Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
11/15/2024
Section Cited
CCR
87470(a)(3)(B)
| 1
2
3
4
5
6
7 | Infection Control Requirements: A syringe and needle shall only be used once per injection on one resident and then properly disposed of in accordance with the California Code of Regulations, Title 8, Section 5193. this requirement was not met as evidenced by LPA observations of syringes disposed | 1
2
3
4
5
6
7 | Facility will ensure all used syringes are disposed of appropriately and provide a written plan of correction indicating the steps facility will take on a daily basis to ensure syringe disposal is conducted appropriately to meet title 22 regulations. |
 | 8
9
10
11
12
13
14 | of in an unlocked cabinet some in an overflowing syringe container and other syringes just placed in the cabinet which poses an immediate health, safety and personal rights risk to residents in care. | 8
9
10
11
12
13
14 | |
Type A
11/15/2024
Section Cited
CCR87405(d)(2)
| 1
2
3
4
5
6
7 | Administrator - Qualifications and Duties: Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by the number and serious nature of the violations identified during the inspection including personal rights, reporting requirements, | 1
2
3
4
5
6
7 | LPA and licensee discussed the departments technical support program and provided statements they would accept referral and participate in TSP. |
| 8
9
10
11
12
13
14 | staff's conduct inimical to the health safety and well-being of residents in care which poses an immediate health, safety and personal rights risk to residents in care. | 8
9
10
11
12
13
14 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
11/15/2024
Section Cited
CCR
87211(a)(1)(D)
| 1
2
3
4
5
6
7 | Reporting Requirements: 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...Any incident which threatens the welfare, safety or health of any resident, | 1
2
3
4
5
6
7 | The facility will provide a written plan of corrections of the daily steps facility will take to ensure all incidents are reported to the department in a manner that meets title 22 regulations. |
| 8
9
10
11
12
13
14 | such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by unreported incidents including a resident's agressive acts against staff and inapropraite actions by staff inluding verbal abuse wich poses an immediate health, safety and personal rights risk to residents in care. | 8
9
10
11
12
13
14 | |
Type B
11/22/2024
Section Cited
CCR87705(c)(4)(A)
| 1
2
3
4
5
6
7 | Care of Persons with Dementia: In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or | 1
2
3
4
5
6
7 | Licensee has agreed to provide documentation of advertisements for employment on multiple professional platforms such as indeed or linked in and additional social media outreach by the POC due date. |
| 8
9
10
11
12
13
14 | observation to require awake night supervision. This requirement was not met as evidence by: LPA review of resident files and identified needs for night supervision and the staff schedule with no identified overnight staff which poses a potential health, safety and personal rights risk to residents in care. | 8
9
10
11
12
13
14 | |