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25 | On this date, Licensing Program Analyst (LPA) Crystal Colvin made an unannounced visit to the facility to investigate a complaint #18-AS-20220715115207. During today's inspection, LPA Colvin observed the following deficiencies, which was reviewed with Administrator Maria Gonzalez:
- Care of Persons with Dementia - LPA Colvin observed while at the facility that the auditory alarms on the front door and back door of the facility were switched to the "off" position, and were not alerting staff as to when the door was opened. The facility retains residents with Dementia, including resident (R1) who recently eloped from the facility on 7/4/22. Deficiency cited. Additionally, LPA Colvin observed that R1, who is diagnosed with Dementia, does not have a Physician's Report dated any more recently than June of 2021. The facility is required to have these reports updated at least annually for persons with Dementia. Deficiency cited.
- Fire Safety - While LPA Colvin was inspecting the front door alarm, LPA Colvin observed that staff had locked the front door using the deadbolt, which was only able to be unlocked from the inside of the facility with a key. This is an dangerous fire hazard to the residents and staff, as in the event of an emergency, they would not be able to quickly exit the front door unless they had the key on hand. Deficiency cited. Fire safety violations result in an immediate civil penalty in the amount of $500.
- Visitor Policy - When LPA Colvin walked up to the facility's front door from the outside, LPA Colvin observed a posted Visitation Policy/Hours, which limited visitation to 9:30am - 5:30pm on Monday - Friday, and 10am - 4pm on the weekends. LPA Colvin did observe an addendum to the hours underneath, which read that these hours could be flexible for family members. This is a violation of resident's rights to visitors, as the hours listed during the week are common working/business hours, and the hours on the weekend are even more severely restricted. Deficiency cited.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
07/25/2022
Section Cited
CCR
87203
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7 | Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by: | 1
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7 | Licensee agrees to have the deadbolt removed and to provide LPA Colvin with photographic proof of removal. The Licensee may choose to replace the deadbolt with one which can be unlatched from the inside without a key. Photos to be provided to LPA Colvin by Plan of Correction date of 7/25/22. |
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14 | Based on observations, the Licensee did not comply with the above regulation with at least one area of the facility. LPA Colvin observed that the front door was locked with a deadbolt that is only able to be unlocked with a key. This is an immediate safety risk to residents in care. | 8
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Type A
07/25/2022
Section Cited
CCR87705(j)
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7 | Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by: | 1
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7 | Licensee agrees to obtain additional alarms (Licensee has one which is used at night which residents do not notice and remove) which Licensee and LPA agree are suitable to meet Regulation Requirements. Licensee to provide LPA Colvin with photos of where alarms are placed. Photos due by 7/25/22. |
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14 | Based on observation, the Licensee did not comply with the above regulation with two exit doors. LPA Colvin observed both the front door and back door of the facility to have their auditory alarms turned off. LPA Colvin also tested the doors to confirm. This is an immediate safety risk to Dementia residents. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
07/25/2022
Section Cited
CCR
87211(a)(1)(D)
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7 | Reporting Requirements: (a) Each licensee shall furnish...reports...including... the following: (1) A written report shall be submitted ...within seven days of...(D) Any incident which threatens the welfare, safety or health of any resident, such as... unexplained absence of any resident. This was not met by: | 1
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7 | Licensee agrees to submit an incident report regarding R1's elopment from the facility and subsequent hospitaliztion. Licensee additionally agrees to review Title 22 Regulation section 87211 regarding Reporting Requirements. Licensee may self-certify to LPA Colvin once complete along with a Statement of |
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14 | Based on record review, the Licensee did not comply with the above regulation with at least one occurance. LPA Colvin confirmed that no report was submitted for R1's elopment from the facility on 7/4/22. This is an immediate safety risk of all residents, as the facility has never submitted a report to Licensing. | 8
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14 | Understanding regarding what types of incidents must be reported to Community Care Licensing. Incident Report for R1, self-certitifcaiton of Regulation Section 87211 review, and Statement of Understandin due by Plan of Correction date of 7/25/22. |
Type B
08/05/2022
Section Cited
CCR87468.1(a)(11)
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7 | Personal Rights of Residents in All Facilities: (a) Residents...have all of the following personal rights: (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours... This requirement was not met as evidenced by: | 1
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7 | Licensee agrees to remove the posted visitor policy and provide LPA Colvin with photographic proof of removal. Licensee additionally agrees to send a notice to all families/recent visitors (within last 60 days) of residents regarding recention of posted visitation policy. Licensee may uphold visitation |
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14 | Based on observations, the Licensee did not comply with the above regulation. LPA Colvin observed Visitor Hours posted outside the facility which were unreasonably restrictive. Additionally, the posted hours are not what is reflected in the facility's Admissions Agreement. This is a potential personal rights violation of all residents. | 8
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14 | policy that is stated in Admissions Agreement, though provisions and considerations must be made with visitors if they cannot visit during regular hours. Photograph and copy of notice to be provided to LPA Colvin by Plan of Correction date of 8/5/22. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
08/05/2022
Section Cited
CCR
87705(c)(5)
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7 | Care of Persons with Dementia: (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...and a reappraisal done at least annually... This requirement was not met as evidenced by: | 1
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7 | Licensee agrees to have R1 seen by their Primary Care Physician (PCP) and have a new Physician's Report completed. Licensee additionally reccomended to conduct self-audit to ensure no other residents are overdue for a new Physician's Report. Licensee to provide LPA Colvin with a copy of R1's updated |
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14 | Based on record review, the Licensee did not comply with the above regulation with at least on resident. LPA Colvin observed that R1's most recent Physician's Report is dated 6/11/21. R1 is diagnosed with Dementia. This is a potential health and safety risk to R1. | 8
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14 | Physician's Report, or appointment date with Statement of Understanding that Physician's Report is to be updated at this time, by Plan of Correction of Date of 8/5/22. |
Type B
08/05/2022
Section Cited
CCR87307(a)(3)(B)
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7 | Personal Accommodations and Services: (a) Living accommodations...shall be related to the facility's function...The following provisions shall apply: (3) Equipment and supplies necessary...licensee shall assure provision of: (B) Bedroom furniture, which shall include, for each resident...a lamp, or lights sufficient for reading... | 1
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7 | Licensee had staff replace the lamp in R1's bedroom during LPA Colvin's inspection. Licensee agrees to review Title 22 Regulations Section 87307 regarding what furniture and supplies are to be provided to residents in each bedroom. Licensee may self-certify once complete. Due by 8/5/22. |
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14 | This requirement was not met by: Based on observation, the License did not comply with the above regulation with one resident. LPA Colvin observed no operational light source in R1's room other than the bedroom window. This is a potential personal rights violation of R1. | 8
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