7. Unannounced Visit: POC Copy

Hours:    None

We would love to hear about  an incident at your facility. Feel free to share in the box below (optional).

Facility Type: 735 (Adult Residential)

Investigation Findings

Licensing Program Analyst (LPA) made an unannounced visit to the facility for the purpose of conducting a Required Annual inspection. LPA met with administrator. The facility is licensed for 80 ambulatory clients, specializing in caring for the mentally ill.

LPA inspected the entire facility inside and out. There are 11 separate buildings used to accommodate living quarters with restrooms and showers for the clients. LPA inspected each building.

LPA observed no pools or bodies of water. There is no ammunition or firearms. LPA observed that facility buildings are kept at a comfortable temperature. Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement was not met as evidenced by: Based on testing the hot water temperature the licensee failed to ensure the temperature of the hot water is not less than 105 and not more than 120 degrees. Hot water was measured in the clients’ bathrooms of each building and all observed hot water measured in Building 7 at 134.1 degrees F and 137.1 degrees F, in Building 8 at 137.7 degrees F, in Building 9 at 125 degrees F and 128 degrees F, in Building 10 at 141 degrees F and 145 degrees F and Building 11 at 130 degrees F. This poses a health and safety risk to clients in care. A deficiency will be cited.

Deficiency Type /
Section Number
DEFICIENCIESPLAN OF CORRECTIONS (POCs)
Type A
10/24/2018
Section Cited
CCR
87303(a)
MAINTENANCE & OPERATION (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: LPA observed dust and grime throughout the facility in the client's bathrooms. The bathrooms in buildings, 1, 5, 6, 7, and 11 are in need of deep cleaning of walls, shower/tub, faucets and fixtures. LPA also observed the tile floor in Building 11 is in need of repair.Licensee will ensure the entire facility is thoroughly cleaned including but not limited to the client buildings, client bedrooms, client bathrooms. The licensee will also have the tile repaired or replaced. Proof of plan will be submitted to CCL by the POC date of 10/24/18.
Type A
10/24/2018
Section Cited
CCR
80088(e)(1)
FIXTURES, FURNITURE EQUIPMENT AND SUPPLIES. Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F and not more than 120 degrees F. This requirement was not met as evidenced by: Hot water was measured in the clients' bathrooms of each building and all observed hot water measured in Building 7 at 134.1F & 137.1F, in Building 8 at 137.7F, in Building 9 at 125F & 128F, in Building 10 at 141F and 145F & Building 11 at 130F.Staff lowered the hot water heater during the visit, however the water temperature remained above 120 degrees Fahrenheit.
Licensee will ensure the water temperature is between 105F and 120F by testing the water temperature and submitting proof to CCL by the POC due date of 10/24/2018.
Type B
10/30/2018
Section Cited
CCR
80076(a)(22)
FOOD SERVICE: Tableware and tables, dishes, and utensils shall be provided in the quantity necessary to serve the clients. This requirement is not met as evidenced by observation of the kitchen and dining room. The licensee failed to provide the quantity of bowls and dishes for the clients in care. There are currently 78 clients in care and only 48 bowls, 67 plates, 56 cups, 44 forks and 65 spoons to serve the clients. Interviews conducted with staff revealed there are no knives to properly cut the food being prepared. The facility is providing plastic plates, bowls.The licensee will increase their supply of dishes and utensils in quantity to serve all the clients in care and submit proof to CCL by the POC due date of 10/30/2018.

 

LPA observed the client’s medications are centrally located and secured and labeled in compliance with state and federal laws. Appropriate number of staff are present in the facility during operating hours and during the evening/sleeping hours.

LPA reviewed staff and client records, which were organized and complete. All staff present have criminal record clearances and are associated to the facility properly.

Deficiencies cited per Title 22, Division 6 of the California Code of Regulations.

LPA conducted an exit interview where this report and appeal rights were discussed and provided to administrator.

LPA observed the toilets, hand washing and bathing facilities were not safe and sanitary. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by: LPA observed the clients’ bathrooms to be unsanitary. The bathrooms in buildings, 1, 5, 6, 7, and 11 in need of deep cleaning of walls, shower/tub, faucets and fixtures. LPA also observed the tile floor in Building 11 is in need of repair. This poses a health and safety risk to clients in care. A deficiency will be cited.

LPA observed a sufficient supply of towels, linens and personal hygiene items. Cleaning supplies were observed to be locked in a storage closet and inaccessible to the clients. The facility’s smoke detectors are hard wired and observed to be in working condition. The carbon monoxide detectors were tested and are all in working condition. LPA observed eleven (11) fire extinguishers throughout the facility and were recently serviced and completely charged.

LPA observed the kitchen to be clean and free of odor and all food is stored and prepared in a healthful manner. All frozen and refrigerated food is sealed correctly and protected against contamination. Food supplies are sufficient to meet Title 22 requirements. LPA observed adequate quantity and variety of fresh fruit and vegetables.

LPA observed an inadequate quantity of tableware, dishes and utensils. Tableware and tables, dishes, and utensils shall be provided in the quantity necessary to serve the clients. The licensee failed to provide the quantity of bowls and dishes for the clients in care. This requirement was not met as evidenced by: There are currently 78 clients in care and LPA observed only 48 bowls, 67 plates, 56 cups, 44 forks and 65 spoons to serve the clients. Interviews conducted with staff revealed this is the entire quantity for the facility. This poses a risk for clients in care. A deficiency will be cited. The courtyard, breezeways and walkways are free of obstruction and revealed no immediate hazards.

Source
Facility Report

https://secure.dss.ca.gov/ccld/TransparencyAPI/api/FacilityReports?facNum=336403045&inx=9

Scroll to Top