Community Care Licensing

Document Has Been Signed on 01/11/2024 01:09 PM - It Cannot Be Edited

FACILITY NAME:	A1SENIOR CARE		FACILITY NUMBER:	312700395
ADMINISTRATOR:	TACANDONG, DAISYREE		FACILITY TYPE:	740
ADDRESS:	217 HINGHAM CT		TELEPHONE:	(916) 740-7715
CITY:	ROSEVILLE	STATE: CA	ZIP CODE:	95747
CAPACITY: 6		CENSUS: 6	DATE:	01/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Daisyree Tacandong, Administrator		TIME COMPLETED:	01:30 PM

SUPERVISORS NAME: Troy Ordonez LICENSING EVALUATOR NAME: Bethany Mirlohi LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024

Link to Parent Document Below:

FACILITY NAME: A1SENIOR CARE	FACILITY NUMBER: 312700395
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/11/2024

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 record review, the licensee did not comply with the section cited above in 1 out of 6 persons which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Administrator to submit into CCL a LIC200 and updated facility sketch indicating what room will be bedridden. LPA will submit request for bedridden clearance into the fire department. POC due by 1/12/24

Section Cited

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

SUPERVISOR'S NAME: Troy Ordonez LICENSING EVALUATOR NAME: Bethany Mirlohi LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024

Link to Parent Document Below:

FACILITY NAME: A1SENIOR CARE	FACILITY NUMBER: 312700395
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/11/2024

Type B

Section Cited

CCR

87411(f)

(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 that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 2 out of 2 employees which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2024
	Plan of Correction
1 2 3 4	Administrator to obtain a health screening and TB test for both caregivers. Documentation due to LPA by 1/25/24.

SUPERVISOR'S NAME: Troy Ordonez LICENSING EVALUATOR NAME: Bethany Mirlohi LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024

Link to Parent Document Below:

FACILITY NAME: A1SENIOR CARE	FACILITY NUMBER: 312700395
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/11/2024

Type B

Section Cited

HSC

1569.618(c)(3)

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 2 out of 2 employees which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2024
	Plan of Correction
1 2 3 4	Administrator to obtain CPR and first aid certification for both caregivers. Documentation to be sent into LPA by 1/25/24.

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 record review, the licensee did not comply with the section cited above in 2 out of 2 employees which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2024
	Plan of Correction
1 2 3 4	Administrator will create a training calendar for 2024 with required hours and subject matter documented. Outlined plan to be sent into CCL by 01/25/2024.

SUPERVISOR'S NAME: Troy Ordonez LICENSING EVALUATOR NAME: Bethany Mirlohi LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024

Link to Parent Document Below:

FACILITY NAME: A1SENIOR CARE	FACILITY NUMBER: 312700395
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/11/2024

Type B

Section Cited

CCR

87506(b)(17)(A)

(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal; 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 2 out of 6 resident which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2024
	Plan of Correction
1 2 3 4	Administrator to send into LPA the pre-admission apprasial that will be used for all potential residents in the future. Documentation to be sent into LPA by 1/25/24.

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 record review, the licensee did not comply with the section cited above in 3 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2024
	Plan of Correction
1 2 3 4	Adminsitrator to update all resident needs and service plan and meet with family and obtain signature for service plan. Documentation to be sent into CCL by 1/25/24.

SUPERVISOR'S NAME: Troy Ordonez LICENSING EVALUATOR NAME: Bethany Mirlohi LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024

Link to Parent Document Below:

FACILITY NAME: A1SENIOR CARE	FACILITY NUMBER: 312700395
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/11/2024

Type B

Section Cited

HSC

1569.695(a)(3)

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (3) Transportation needs and evacuation procedures to ensure that the facility can communicate with emergency response personnel or can access the information necessary in order to check the emergency routes to be used at the time of an evacuation and relocation necessitated by a disaster. If the transportation plan includes the use of a vehicle owned or operated by the facility, the keys to the vehicle shall be available to staff on all shifts. 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 leaving multiple sections in 610E blank which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2024
	Plan of Correction
1 2 3 4	Administrator to complete 610E and send an updated copy into LPA by 1/25/24.

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 record review, the licensee did not comply with the section cited above in 1 out of 1 documents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2024
	Plan of Correction
1 2 3 4	Administrator agrees to complete an emergency drill quarterly with staff. Administrator to complete first emergency drill by 1/25/24 and send documentation into LPA by 1/25/24.

SUPERVISOR'S NAME: Troy Ordonez LICENSING EVALUATOR NAME: Bethany Mirlohi LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024

Link to Parent Document Below:

FACILITY NAME: A1SENIOR CARE	FACILITY NUMBER: 312700395
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/11/2024

Type B

Section Cited

CCR

87608(a)(5)(B)

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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 2 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2024
	Plan of Correction
1 2 3 4	Administrator to remove full bedrails from 2 resident hospital beds. Administrator to send LPA a picture of full bedrails removed by 1/25/24.

Type B

Section Cited

CCR

87705(c)(5)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. 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 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/31/2024
	Plan of Correction
1 2 3 4	Administrator to obtain an updated LIC602 and needs and service plan for R1. Documentation to be sent into CCL by 1/31/24.

SUPERVISOR'S NAME: Troy Ordonez LICENSING EVALUATOR NAME: Bethany Mirlohi LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024

Link to Parent Document Below:

FACILITY NAME: A1SENIOR CARE	FACILITY NUMBER: 312700395
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/11/2024

Type B

Section Cited

CCR

87211(a)(1)

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. 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 by not reporting several incidents in which resident was sent out to the hospital which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2024
	Plan of Correction
1 2 3 4	Administrator to send into LPA a written statement of understanding that incident reports need to be sent into CCL within 7 days of occurrence when incident occurs. Statement to be sent into CCL by 1/25/24.

Type B

Section Cited

CCR

874659a)(4)

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. 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 by providing expired medications to residents in care which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2024
	Plan of Correction
1 2 3 4	Administrator agrees to dispose of expired medications and obtain new medications for residents. Administrator to send into LPA a plan of how staff will ensure residents will not receive expired medications. Plan to be sent into CCL by 1/25/24.

SUPERVISOR'S NAME: Troy Ordonez LICENSING EVALUATOR NAME: Bethany Mirlohi LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024