FREMONT HILLS

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by having 3 tubs of paint in R1's room, lysol wipes and cleaning spray in R2's room, the tool shed unlocked in the courtyard of the memory care unit, Bissell, Alcohol Antiseptic, staff eyedrop in the backpack, etc. in the memory care unit dining hall which posed an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2025 Plan of Correction The Executive Director agrees to self-certify with the staff the regulation, remove the items, and send proof to CCLD by POC date.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above by not having the current liability insurance on file which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 11/03/2025 Plan of Correction The Executive Director agrees to send the current liability insurance to CCLD by POC date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in having R7's toilet, window blinds, and shower soap bar holder in disrepair and R3 and R4's call button that had a paper towel holding the button up which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 11/14/2025 Plan of Correction The Executive Director agrees to repair the items and remove the paper towels from the emergency call light button up. Proof of correction will be sent to CCLD by POC date.

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in having expired sesame sauce, soy sauce, Hershey chocolate powder, etc. which posed a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/07/2025 Plan of Correction The Executive Director agrees to self-certify the regulation with staff and send proof to CCLD by POC date.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(2) Personal Rights of Residents in All Facilities (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced: Based on interviews, the licensee did not comply with the section cited above by giving R1 the wrong medication dosage which posed a potential safety risk to person in care.

Official plan of correction

The Executive Director agrees to do a medication in-service training and send proof to CCLD by POC date.

Deadline recorded: Oct 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309(a) (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances...locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having Fluticasone Propionate Nasal Spray and medication syrup on top of the medication cart unsupervised by staff which poses an immediate health and safety risk to persons in care.

Official plan of correction

The Executive Director agrees to self certify the regulation and send proof to CCLD by POC date.

Deadline recorded: Aug 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above by having the call button system in disrepair which posed a potential safety risk to persons in care.

Official plan of correction

The Executive Director agrees to send a log of all the shifts testing the call button system for two weeks and send proof to CCLD by POC date.

Deadline recorded: Aug 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not having a health screening for S1 and S2 on file. Also, S1, S2, and S5 do not have a TB test on file which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 12/02/2024 Plan of Correction Generations Program Director agrees to have a health screening completed for S1 and S2. Generations Program Director also agrees to have a TB test completed for S1, S2, and S5. Proof of correction will be sent to CCLD by POC date. Proof of Corrections will be sent to CCLD by POC date.

Official classification

Type B

Official code

87468(c)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in not having the post of personal rights, nondiscrimination notice, and the right size for the complaint and ombudsman poster which poses a potential health and safety risk to persons in care. Proof of Corrections will be sent to CCLD by POC date.

Official plan of correction

POC Due Date: 11/22/2024 Plan of Correction Generations Program Director agrees to post the personal rights, nondiscrimination poster, and to obtain the right size for the complaint and ombudsman poster by POC date.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211(a)(1) Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement is not met as evidenced by: Based on interview and record review, the administrator did not comply with the section cited above by not reporting an incident to CCL within 7 days of the occurrence which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agreed to conduct a in-service training on the regulation Reporting Requirements and to have staff sign the in-service training and to submit to CCL by POC due date.

Deadline recorded: Jan 20, 2023. A deadline is not proof that correction was completed.