COLONIAL ACRES RESIDENTIAL CARE HOME

Official classification

Type A

Official code

1569.311

Regulation authority

HSC

What the official deficiency says

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. 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 carbon monoxide not working due to no battery which poses an immediate safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/14/2025 Plan of Correction Corrected. Licensee put battery while LPA was at the facility.

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 the following which pose an immediate safety and/or personal rights risk to persons in care: unlocked knives, kitchen shears, lighter, razor, cleaning agents in the kitchen. THIS IS A REPEAT VIOLATION WITHIN 12 MONTH PERIOD.

Official plan of correction

POC Due Date: 11/14/2025 Plan of Correction Staff removed and locked all the items. In addition, licensee to in-service the staff and stated he will have lock installed on the kitchen drawers. Copy of in-service and pictures to be submitted by 11/14/25.

Official classification

Type A

Official code

87309(a)(1)

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. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above inunlocked utility room where cleaning supplies are kep which poses an immediate safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/14/2025 Plan of Correction Licensee locked the room. In addition, licensee to in-service the staff.

Official classification

Type A

Official code

87465(h)(1)(C)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications ........(1) Medications shall be centrally stored........ (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others. 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 medication on the kitchen counter and resident's medications unlocked in the refrigerator which pose an immediate health, safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/14/2025 Plan of Correction Staff locked the items. Licensee to in-service the staff and submit proof by 11/14/25.

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 loose light switch cover in resident's room which poses a potential safety and/or personal rights risks to persons in care. THIS IS A REPEAT VIOLATION WITHIN 12 MONTH PERIOD.

Official plan of correction

POC Due Date: 11/27/2025 Plan of Correction Licensee to have the switch cover fixed and submit picture by 11/27/25.

Official classification

Type B

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 in hot water temperature at 121.3 degrees Fahrenheit which poses a potential health and/or personal rights risks to persons in care. THIS IS A REPEAT VIOLATION WITHIN 12 MONTH PERIOD.

Official plan of correction

POC Due Date: 11/27/2025 Plan of Correction Licensee to have the water temperature adjusted to a temperature within Regulations range and submit proof by 11/27/25.

Official classification

Type B

Official code

87463(h)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in R2 and R3's medical assessments (Physician's Report) over a year old which pose a potential health and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 11/27/2025 Plan of Correction Licensee to have a medical assessment schedule for R2 and R3 and submit copies of LIC602A by 11/27/25.

Official classification

Type B

Official code

87463(i)

Regulation authority

CCR

What the official deficiency says

(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making. 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 R4's LIC625 Appraisal/Needs and Services Plan more than 2 years old which poses a potential health and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 11/27/2025 Plan of Correction Licensee to have the re-appraisal performed and submit copy of LIC625 by 11/27/25.

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 record review, the licensee did not comply with the section cited above in not conducting drills every quarter which poses a potential safety and/or personal rights risks to persons in care. THIS IS A REPEAT VIOLATION WITHIN 12 MONTH PERIOD.

Official plan of correction

POC Due Date: 11/27/2025 Plan of Correction Licensee to have drills conducted and submit copy by 11/27/25,

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (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 records review, the licensee did not comply with the section cited above in staff (S2 and S5) certificates expired which pose a potential health, safety and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 11/27/2025 Plan of Correction Licensee to have S2 and S5 register for training and submit copies of certificates by 11/27/25.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician… A signed statement shall be obtained from each volunteer affirming that he/she is in good health…… This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in S3 and S4 not having TB test and LIC503 Health Screening on file which pose a potential health and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 11/27/2025 Plan of Correction Licensee to have the staff undergo health screening and submit proof by 11/27/25.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

CCR

What the official deficiency says

§1569.625 Staff training; legislative findings; contents : (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in S3 & S4 not have the required total 40 hours required training which pose a potential health, safety and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 11/27/2025 Plan of Correction Licensee to have the staff complete training and submit proof by 11/27/25.

Official classification

Type B

Official code

87465(h)(6)(AtoF)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A)to(F). This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above for not having LIC622 Centrally Stored Medication and Destruction for all the medications received by the facility nor have complete record for medications administered for R5 which pose a potential health and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 11/27/2025 Plan of Correction Licensee to have the records completed and submit proof by 11/27/25.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in not having doctor's orders for R1 and R2's half bed rails which pose a potential health, safety andor personal rights risks to persons in care. THIS IS A REPEAT VIOLATION WITHIN 12 MONTH PERIOD.

Official plan of correction

POC Due Date: 11/27/2025 Plan of Correction Licensee to obtain doctor's orders and submit copies by 11/27/25.

