LPA with proof of staff training conducted via email by POC date.

SUPERVISOR'S NAME: Armando J Lucero LICENSING EVALUATOR NAME: Claudia Gutierrez LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024

Link to Parent Document Below:

FACILITY NAME: JEWEL HOMECARE 1	FACILITY NUMBER: 306005501
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2024

Type B

Section Cited

HSC

1569.696(a)

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, AD interview, and record review, the licensee did not comply with the section cited above as AD was unable to provide any documentation of staff training conducted, which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	AD stated staff training will be conducted immediately to meet regulation requirement. AD will provide LPA with proof of staff training conducted via email by POC date.

Type B

Section Cited

HSC

1569.69(a)(2)

(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: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, AD interview, and record review, the licensee did not comply with the section cited above as AD was unable to provide any documenation of initial staff training conducted, which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	AD stated intial staff training was conducted and has been completed and stated documentation will be provided to LPA via email by POC date.

SUPERVISOR'S NAME: Armando J Lucero LICENSING EVALUATOR NAME: Claudia Gutierrez LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024

Link to Parent Document Below:

FACILITY NAME: JEWEL HOMECARE 1	FACILITY NUMBER: 306005501
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2024

Type B

Section Cited

CCR

87465(h)(5)

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and staff interview, the licensee did not comply with the section cited above as six out of six resident rountine medications are pre-poured into a weekly medication organizer a week in advanced, which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	AD stated medication will no longer be prepared a week in advance and weekly medication organizer will no longer be used, medication will be maintained in its originally received container and medication management training will be conducted. AD will provide LPA with proof of staff training conducted via email by POC date.

Type B

Section Cited

CCR

87463(a)

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in two out of two resident files which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	AD stated they will update all appraisals as needed and as frequently as necessary. AD will provide LPA with a copy of re-appraisals for residents via email by POC date.

SUPERVISOR'S NAME: Armando J Lucero LICENSING EVALUATOR NAME: Claudia Gutierrez LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024

Link to Parent Document Below:

FACILITY NAME: JEWEL HOMECARE 1	FACILITY NUMBER: 306005501
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/19/2024

Type B

Section Cited

CCR

87463(c)

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, AD interview, record review, the licensee did not comply with the section cited above in two out of two resident records, which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	AD stated they will arrange a meeting when there is a significant change in residents' condition, or once every 12 months, whichever occurs first, AD will provide LPA with proof of POC via email by POC date.

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 AD interview and record review, the licensee did not comply with the section cited above as disaster drills are not being documented which poses a potential health and safety risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	AD stated a record will be maintained of disaster drills conducted and will provide LPA with a copy via email by POC date.

SUPERVISOR'S NAME: Armando J Lucero LICENSING EVALUATOR NAME: Claudia Gutierrez LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024

FACILITY NAME: JEWEL HOMECARE 1	FACILITY NUMBER: 306005501
	VISIT DATE: 03/19/2024