BELOVED HOME RETREAT

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 unlocked scissors in R2's room, prescribed mouthwash in R3's room, and paint in the living room which poses an immediate health and safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/28/2026 Plan of Correction By POC date, the Administrator agrees to self-certify the regulation and lock the items. Proof of correction will be sent to CCLD by POC date.

Official classification

Type B

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 S4 associated with the facility which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 06/04/2026 Plan of Correction By POC date, the Administrator agrees to have S4 associated with the facility and send proof to CCLD by POC date.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 first aid certification for S1 which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 06/04/2026 Plan of Correction By POC date, the Administrator agrees to obtain first aid certification for S1 and send proof to CCLD by POC date.

Official classification

Type B

Official code

87555(b)(28)

Regulation authority

CCR

What the official deficiency says

(28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. 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 rotten bananas and cucumbers which posed a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/04/2026 Plan of Correction During the visit, staff removed the items. Deficiency cleared.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above by not having 2 of R4's medications in the facility and a doctor's order for 4 medications for R4 which poses a potential health and safety or risk to persons in care.

Official plan of correction

POC Due Date: 06/10/2026 Plan of Correction By POC date, the Administrator agrees to obtain doctor's order for the R4's medication and obtain the other two medications to be in the facility. Proof of correction will be sent to CCLD by POC date.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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 doctor orders for bed rails for 4 of 4 residents which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/10/2026 Plan of Correction By POC date, the Administrator agrees to self-certify the regulation and obtains doctor’s order for all of the residents’ half bed rail. Proof of correction will be sent to CCLD.

Official classification

Type B

Official code

87465(a)(8)(A)

Regulation authority

CCR

What the official deficiency says

(A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. 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 not having a first aid manual book in the facility which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 06/04/2026 Plan of Correction By POC date, the Administrator agrees to purchase a first aid manual book and send proof to CCLD.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions...are in 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 the Clorox wipes and Lysol spray unlocked in the living room which poses an immediate health and safety risk to persons in care.

Official plan of correction

The Administrator agrees to self certify the regulation with staff and locked the items. Proof of correction will be sent to CCLD by POC date.

Deadline recorded: Oct 23, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(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. 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 the medication cart unlocked which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/02/2025 Plan of Correction Administrator locked the medication cart during the visit. Deficiency cleared.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 the hot water temperature measured at 124.8 degrees Fahrenheit which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/02/2025 Plan of Correction Administrator agrees to have the water temperature within range and send proof to CCLD by POC date.

Official classification

Type B

Official code

87465(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above by having medication for residents without a doctor's order which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/16/2025 Plan of Correction Administrator agrees to obtain a doctor's order for the medications and send proof to CCLD by POC date.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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 doctor's order for the half bed rail for both residents which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/23/2025 Plan of Correction Administrator will obtain a doctor's order for the half bed rail for both residents and send proof to CCLD by POC date.

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to construction or alterations, all facilities shall obtain a building permit. 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 alterations done without a building permit which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/16/2025 Plan of Correction The Administrator will send a new sketch, will request for fire department to do an inspection, and send proof to CCLD by POC date.

Official classification

Type B

Official code

1569.185(e)

Regulation authority

HSC

What the official deficiency says

(e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. 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 paying annual fees which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/09/2025 Plan of Correction The Administrator agrees to pay the annual fees that are due and send proof to CCLD by POC date.

Official classification

Type B

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof. This requirement was not met as evidenced by open trash bins without foot operated lids observed in bathrooms and bedrooms which posed a potential health & safety risk to residents in care.

Deadline recorded: Jul 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 in not obtaining a current First aid and CPR for S1, S2, and S3. S1 and S2's certificate expired on 5/15/2020, and S3 does not have first aid and CPR training in file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/09/2023 Plan of Correction Administrator agree to complete First aid and CPR training for S1, S2, and S3 and to submit proof of training to CCL by POC due date.

Official classification

Type B

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203: Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. 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 not re-servicing facilities fire extinguisher in common area near the backyard door that expired on 4/4/2019 which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/07/2023 Plan of Correction Administrator agreed to service fire extinguisher in common area room and to submit proof of re-service date shown on receipt of purchase to CCL by POC due date.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

Criminal clearance: (e) An applicant and any other person specified in subdivision (b) shall submit fingerprint images and related information to the Department of Justice and the Federal Bureau of Investigation… (1) adult responsible for administration or direct supervision of staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing a staff member work in the facility without having fingerprint clearance which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/06/2022 Plan of Correction Administrator removed S1 during visit. Administrator agreed to submit a self-certification to CCL by explaining that no Staff shall work in the facility without proper fingerprint clearance by POC due date.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia: (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). 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 not locking up sharps and pair of scissors that were accessible to dementia residents which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/06/2022 Plan of Correction Deficiency cleared. Administrator locked up sharps and medications during visit.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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 prepared residents medication on the kitchen counter, and having cleaning supplies accessible to residents in the laundry room unlocked which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/06/2022 Plan of Correction Administrator purchased and replaced pad locks which locked all medications and cleaning supplies. Deficiency cleared

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation (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 unrepaired and greasy cabinets in the facility which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2022 Plan of Correction Adminstrator agreed to fix and clear the kitchen cabinet(s) and to submit a photo copy to CCL by POC due date.