Official classification

Type A

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 in Installing a door hardware operable with code in 2 entrance/exit doors and having dowels in the other entrance/exit door which poses an immediate health, safety or personal rights risk to persons in care. A $500.00 civil penalty is assessed.

Official plan of correction

POC Due Date: 11/14/2025 Plan of Correction Corrected. Licensee removed and replaced the door hardwares and replaced with a 'no-knowledge' type and removed the dowels while LPA was at the facility.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (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 record review, the licensee did not comply with the section cited above in not having one of R5's prescribed medications which poses an immediate health and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 11/14/2025 Plan of Correction Licensee to have the medication obtained and submit picture by 11/14/25.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

87202 Fire Clearance: (a) All facilities shall maintain a fire clearance approved by...... Prior to accepting or retaining any of the following types of persons.... licensee shall .... obtain an appropriate fire clearance approved by city, county, tor district..... ....(2) Bedridden persons. -This requirement is not met as evidenced by: -Based on record review and interviews, the licensee did not comply with the section above when R1 who is bedridden was admitted and facility does not have bedridden fire clearance.

Official plan of correction

R1 is no longer at the facility. Administrator to review all residents files and check their ambulatory status. Proof to be submitted by 12/21/24. A $500.00 civil penalty is assessed.

Deadline recorded: Dec 21, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87615(a)(5)

Regulation authority

CCR

What the official deficiency says

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:(5) Residents who depend on others to perform all.... ... activities of daily living for them.... -This requirement is not met as evidenced by: -Based on record review and interviews, the licensee did not comply with the section above when R1 who is dependent on others will all ADLs was admitted which posed a potential health risks to person in care.

Official plan of correction

Licensee and administrator to read the Regulations and ensure no resident with prohibited health conditions is admitted to the facility. Self-certification to be submitted by 1/03/25.

Deadline recorded: Jan 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. -This requirement is not met as evidenced by: -Based on records review, the licensee did not comply with the section in R1's incomplete LIC9172 which posed a potential health, safety and/or personal rights risks to person in care.

Official plan of correction

Administrator to review all residents files and complete the records. Self-certification to be submitted by 1/03/24.

Deadline recorded: Jan 3, 2025. A deadline is not proof that correction was completed.

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 in hot water at 127.4 degrees Fahrenheit which poses an immediate health and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 11/15/2024 Plan of Correction Licensee to have the temperature adjusted within Regulations range and submit proof by 11/15/24.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 the following which pose an immediate safety and/or personal right risks to persons in care: unlocked kitchen cabinet where cleaning supplies are kept; insect killer, laundry soap, Clorox spray, wound cleanser, staff's medications in unlocked staff room

Official plan of correction

POC Due Date: 11/15/2024 Plan of Correction License locked the items and the staff room. In addition, licensee and/or administrator to in-service the staff and submit copy of training topic with attendees signatures by 11/15/24.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. 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 all 3 entrance/exit doors' auditory signals/device turned off & not working which pose an immediate safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/15/2024 Plan of Correction Corrected. Staff fixed and turned on the auditory signals.

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 the following which pose an immediate health, safety and/or personal rights risk to persons in care: residents medications unlocked in the refrigerator; saline solution, wound and peritoneal cleansers, grooming kit in residents' rooms

Official plan of correction

POC Due Date: 11/15/2024 Plan of Correction Licensee locked all the items. In addition, licensee and/or administrator to in-service the staff and submit copy of training topic with attendees signatures by 11/15/24.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 broken drawer in resident's room which poses a potential safety and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 11/28/2024 Plan of Correction Licensee and/or administrator to have the drawer fixed and submit picture by 11/28/24.

Official classification

Type B

Official code

87463(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. 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 R2 who had change in condition and admitted back to the facility and LIC625 not updated which poses a potential health, safety and/ or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 11/28/2024 Plan of Correction Administrator to update R2's LIC625 and submit copy by 11/28/24.

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 record review, the licensee did not comply with the section cited above in not conducting the disaster drill every quarter which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 11/28/2024 Plan of Correction Administrator to have the drill conducted and submit copy by 11/28/24.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in 5 out of 5 residents' half bed rails not having doctor's orders on file which pose a potential safety and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 11/28/2024 Plan of Correction Administrator to obtain doctor's order and submit copies by 11/28/24.

Official classification

Type B

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above In R2 who has stage 3 pressure injury was admitted back to the facility. which poses a potential health and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/28/2024 Plan of Correction Licensee to obtain an updated stage of pressure injury from a wound doctor or wound nurse. If stage is still stage 3, licensee stated he'll submit exception request; otherwise submit an updated copy of wound assessment. Document(s) to be submitted by 11/28/24.

