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25 | Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management Visit to cite deficiencies identified during a separate complaint investigation. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Christopher Diaz. LPA also spoke via phone with Licensee Dr. Mohammed Rahman, during the visit.
During review of the residents’ care records, LPA observed, and Licensee/manager interview confirmed:
For Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4), Licensee did not have written proof of a negative tuberculosis (TB) test result for them, which was required before each of these residents moved-in. (During LPA’s site visit, these residents did not show signs/symptoms, observable to the layperson, of active tuberculosis infection). For R4, Licensee also did not have any LIC602 Physician’s Report (or equivalent Medical Assessment) or a LIC603 Pre-Placement Appraisal (or equivalent preadmission appraisal document) for them; these were both required to be completed before they moved in. There were also no subsequent written care appraisals on file for R4.
For Resident #5 (R5), their latest LIC602 Physician’s Report (from 12/06/2019) showed they were diagnosed with Dementia by their doctor. However, Licensee did not have an updated LIC602 Physician’s Report (or equivalent Medical Assessment) or a care reappraisal completed for R5 within the last year, which was required for residents diagnosed with Dementia. For Resident #1 (R1), R2, R4, and R5, Licensee also did not have file an LIC625 Appraisal/Needs and Services Plan (or equivalent “written record of care the resident will receive”). There was also no evidence that Licensee held a care-conference meeting with their respective responsible persons (RPs) within the last twelve (12) months, as was required. Interviews of multiple RPs confirmed this.
[CONTINUED ON LIC 809-C] |
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32 | [CONTINUED FROM LIC 809]
According to their latest respective LIC602 Physician’s Reports, at least 4 of 6 residents in care [Resident #1 (R1), R2, R4, and Resident #6 (R6)] were diagnosed with Dementia, and R3 was diagnosed with Mild Cognitive Impairment. LPA observation and interview of their RP showed that R4 also likely had Dementia. Per interviews of staff and available care records, of these residents, R1 through R6, was safe to leave the facility unassisted. During today’s inspection, LPA observed, and interview of staff confirmed: Licensee installed staff auditory alert devices on its seven (7) exterior exit doors. However, caregivers had used the switches on these devices to disable the door chimes, rendering the devices ineffective. Regulation required Licensee to maintain an auditory alert device or other staff feature to monitor these exit doors.
LPA also observed that both during today’s visit and a during a prior visit, the lead caregiver, who was also acting as the administrator on duty, did not have keys to access the staff records, upon CCLD demand during normal business hours.
Seven (7) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D pages). Plans of Correction were jointly developed with the Licensee.
An exit interview was conducted with Dr. Rahman, to whom a copy of this report, the LIC 809-D page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
11/11/2024
Section Cited
CCR
87458(b)
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7 | 87458 Medical Assessment: “(b) The medical assessment shall include, but not be limited to: …results of an examination for communicable tuberculosis…” This requirement was not met, as evidenced by: | 1
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7 | Licensee agreed to coordinate with the physicians and/or responsible persons for R2, R3, and R4, as needed, to ensure completion of tuberculosis (TB) testing for these residents, either by PPD or Chest X-ray. Licensee agreed to place the results of such testing in the resident’s care binders beside their LIC602 Physicians Report, and to E-mail the negative TB test results to LPA, by the POC due date. |
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14 | Based on records review and manager interview, for 3 of 5 residents (R2, R3, and R4), Licensee did not ensure that the resident had a medical assessment that also included the results of a complete examination for communicable tuberculosis. This posed a potential health risk to persons in care. | 8
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Type B
11/11/2024
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 form LIC602…to obtain the medical assessment.” This requirement was not met, as evidenced by: | 1
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7 | Licensee agreed to coordinate with the physician and/or responsible person for R4, as needed, to ensure completion of an LIC602 Physician’s Report for R4. Licensee agreed to E-mail the completed and signed LIC602 for R4 to LPA, by the POC due date. |
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14 | Based on records review and manager interview, for 1 of 5 residents (R4), prior to the person’s acceptance as a resident, Licensee did not obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. This posed a potential health, safety, and personal rights risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
11/11/2024
Section Cited
CCR
87705(c)(5)
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7 | 87705 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 as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually…” | 1
