Alcohol Drug Care Services Residential Treatment Program

Published
0.000
Contact Information
Licensee Name
Alcohol/Drug Care Service's, Inc.
S1321, 1335C Streetand 217 1401 Street, Eurek, CA 95501
Facility Name
Identification Number
120009AN
Reviews & Findings
Dates of Review
28-Jun-16
Type of Review
CERTIFICATION COMPLIANCE REVIEW
Deficiencies

1) Section 16020 Residential Detoxification Practices

The above section states, in part, “Each individual will be closely observed and physically checked at least every 30 minutes during the first 12 hours following admission by a staff person or volunteer. The close observation and physical checks will continue beyond the initial 12-hour period for as long as the withdrawal signs and symptoms warrant. Documentation of the information that supports a decrease in observation and physical checks will be recorded in the participant’s file by a staff person or volunteer.”
a. At least one staff member or volunteer will be assigned to the observation of detoxification participants at all times.
b. Staff or volunteer will physically check each participant for breathing by a face-to-face physical observation at least every 30 minutes.
c. Documentation of observations and physical checks will be recorded in a systematic manner.”

The provider was deficient in meeting the above standard the following:

1. The program’s detoxification protocols say the residents will be under “24 hour monitoring”
2. In the detox logs for participant was documented that they were checked every hour during the first 12 hours.

2) Section 17010 Program Policies

The above section states, in part, “All Program policies and procedures will be contained in an operation manual that is located at each certified site and that will be available to staff and volunteers. The policies and procedures manual will contain but not be limited to the following (a) Program mission and philosophy statement(s); (b) Program description; (c) Program objectives; (d) Program evaluation plan; and (e) Policies and procedures for: (1) Admission and readmission; (2) Intake; (3) Discharge; (4) Individual and group sessions; (5) Alumni involvement; (6) Use of volunteers; (7) Recreational activities; (8) Detoxification services, if applicable; (9) Program administration; (10) Personnel practices; (11) Participant grievances/complaints; (12) Fiscal practices; (13) Continuous quality management; (14) Participant rights; (15) Nondiscrimination in provision of employment and services (16) Confidentiality; (17) Community relations; (18) Maintenance of Program in a clean, safe and sanitary physical environment; (19) Use of prescribed medications by participants; (20) Maintenance and disposal of participant files; (21) Drug screening; and (22) Code of conduct.”

The provider was deficient in meeting the above standard because there was no policy and procedure for the following:

1. Individual and group sessions.
2. Alumni involvement.
3. Use of volunteers.
4. Recreational activities.

3) Section 19005(b)(1-7) Personnel Policies

The above section states, in part, The program shall maintain personnel files for all employees. Each personnel file shall contain:
* Application for employment and resume
* Employment confirmation statement
* Job description
* Employee evaluations

The provider was deficient in meeting the above standard because the following items were missing from the employee’s file:

(1) No job application for employee #’s 1, 3, 4, 8, 10 and 12.
(2) No resume’ for employee #’s 1, 2, 3, 4, 5, 7, 8, 9, 11, 12, 13 and 14.
(3) No job description for employee #’s 4, 5, 6, 10 and 14.
(4) No employee evaluation for employee #’s 12, 13 and 14.

4) Section 19015(a) Health Screening and Tuberculosis Requirements

The above section states, “All staff and volunteers whose functions require or necessitate contact with participants or food preparation shall complete a health screening report or health questionnaire.”

The provider was deficient in meeting the above standard because there was no health screening report in the personnel file for employee numbers 1, 3, 4, 5, 6, 7, 8, 10, 11, 12 and 14.

5) Section 26010(a) Health and Safety

The above section states, in part, “Program will be clean, safe, sanitary and in good repair at all times for the safety and well-being of participants, employees and visitors. (1)The Program will be free from: (A) Broken glass, filth, litter, or debris; (B) Flies, insects, or other vermin; (E) Peeling paint or broken plaster; and (F) Other health or safety hazards. (2) The Program will maintain all carpets and floors free from filth, holes, cracks, tears, broken tiles, or other safety hazards.”

The provider was deficient in meeting the above standard because of the following: Address 1335 C Street:
1. Raccoons living in the walls of 1335 C Street.
2. Women’s detox room- paint peeling off the walls.
3. Resident advisor’s room- paint peeling off the walls.
4. Living room- couch torn and ripped.
5. Living room- 2 broken dressers, missing drawers.
6. Kitchen- stove, stove top and oven dirty.
7. Kitchen cupboards- opened coconut, pancake mix, powdered sugar and shaken’ bake.
8. Kitchen cupboards- expired canned foods.
9. Upstairs hallway- light missing a cover.
10. Hallway outside of resident advisor’s room- loose from the wall.
11. Women’s detox bathroom- mold in and around shower.
12. Men’s upstairs bathroom- mold in the shower and fan rusted.
13. Kitchen bathroom- mold in the shower, baseboards peeling off the wall.

Deficiencies 2

1) Title 9, Section 10501(a)(4) Definitions Class C

The above section states, in part, “Alcoholism or Drug Abuse Recovery or Treatment Planning” means the development of a resident specific goal and a continuum of recovery or treatment objectives.”

The licensee was deficient in meeting this regulation because the treatment plans for participant did not have a specific goal related to recovery or treatment objectives.

2) Title 9, Section 10563 Accountability Class B

The above section states, “The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning operation.”

The licensee was deficient in meeting this regulation because there were raccoons living in the walls of 1335 C Street.

3) Title 9, Section 10563 Accountability Class B

The above section states, “The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation.”

The licensee was deficient in meeting this regulation because Participants had a prescription for in medication bag, but were not written or Medication log.

