St Joseph Senior Care

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

Based on observation, the licensee did not comply with the section cited above in leaving Lysol and other cleaning chemicals unlocked in the bathroom which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 10/17/2025 Plan of Correction 1 2 3 4 The Administrator will lock all chemicals and submit self certification of correction by POC date.

(c) With the prior written approval of the resident or conservator and provided such devices do not violate the resident’s rights as specified in Section 87468.1 Personal Rights of Residents in All Facilities, the licensee may use egress alert and location tracking devices as needed to ensure resident safety.

Based on observation, the licensee did not comply with the section cited above in installing a child gate on R1's room which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 10/17/2025 Plan of Correction 1 2 3 4 The Administrator states child gate will be removed and will submit photo proof to CCL by POC date.

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

Based on observation, the licensee did not comply with section cited above by having gardening and construction supplies in the backyard and leaving dishes on counter top which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 10/23/2025 Plan of Correction 1 2 3 4 The Administrator will clean up the kitchen and backyard and submit photo proof to CCL by POC date.

(f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. (1) All containers storing waste shall be in good repair, free of leaks, and emptied in a timely manner.

Based on observation, the licensee did not comply with the section cited above in having garbage can without lid which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 10/23/2025 Plan of Correction 1 2 3 4 The Administrator will purchase garbage cans with lid and submit photo proof to CCL by POC date.

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degre…

Based on observation, the licensee did not comply with the section cited above in having hot water measure at 144.9 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 11/14/2024 Plan of Correction 1 2 3 4 Hot water temperature was adjust to 111 degrees Fahrenehit during the visit. This deficiency is cleared.

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

Based on observation, the licensee did not comply with the section cited above in having knives and scissor unlocked which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 11/15/2024 Plan of Correction 1 2 3 4 The Licensee will install a lock in the cabinet to store knives and other sharp objects and send photo proof to CCL.

(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (A) Surfaces such as …

Based on observation, the licensee did not comply with the section cited above in having crumbs on the stove top, crumbs by the window sill, toilet with trace of feces, etc which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 11/30/2024 Plan of Correction 1 2 3 4 By POC date, the facility will clean and disinfect the facility and send photo proof to LPA. LPA will come back to verify.

(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (B) Walls and window …

Based on observation the licensee did not comply with the section cited above in having dusts/mold on window and sliding doors which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 11/30/2024 Plan of Correction 1 2 3 4 The facility will clean and disinfect window covering and walls and submit photo proof to CCL. LPA will come back to verify.

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

Based on observation, the licensee did not comply with the section cited above in having empty boxes, unused medical equipment, lots of stray cats in the backyard, etc which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 11/21/2024 Plan of Correction 1 2 3 4 By POC date, the Administrator will dispose all unused equipment/empty boxes, trim bushes, ensure there are no stray cats in the backyard and clean up backyard and submit photo proof to CCL…

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

Based on observation, the licensee did not comply with the section cited above in having a side table and fan blocking exit door in Room #2 which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 11/14/2024 Plan of Correction 1 2 3 4 The Administrator removed the fan and side table during the visit. This deficiency is cleared.

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physicia…

Based on observation, the licensee did not comply with the section cited above in failing to obtain doctor's orders for the two residents using 1/2 rail which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 11/21/2024 Plan of Correction 1 2 3 4 The Administrator will obtain a doctor's order for the 1/2 rails and submit proof to CCL.

(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, both of which shall include a reassessment of the resident's dementia care …

Based on observation, the licensee did not comply with the section cited above in failing to obtain R2's updated Physician's Report which poses/posed a potential health, safety or personal rights risk to persons in care. R2 has Dementia. POC Due Date: 11/21/2024 Plan of Correction 1 2 3 4 By POC date, the Administrator will submit to CCL R2's updated Physician's Report.

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after …

Based on record review,, the licensee did not comply with the section cited above in not having S2 complete health screening and tb test which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 10/31/2023 Plan of Correction 1 2 3 4 S2 will get screened for TB and complete health screening. A copy of Lic 503/TB test result will be submitted to CCL by POC date.