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7 | Licensee agreed to coordinate with the physician and/or responsible person for R5, as needed, to ensure completion of both an LIC602 Physician’s Report and an LIC625 Appraisal/Needs and Services Plan for R5. Licensee agreed to E-mail the completed and signed LIC602 and LIC625 for R5 to LPA, by the POC due date. |
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14 | This requirement was not met, as evidenced by: Based on records and manager interview, for 1 of 5 residents (R5), who was diagnosed with dementia, Licensee did not ensure that they had a medical assessment and care reappraisal done at least annually. This posed a potential health risk to persons in care. | 8
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Type B
11/11/2024
Section Cited
CCR87456(a)(2)
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7 | 87456 Evaluation of Suitability for Admission: “(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall…: (2) Perform a pre-admission appraisal.” This requirement was not met, as evidenced by: | 1
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7 | Licensee agreed to complete an LIC603 Pre-Placement Appraisal form on R4 and to have it signed by both R4’s responsible person and by a facility representative, after joint-review. Licensee agreed to keep this document as part of R4’s care file. Licensee agreed to E-mail the completed and signed LIC603 for R4 to LPA, by the POC due date. |
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14 | Based on records review and manager interview, for 1 of 5 residents (R4), Licensee did not have on file a completed LIC603 Pre-Placement Appraisal (or equivalent pre-admission appraisal document) to evidence that they performed a pre-admission appraisal to evaluate his/her suitability, prior to accepting the resident for care. This posed a potential health, safety, and personal rights risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
11/11/2024
Section Cited
CCR
87467(a)
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7 | 87467 Resident Participation in Decisionmaking: “(a) Prior to, or within two weeks of the resident’s admission, 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, and any other appropriate parties, to prepare a written record of care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility.” | 1
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7 | Licensee agreed to complete an LIC625 Appraisal/Needs and Services Plan form on R1, R2, R4 and R5, and to have both signed by their respective responsible person and a facility representative, after a joint-review during a care-conference meeting. Licensee agreed to E-mail the completed and signed LIC625s for R1, R2, R4, and R5 to LPA, by the POC due date. Going forward, Licensee agreed to update the LIC625 and hold a care conference, for all residents, whenever there is a significant change in their condition, but also at least once every twelve (12) months, whichever occurs first. |
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14 | This requirement was not met, as evidenced by: Based on records reviewed and interviews, for 4 of 5 residents (R1, R2, R4, and R5), Licensee did not have on file a completed LIC625 Appraisal/Needs and Services Plan (or equivalent “written record of care the resident will receive”), to include the resident’s preferences regarding the services provided at the facility. This posed a potential health and personal rights risks to persons in care. | 8
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Type B
11/11/2024
Section Cited
CCR87705(j)
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7 | 87705 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 | During today’s inspection, LPA, accompanied by staff, switched the staff alert devices back on for each exterior door (so that they would chime when the door is opened). Licensee agreed to retrain its current and future caregivers on the expectation for door chimes on exterior doors to remain continuously active, and to E-mail the training sign-in sheet to LPA, by the POC due date. |
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14 | Based on LPA observation and staff interviews, Licensee did not continuously maintain an auditory device or other staff alert feature to monitor exits. This posed a potential safety risk to 6 of 6 residents (R1 through R6) in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
11/11/2024
Section Cited
CCR
87412(f)
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7 | 87412 Personnel Records: “(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.” This requirement was not met, as evidenced by: | 1
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7 | Licensee agreed to provide a set of keys to the staff who act as the administrator on duty, and which always remain at the facility, which provide them controlled access to staff records/files. Licensee agreed to send LPA a photograph of said key(s) in the designated spot at the facility where they are to be kept, by the POC due date. |
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14 | Based on LPA observation and staff interviews, for 9 of 9 staff (S1 through S9), Licensee did not ensure that their personnel records were available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This posed a potential safety risk to persons in care. | 8
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