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25 | Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management visit. LPA Valerio met with facility staff Etta Mae, and explained the purpose of the visit. LPA Valerio was later met by Administrator Beatrice Clark.
05/29/2024, LPA Valerio was initially at the facility to conduct a 10-Day Complaint Investigation related to Complaint # 27-AS-20240528100935. During the facility walk through, LPA Valerio observed multiple health and safety concerns. Pictures were taken for future reference.
- On top of the kitchen counter, LPA observed 2 gallon bleach containers, a spray bottle labeled bleach, and a screw driver next to the kitchen sink. On the dryer rack located near the kitchen sink, LPA Valerio observed a large kitchen knife.
- During an interview with a resident, LPA observed ants crawling on the table and on the resident's hand. The resident was unaware of the ants until LPA Valerio pointed it out. According to an interview with Administrator Beatrice, the pest control service was last at the facility 6 months ago, staff clean daily, and they have a housekeeper that cleans frequently. Technical Assistance provided for 87555(b)(27).
- LPA Valerio observed a nail screwed into the wall in front of a resident bathroom door and a bedroom door. The bedroom door was learned to be used for live-in care staff. Behind the door, LPA observed a rope tied to the doorknob. LPA Valerio asked Staff 2 (S2) to demonstrate the reason behind the rope and nail. S2 showed that the facility takes the rope and ties it over the nail. S2 stated it is used for staff privacy when using the restroom or inside the staff room due to the doors being unable to lock. Administrator Beatrice and Staff 2 denied that the nail and rope are used if a resident is inside. Administrator Beatrice stated she reminded staff multiple times to never install the nails and have repeatedly told them to not use it in the past. Administrator removed the rope and nails during the visit.
Per California Code of Regulations (CCR) Title 22, deficiencies are being cited today on the attached LIC 809-D page. Appeal Rights were provided. An exit interview was held with Administrator Beatrice, and a copy of report was provided to the Administrator. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
05/30/2024
Section Cited
CCR
87705(f)
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7 | 87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(1) Knives,...tools and other items that could constitute a danger to the resident(s).(2)... cleaning supplies and disinfectants. This requirement was not met as evidenced by: | 1
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7 | Licensee had staff lock away the sharps and cleaning supplies during the visit. Licensee to submit a Training Plan by POC due date. The plan will describe when training related to 87705 will be held with all staff. |
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14 | Based on observations, LPA Valerio observed, cleaning supplies, a knife, and a tool out on the kitchen area accessible to the residents in care. This poses an immediate health, safety, and personal rights risk to residents in care. | 8
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Type A
05/30/2024
Section Cited
CCR87468.1(a)(6)
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7 | 87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6)... to not be locked into any room, building, or on facility premises by day or night. This requirement was not met as evidenced by: | 1
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7 | Licensee removed nails and ropes during LPA's visit. Licensee to submit a Training Plan by POC due date. The Training Plan will describe when an all staff training will be held regarding 87468.1 Personal Rights of Residents in All Facilities. |
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14 | Licensee did not ensure facility staff did not install a locking mechanism on the resident bathroom and bedroom. This poses an immediate health, safety, and personal rights risk to residents in care. | 8
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