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32 | LIC 809-C
Additionally, during file review of resident files, facility did not have LIC 602 and/or any medical assessment conducted for R1. When asked, Licensee provided LPA a copy of R1's Skilled Nursing Discharge form. Licensee stated "this is all that they gave me when he came here."
LPA and Licensee discussed that prior to admission for residents in care, LIC 602 is required in order for needs and service to be assessed. Licensee stated she did not know it was not the LIC 602. The following form did not have physician's primary diagnosis and secondary diagnosis, Documentation of prior medical services and history and current medical status including, but not limited to height, weight, and blood pressure, Identification of physical limitations of the person to determine his/her capability, determination whether the person is ambulatory or nonambulatory and Information applicable to the pre-admission appraisal.
As a result of the inspection, deficiencies were observed and cited.
Please see LIC 809-D, additionally, civil penalties accessed.
Exit interview conducted and a copy of report and appeal rights provided. Due to Licensee no longer being at the facility, S1 has signed the following report, signature on this form acknowledges receipt. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
11/06/2024
Section Cited
CCR
87355(c)
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7 | 87355 Criminal Record Clearance
(c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department:
This requirement is not met as evidenced by: | 1
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7 | Licensee is to submit paperwork required for criminal clearance transfer for the facility and/or associate S1 on Guardian immediately or S1 is to vacate the facility. Proof of association is due to LPA on 11/6/2024.
Failure to provide POC by due date may result to civil penalty of $100 per day until received. |
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14 | Based on observation, file review and interview, the licensee did not comply with the section cited above as S1 was observed to be working but are not associated to the facility roster which poses an immediate health, safety or personal rights risk to persons in care. | 8
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14 | Civil penalty and repeated violation civil penalty assessed. |
Type B
12/05/2024
Section Cited
CCR87458(a)
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7 | 87458 Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: | 1
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7 | Licensee is to obtained an updated LIC 602 / Medical Assessment for R1.
Licensee is to notify LPA once completed - POC is due by December 5, 2024. |
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14 | Based on file review, Licensee did not comply as R1 did not have a LIC 602 / Medical Assessment present on file which poses a potential risk for residents in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
11/15/2024
Section Cited
CCR
87405(d)(3)
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7 | 87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (3) Ability to maintain or supervise the maintenance of financial and other records. This requirement is not met as evidenced by: | 1
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7 | Licensee and Administrator are have a training of 87458 Medical Assessment and 87506 Resident Records .
Notification of completion is to be submitted to LPA by November 15, 2024.
Failure ot correct in a timely manner may assessed to civil penalty of $100 per day. |
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14 | Based on file review and interview, Licensee did not comply as R1's skilled nursing facility discharge paperwork was mistaken for LIC 602 which R1 has no current LIC 602 on file, which poses a potential risk for residents in care. | 8
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