K & J RESIDENTIAL CARE HOME

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 observations, the licensee did not comply with the section cited above by having multiple items in the house such as disinfectant spray, disinfectant wipes, laundry detergent, Fabuluso, Scrubbing Bubbles Cleaner, etc. accessible to residents in care which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/09/2026 Plan of Correction By POC date, the Administrator agrees to self-certify the regulation and locked all the chemicals. Proof of correction will be sent to CCLD.

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 by havin multiple medications in the living room, eyedrops in R1's room, and R2's medications in the fridge unlocked and accesscible to residents in care which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/09/2026 Plan of Correction By POC date, the Administrator agrees to self-certify the regulation and locked all the medications. Proof of correction will be sent to CCLD.

Official classification

Type B

Official code

87307(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations and interview, the licensee did not comply with the section cited above by having a bed in the living room and staff living in the shed in the backyard which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/16/2026 Plan of Correction By POC date, the Administrator agrees to remove the bed in the living room and speak to the licensee about what the plan will be for the shed whether a permit will be obtained or we will remove the staff belongings. 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

(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, licensee did not comply with the section cited above by having rotten onions which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/12/2026 Plan of Correction Staff threw the onions away during the visit. Deficiency cleared.

Official classification

Type B

Official code

87555(b)(25)

Regulation authority

CCR

What the official deficiency says

(25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. 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 food items such as cereal, cocoa almond spread, etc. in the same storage cabinet as cleaning chemicals which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/16/2026 Plan of Correction By POC date, the Administrator agrees to separate the food supplies from the chemicals. Proof of correction will be sent to CCLD by POC date.

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, the licensee did not comply with the section cited above by having the Medication Administratation Record (MAR) for May 2026 and June 2026 is not filled out which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/22/2026 Plan of Correction By POC date, the Administrator agrees to have in-service on medication administratation and documentation. Proof of correction will be sent to CCLD.

Official classification

Type B

Official code

1569.605

Regulation authority

CCR

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, the licensee did not comply with the section cited above by not having the liability insurance on file and the one present does not show the coverage insurance which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/22/2026 Plan of Correction By POC date, the Administrator agrees to obtain the liability insurance and send proof to CCLD.

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...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 unlocked sanitizing wipes and hydrocortisone cream in the bathroom which posed an immediate safety risk to persons in care.

Official plan of correction

Staff agrees to lock the items and send proof to CCLD by POC date.

Deadline recorded: Jan 27, 2026. 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

(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 in by having unlocked cleaning supplies such as Ajax, Lysol Spray, Borax and unlocked medications such as Nyquil, Allergy Medicine, and Suppositories which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/19/2025 Plan of Correction The Administrator will sent proof of the items removed and locked away by POC date.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 conducting annual staff training which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/02/2025 Plan of Correction The Administrator agrees for staff to complete their training and send proof 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 by having a rotten tomato in the fridge and expired canned goods in the storage room which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/19/2025 Plan of Correction The Administrator will sent proof of the items removed by the POC date.

Official classification

Type B

Official code

87506(b)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: 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 complete file for all the residents which poses a potential health and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/02/2025 Plan of Correction The Administrator agrees to send proof of the residents' file complete 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 half bed rail order for R1, R2, and R4 which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/02/2025 Plan of Correction The Administrator agrees to obtain an order for the residents' half bed rail and send proof to CCLD by POC date.

Official classification

Type B

Official code

87412(a)

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: 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 the Administrator's file in the facility which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 06/25/2025 Plan of Correction The Administrator agrees to have their file accessible in the facility and send proof to CCLD by POC date.

Official classification

Type B

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

87412(d) Personnel Records: (d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. 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 having a current administrator certificate on file which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2024 Plan of Correction By POC date administrator agrees to submit the required documentation to start the certificate renewal process.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in R2 being bedridden which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2024 Plan of Correction By POC date Administrator agrees to have resident reassesed or come up with a placement plan and notify CCLD.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(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 in having dangerous items unlocked which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/21/2024 Plan of Correction Administrator removed and secured items.

Official classification

Type B

Official code

87307(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building. 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 in having a bed set up in the living room for staff to sleep on which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2024 Plan of Correction By POC date Administrator agrees to remove bed and notify CCLD.

Official classification

Type B

Official code

87506(b)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: 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 in R2 not having a needs and services plan which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2024 Plan of Correction By POC date Administrator agrees to review all residents files to ensure the are complete and up to date and notify CCLD.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(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, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited abovenot having done a disaster drill this year which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2024 Plan of Correction By POC date administrator agrees to complete and log emergency disaster drill and notify CCLD.

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 by allowing S1 to work in the facility with no First aid and CPR training on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/07/2023 Plan of Correction Administrator agreed for S1 to attend First aid and CPR training and to submit proof of training to CCL by POC due date.

Official classification

Type B

Official code

87412(a)

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: 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 maintaing staff records for S1, and S2; S1 does not have an Lic501 (Personnel record), 503 (Health screening), and 508 (Criminal record statement) on file, and S2 does not have an Lic508 on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/07/2023 Plan of Correction Administrator agreed to fill out an Lic 501, 503, and 508 for S1, and for S2 an Lic 508 and to submit to CCL by POC due date.

Official classification

Type B

Official code

87506(b)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: 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 maintaining an Lic625 (Needs and service plan) for R1, R2, and R3 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/07/2023 Plan of Correction Administrator agreed to fill out an Lic625 form for R1, R2, and R3, and to submit to CCL by POC due date.

Official classification

Type B

Official code

87307(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services: (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building. 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 a bed placed in the living room that staff are using for sleeping, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/07/2023 Plan of Correction Submit to CCL by POC date. Administrator agreed to remove the bed from the living room and to submit a picture as proof.

Official classification

Type B

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

87412(d) Personnel Records: (d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. 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 having a current administrator certificate on file for S2 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/21/2023 Plan of Correction Administrator agreed to follow up with Sacramento's Administrator Certificate office to get S2's certificate and to submit proof of certificate to CCL 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 in having inaccessible Sharps, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/11/2022 Plan of Correction Administrator agreed to re-train staff on regulations and submit an in service training with staff signatures to CCL by POC date. Administrator locked up knifes and sccissors 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 in having inaccessible toxins, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/11/2022 Plan of Correction Administrator agreed to re-train staff on regulations and submit an in service training with staff signatures to CCL by POC date. Administrator locked up knifes and sccissors during visit.

Official classification

Type B

Official code

87555(27)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. 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 kitchen free of insects, which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/17/2022 Plan of Correction Administrator agreed to submit a photo copy to CCL by POC date by patching up the crack under the sink so flies will not enter the facility.

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

87305 Alterations to Existing Building or New Facilities: (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 and record review, the licensee did not comply with the section cited above by not obtaining a permit for shed located in backyard using to reside staff member which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/17/2022 Plan of Correction Licensee agrees to submit a copy of a permit for the shed located in the backyard by POC date.

Official classification

Type B

Official code

87608(5)(A)

Regulation authority

CCR

What the official deficiency says

87608 Postural Support: (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (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 observation and record review, the licensee did not comply with the section cited above by not having a doctor’s order for half bed rail for R1, Which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 06/17/2022 Plan of Correction Adminisinstraor agrees to submit a physcians order for half bed rail for R1 to CCL by POC due date.