Official classification

Type B

Official code

87458(c)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (c) The licensee shall obtain an updated medical assessment when required by the Department. 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's LIC602A indicating R2 needs assistance with all ADLs but R2 can feed self. This poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/28/2024 Plan of Correction Administrator to obtain updated LIC602A and submit copy by 11/28/24

Official classification

Type B

Official code

87211(g)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. 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 not notifying the Department when a new administrator was hired poses a potential health and/ or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 11/28/2024 Plan of Correction Licensee to submit a signed letter along with copies of the new administrator's certificate, LIC501 Personnel Record by 11/28/24.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (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 records review, the licensee did not comply with the section cited above in R1 and R5 not having the right medication dosages, not having certain medications, and facility not administering the dosage as precribed which pose an immediate health and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/15/2024 Plan of Correction Licensee and/or administrator to check with R1 and R5’s physicians for updated doctor’s orders and administer the medications with correct dosage accordingly. If medications are no longer needed, to discontinue administration. Proof to be submitted by 11/15/24.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator.... The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the .facility as specified in this section......... -This requirement is not met as evidenced by: -Based on interviews, the licensee did not comply with the section abuve for not having administrator in January 2024 and the new administrator working only at most 4 hours per week.

Official plan of correction

Licensee to hire a full time administrator, and submit proof by 4/04/24.

Deadline recorded: Apr 4, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above for the shower area in the 2 bathrooms with not non-skid mats or strips which pose an immediate safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/10/2023 Plan of Correction Administrator to purchase non-skid mats or have strips inslalled. Pictures to be submitted by 11/10/23.

Official classification

Type A

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 for the expired sour cream which poses an immediate health risk to persons in care.

Official plan of correction

POC Due Date: 11/10/2023 Plan of Correction Staff discarded the item. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures bu 11/10/23.

Official classification

Type A

Official code

87465(h)(1)(C)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above for mediications in the storage box with broken lock and Albuterol soltuon in one of ther residents' rooms which pose an immediate health, safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/10/2023 Plan of Correction Staff locked the items. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures bu 11/10/23.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (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 record review, the licensee did not comply with the section cited above for facility not having the 4 medications for resident (R1) which were on the list of order which poses an immediate health risk to person in care.

Official plan of correction

POC Due Date: 11/10/2023 Plan of Correction Administrator to check with the doctor and if no llonger needed. to obtain discontinued order. Otherwise, obtain the medicaitons. Proof to be submitted by 11/10/23.

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 for S3 not having the required annual training on file which poses/posed a potential safety and/orpersonal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/23/2023 Plan of Correction Administrator to have the staff complete the training and submit proof by 11/23/23.

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. 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 5 out of 5 residents' LIC625 with no signatures of residents' responsible person; it's not clear whether or not the assessment been discussed which pose a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/23/2023 Plan of Correction Administrator to meet with the residents' responsible persons and have the LIC625 signed. Self-certificattion to be submitted by 11/23/23.

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 above for not conducting disaster drills which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 11/23/2023 Plan of Correction Administrator to have drills conducted and submit copy by 11/23/23,

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (c) (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 for S1, S4 and S5 expired first aid certificates which pose a potential safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/23/2023 Plan of Correction Administrator to have the staff complete the training and submit copies of certificates by 11/23/23.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 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 for shave cream, shaver, glucose lancets, and ointment unlocked in resident's room which pose an immediate safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/10/2023 Plan of Correction Staff locked all the items. In addition, administrator to add to in-service and submit copy of training topic with attendees signatures by 11/10/23.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above for unlocked utility room and storage where bleach and cleaning supplies are kept which pose an immediate health and safety risks to persons in care.

Official plan of correction

POC Due Date: 11/10/2023 Plan of Correction Administrator lock the room and storage. In addition, administrator to add to in-service and submit copy of training topic with attendees signaures by 11/10/23.

Official classification

Type B

Official code

87615(a)(5)

Regulation authority

CCR

What the official deficiency says

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities. 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 for R1 who is dependent on staff with all activities of daily living which poses a potential safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/23/2023 Plan of Correction Administrator to submit an exception request with supporting documents by 11/23/23.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. 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 for R3's LIC602A over a year old which poses a potential health and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/23/2023 Plan of Correction Administrator to arrange a doctor's appointment and submit a copy of LIC602A by 11/23/23.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (a)(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. 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 for not having doctor's order on R1's file for half bed rails which poses a potential safety and/or personal rights risks to person in care.