(c) 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, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Parti…

Based on record review, the licensee did not comply with the section cited above in not conducting Reappraisal for R2 who is on catheter which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 10/31/2023 Plan of Correction 1 2 3 4 By POC date, Administrator will complete Reappraisal for R2 addressing R2's catheter and submit a copy to CCL.

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

Based on observation, the licensee did not comply with the section cited above in not havong medicines in the kitchen cabinet locked which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 10/25/2023 Plan of Correction 1 2 3 4 Staff locked medicines during visit. Deficiency is cleared.

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

Based on record review, the licensee did not comply with the section cited above in not having an updated Emergency Disaster Plan which poses an immediate health, safety or personal rights risk to persons in care. Last plan is dated 2011. POC Due Date: 10/31/2023 Plan of Correction 1 2 3 4 Administrator will submit to CCL updated Emergency Disaster Plan.

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (2) The Emergency Disaster Plan, as required in Section 87212, addresses the safety of residents with dementia.

Based on record review, the licensee did not comply with the section cited above in not having an updated disaster plan that addresses the safety of residents with dementia which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 10/31/2023 Plan of Correction 1 2 3 4 Administrator will submit an updated Disaster plan to CCL addressing the safety of residents with dementia and submit a copy to CCL.

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (D) Number of training hours per subject.

Based on observation, the licensee did not comply with the section cited above in not indicating training hours per subject for S1 which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 10/31/2023 Plan of Correction 1 2 3 4 Administrator will indicate training hours completed by S1 and submit proof to CCL.

(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs. (B) Training shall be completed prior to the staff providing services to the resident.

Based on record review, the licensee did not comply with the section cited above in not having staff complete training with R2's catheter prior to staff providing service to R2 which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 10/31/2023 Plan of Correction 1 2 3 4 Administrator will train staff on R2's catheter.

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

Based on observation, the licensee did not comply with the section cited above in not having S2 complete first aid training which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 10/31/2023 Plan of Correction 1 2 3 4 S2 will complet first aid training and submit proof to CCL.

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be…

Based on record review, the licensee did not comply with the section cited above in not having staff complete required dementia training which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 11/20/2023 Plan of Correction 1 2 3 4 Administrator will conduct required training and submit proof to CCL.

(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

Based on record review, the licensee did not comply with the section cited above in not having staff complete required medication training hours which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 10/31/2023 Plan of Correction 1 2 3 4 Administrator will conduct training and submit proof to CCL.

(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.

Based on record review, the licensee did not comply with the section cited above in not having the SPV form in the residents' files which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 10/31/2023 Plan of Correction 1 2 3 4 Administrator will contact families to complete SPV and submit completed copy of the form to CCL.

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

Based on observation, the licensee did not comply with the section cited above in having fruit flies in the kitchen/dining which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 10/31/2023 Plan of Correction 1 2 3 4 Administrator will clean, declutter and organize kitchen and dining areas and submit photo proof to CCL.

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill,…

Based on record review, the licensee did not comply with the section cited above in not having an updated disaster drill which poses/posed a potential health, safety or personal rights risk to persons in care. Last fire drill was done on April 2023. POC Due Date: 10/31/2023 Plan of Correction 1 2 3 4 Administrator will conduct drill and submit proof to CCL.

(b) Written requests shall include, but are not limited to, the following:

Based on record review, the licensee did not comply with the section cited above in not having an approved exception for R2's catheter which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 11/20/2023 Plan of Correction 1 2 3 4 Administrator will submit a request for exception for R2 by POC date.

(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, both of which shall include a reassessment of the resident's dementia care …

Based on record review, the licensee did not comply with the section cited above in not having an updated medical assessment for R1 who has dementia which poses/posed a potential health, safety or personal rights risk to persons in care. POC Due Date: 10/31/2023 Plan of Correction 1 2 3 4 Administrator will request an updated medical assessment for R2 and submit a copy ot CCL.

Based on observation, the licensee did not comply with the section cited above in installing a video camera with audio inside R1's room which poses an immediate health, safety or personal rights risk to persons in care. R1 has dementia and is able to use the bathroom independently. POC Due Date: 10/26/2023 Plan of Correction 1 2 3 4 Administrator will remove camera and will update R1's needs and services to address R1's safety. Administrator will send certifcate of removal of camera by 10/26 a…