4) Title 9, Section 10565(a) Personnel Records Class C

The above section states, in part, “Personnel records shall be completed and maintained for each employee, shall be available to the department for review, and shall contain the following information: .. .Past experience, including types of employment and former employers. Duty statement: All personnel shall have on file the record of the health screening as specified in Section 10564(c)(1), (2) of this sub chapter.”

The licensee was deficient in meeting this regulation because of the following:
1. No resume for employee #’s 1, 2, 3, 4, 5, 7, 8, 9, 11, 12, 13 and 14.
2. No application n for employee #’s 1, 3, 4, 8, 10 and 12.
3. No job description/duty statement for employee #’s 4, 5, 6, 10, and 14.
4. No health screening report for employee #’s 1, 3, 4, 5, 6, 7, 8, 10, 11, 12 and 14.

5) Title 9, Section 10573(a) Food Service Class C

The above section states, in part, “In facilities providing meals to residents, the following shall apply: All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption.”

The licensee was deficient in meeting this regulation because of the following: Address 1335 C Street:
1. Kitchen cupboards- opened coconut, pancake mix, powdered sugar and shake n’ bake.
2. Kitchen cupboards- expired canned foods.

Address 217 14th Street:

1. Kitchen refrigerator- cooked food stored in a pot with tin foil covering it.
2. Kitchen cupboards- opened chips, cereal and cream of wheat.
3. Kitchen cupboards- expired canned foods.

6) Title 9, Section 10581(a) Buildings and Grounds Class C

The above section states, in part, “Facilities shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors.

The licensee was deficient in meeting this regulation because of the following: Address 1335 C Street:
1. Women’s detox room- paint peeling off the walls.
2. Resident advisor’s room- paint peeling off the walls.
3. Living room- couch torn and ripped.
4. Living room- 2 broken dressers, missing drawers.
5. Kitchen- stove, stove top and oven dirty.

Address 217 14th Street:

1. 4 person room- dresser broken and missing drawers.
2. 4 person room- paint peeling off the walls..
3. 4 person room- carpets dirty.
4. 2 person room- door frames broken.
5. 2 person room- paint peeling off the walls.
6. Dining room- paint peeling off the walls.
7. Kitchen- floor damaged in between kitchen and living room.
8. Upstairs hallway- fire extinguisher with no service tag and needle out of the green.

Address 1321 C Street:

1. Kitchen- oven, stove top and overhead fan dirty.
2. Kitchen- floor dirty, 2×2 square of linoleum by the refrigerator torn up from the ground.
3. Living room- paint peeling from the walls.

7) Title 9, Section 10584(b) Fixtures, Furniture, Equipment and Supplies Class C

The above section states, in part, “All window screens shall be in good repair and free of insects, dirt and other debris.”

The licensee was deficient in meeting this regulation because of the following: Address 217 14th Street:
1. Living room- cobwebs on the inside window sills.
2. 4 person room- blinds broken on the windows.

Address 1321 C Street:

1. No screens on bedroom windows.
2. No blinds on windows, windows covered with blankets.

8) Title 9, Section 10584(c) Fixtures, Furniture, Equipment and Supplies Class C

The above section states, “The licensee shall provide lamps or lights as necessary in all rooms and other areas to ensure the safety of all persons in the facility.”

The licensee was deficient in meeting this regulation because of the following: Address 1335 C Street:
1. Upstairs hallway- light missing a cover.
2. Hallway outside of resident advisor’s room- loose from the wall.

Address 217 14th Street:

1. 4 person room- light cover and light bulbs missing on overhead light.
2. 2 person room- no light bulbs in overhead light and desk lamp does not work.
3. Livingroom- light fixture over orange couch missing light bulbs.
4. Dining room- light bulbs out over the table.

Address 1321 C Street:

1. Bedroom #3- overhead light bulbs out.

9) Title 9, Section 10584(e) Fixtures, Furniture, Equipment and Supplies Class C

The above section states, “All toilets, hand washing and bathing facilities shall be maintained in safe and sanitary operating conditions.”
The licensee was deficient in meeting this regulation for the following:

Address 1335 C Street:

1. Women’s detox bathroom- mold in and around shower.
2. Men’s upstairs bathroom- mold in the shower and fan rusted.
3. Kitchen bathroom- mold in the shower, baseboards peeling off the wall.

Address 217 14th Street:

1. Bathroom #1- no light over sink, wall damaged and paint peeling off the wall.
2. Bathroom #2- paint peeling off the wall.
3. Bathroom #3- paint peeling off the wall.

Address 1321 C Street:

1. Kitchen bathroom- mold in the shower, cobwebs on the ceiling and chipped paint by the sink.
2. Hallway bathroom- overhead fan dirty.

10) Title 9, Section 10584(f) Fixtures, Furniture, Equipment and Supplies Class C

The above section states, in part, “Solid waste shall be stored, located and disposed in such a manner that will not transmit communicable diseases, emit odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid waste shall have tight fitting covers that are kept in place.”

The licensee was deficient in meeting this regulation because the trash can in the kitchen of 1335 C Street, did not have a tight fitting lid.

11) Title 9, Section 10584(g) Fixtures, Furniture, Equipment and Supplies Class C

The above section states, “The licensee shall provide clean linen in good repair, including lightweight, warm blankets, top and bottom bed sheets, pillow cases, mattress pads, bath towels, and wash cloths. The quantity of linen provided shall permit changing, at a minimum, once a week or with greater frequency if needed. ”

The licensee was deficient in meeting this regulation because there was were no mattress pads on the following beds:

1. 1335 C Street-Men’s bed #7.
2. 217 14th Street- All 6 beds.
3. 1321 C Street- All 6 beds.

Detailed Information
Census Data

TOTAL OCCUPANCY:
Approved: 23
Census: 19

TREATMENT CAPACITY:
Approved: 21
Census: 16