Official plan of correction

POC Due Date: 11/23/2023 Plan of Correction Administrator to obtain doctor's order and submit copy by 11/23/23.

Official classification

Type B

Official code

87506

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. 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 for R1's LIC622 not recording the dates medications were filled and started which pose a potential health, safety or personal rights risk to person in care.

Official plan of correction

POC Due Date: 11/23/2023 Plan of Correction Administrator to check all the residents' LIC622 and complete accordingly. Self-certification to be submitted by 11/23/23.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned,...... 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 for S3 not having LIC503 Health Screening and TB test on file which pose a potential health risk to persons in care.

Official plan of correction

POC Due Date: 11/23/2023 Plan of Correction Administrator to have the staff TB tested and have the LIC503 completed. Copy to be submitted by 11/23/23.

Official classification

Type B

Official code

87211(g)(1)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following: (1) Name and residence and mailing addresses of the new administrator. (2) Date he/she assumed his/her position. (3) Description of his/her background and qualifications, including documentation of required education and administrator certification. -This requirement is not met as evidenced by:

Official plan of correction

Licensee to submit the requested documents by 1/17/23.

Deadline recorded: Jan 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

00000000

Regulation authority

CCR

What the official deficiency says

CONTINUATION: -Licensee did not comply with the section above for not submitting the requested documents which poses potential personal rights risks to persons in care.

Deadline recorded: Jan 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidence -Based on inspection, records review and interview, the licensee did not comply with the section cited above. R1 was able to leave the facility unnoticed which posed immediate health and safety risks to person in care. LPA observed the auditory signal not properly working.

Official plan of correction

Licensee to do the following and submit proof by 1/11/23: 1. Replace the auditory signal. 2. In=service the staff.

Deadline recorded: Jan 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)(A)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (c) (5) (A)When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. -This requirement is not met as evidence:by: -Based on, records review, the licensee did not comply with the section above for not updating the Appraisal/Needs and Services to meet R1's current needs which poses potential health and safety risks to person in care,

Official plan of correction

Licensee o do the following and submit proof by 1/17/23: 1, Updated resident's Care Plan. 2. n-service the staff.

Deadline recorded: Jan 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 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: -Based on observation, the licensee did not comply with the section above for having unlocked medications, knives and cleaning supplies in unlocked kitchen which pose immediate safety risks to persons in care.

Official plan of correction

Staff locked the kitchen. Licensee to do the following and submit proof by 09/30/2022. 1. Install locks on the kitchen drawers where cleaning supplies and knives are kept. 2. Purchase a lockbox for medications that need refrigeration, 3. In-service staff

Deadline recorded: Sep 30, 2022. 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 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for the unlocked utility room which poses immediate safety risk to persons in care.

Official plan of correction

Staff locked the room. In addition, licensee to in-service the staff and submit copy of in-service training with attendees signatures by 09/30/2022.

Deadline recorded: Sep 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for having the auditory signal on the entrance door disabled which poses immediate safety risk to persons in care.

Official plan of correction

Staff turned-on the auditory signal. Licensee to in-service the staff and submit copy of in-service training with attendees signatures by 09/30/2022.

Deadline recorded: Sep 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following:(3) Ensuring that the use of oxygen equipment meets the following requirements:(B) " No Smoking-Oxygen in Use " signs shall be posted in the appropriate areas. -This requirement is not met as evidenced by: -Based on observation, records review and interview, the licensee did not comply with the section above for not having the poster posted which poses potential safety risk to persons in care.

Official plan of correction

Licensee to post posters and submit pictures by 10/13/2022.

Deadline recorded: Oct 13, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(e)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. -This requirement is not met as evidenced by: -Based on interviews, the licensee did not comply with the section above for not keeping/retaining R1's record which poses potential personal rights risk to person in care.

Official plan of correction

Licensee to designate a location/storage of records for residents who are no longer at the facility and keep the records for at least 3 years. Proof to be submitted by 10/13/2022.

Deadline recorded: Oct 13, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

87202 Fire Clearance (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 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 adding 3 bedrooms inside the staff rooms. License failed to submit updated facility sketch so CCL can request for fire safety inspection. This poses an immediate safety risk to persons in care. A $500.00 civil penalty is assessed.

Official plan of correction

POC Due Date: 11/10/2021 Plan of Correction Administrator to submit the following by November 10, 2021: 1. Updated facility sketch showing the follwing: exit doors and windows; use and dimension of each room; number of residents in each of resident's room; utility shut off locations. 2. LIC9054 Local Fire Inspection Authority Information