MONTGOMERY SPRINGS MANOR

Official classification

Type A

Official code

87202(a)(1)

Regulation authority

CCR

What the official deficiency says

87202 Fire Clearance: (a) All facilities shall maintain a fire clearance approved by...... 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....... ...(1) Nonambulatory persons. -This requirement is not met as evidenced by: -Based on review of records and inspection, the licensee did not comply with the section above in having R1 who is non-ambulatory in the bedroom fire cleared for ambulatory only which poses an immediate safety risk to person in care

Official plan of correction

Administrator stated she'll have the resident moved to their other facilty with non-ambulatory fire clearance. Proof to be submitted by 7/03/26. A $1,000.00 civil penalty is assessed.

Deadline recorded: Jul 3, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(c)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements: (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as.... ...required by Welfare and Institutions Code.... -This requirement is not met as evidenced by: -Based on interviews, the licensee did not comply with the section above when R1 and R2 had incident and report not submitted which posed a potential health, safety and/or personal rgihts risks to persons in care.

Official plan of correction

Administrator to do the following and submit proof by 7/16/26: 1. Read the Regulations and submit self-certication of understanding and ensure timely reporting. 2. Submit incident report.

Deadline recorded: Jul 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(1)

Regulation authority

CCR

What the official deficiency says

87202 Fire Clearance: (a) All facilities shall maintain a fire clearance approved by...... 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 ...(1) Nonambulatory persons. -This requirement is not met as evidenced by: -Based on review of records and inspection, the licensee did not comply with the section above in having R1 who is non-ambulatory in the bedroom fire cleared for ambulatory only which poses an immediate safety risk to person in care

Official plan of correction

Administrator stated she'll have the resident moved to their other facilty with non-ambulatory fire clearance. Proof to be submitted by 6/19/26, A $500.00 civil penalty is assessed.

Deadline recorded: Jun 19, 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

87309 Storage Space and Access (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: -Based on observation, the licensee did not comply with the section above in vitamins and razor in the closet in resident's room which pose an immediate health, safety and/or personal rights risks to persons in care.

Official plan of correction

Staff removed the items while LPA was at the facility. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 6/19/26. $250.00 civil penalty is assessed.

Deadline recorded: Jun 19, 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 the following which pose an immediate health, safety and/or personal rights risks to persons in care: Neosporin and muscle rub in resident's room; unlocked gate leading to storage where cleaning and laundry supplies are kept; Clorox bleach in the backyard; rubbing alcohol, rust remover and hammer in unlocked basement room; unlocked peritoneal cleanser and medications

Official plan of correction

POC Due Date: 03/25/2026 Plan of Correction Staff locked the medications and gate. Administrator have the basement cleaned and discarded the items in the basement. In addition, administrator to in-service the staff and submit copy of training topics with attendees signatures by 3/25/26.

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. 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 residents current medications not having doctor's orders on file which pose an immediate health and/orr personal rights risks to persons in care.

Official plan of correction

POC Due Date: 03/25/2026 Plan of Correction Administrator stated she'll obtain doctor's orders. Copies to be submitted by 3/25/26.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above in not submitting incident report when one of the residents was sent out to the hospital which posed a potential personal rights risk to person in care.

Official plan of correction

POC Due Date: 04/07/2026 Plan of Correction Administrator to submit incident report by POC date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in the following which pose a potential health, safety and/or personal rights risks to persons in care: broken glass window; cat's feces, rusted paint pan, paint roller, piece of wood and metal on top stairs; rusted sink in area adjacent to kitchen; broken drawer knob in residents' room; pieces of metal and pieces of wood, rusted grills, soiled placemat, empty milk container on the backyard ground

Official plan of correction

POC Due Date: 04/07/2026 Plan of Correction Administrator to do the following. Pictures to be submitted by 4/07/26: (1) Stated she'll have the sink remove. (2) Replace the glass window. (3) Replace the drawer knob. (4) Clean the yard and stair. A $250.00 civil penalty is assessed for repeat violation.

Official classification

Type B

Official code

87411(d)(1)

Regulation authority

CCR

What the official deficiency says

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (1) Principles of good nutrition, good food preparation and storage, and menu planning. 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 S3, a cook, not having food preparation training on file which poses a potential health and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 04/07/2026 Plan of Correction Administrator to have S3 trained and submit copy of training certificate.

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 residents' (R1 and R2) LIC602A Physician's Report/medical assessments over a year old which pose a potential health, safety or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 04/07/2026 Plan of Correction Administrator to call the residents' doctor to schedule assessment and submit copies of LIC602A by 4/07/26.

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 required drills at least every quarter which poses a potential safety and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 04/07/2026 Plan of Correction Administrator to read the Regulation and self-certify that drills are conducted as required.

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 not having doctor's orders for half bed rails for 2 residents which pose a potential safety and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 04/07/2026 Plan of Correction Administrator stated she'll obtain doctor's orders. Copies to be submitted by 4/07/26.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (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 in S2 not having LIC501 on file which poses a potential safety and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 04/07/2026 Plan of Correction Administrator to have the LIC501 completed and submit copy by 4/07/26.

Official classification

Type B

Official code

87463(e)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (e) The licensee shall immediately, or as soon as reasonably possible, bring any significant change in condition....to the attention of the appropriate licensed medical professional .... -This requirement is not met as evidenced by: -Based on record review, interviews and observation, the licensee did not compy with the section above for not having R1's LIC602A updated when R1's conditions changed which poses a potential health and/or personal rights risks to person in care.

Official plan of correction

Administrator to have the resident assessed and submit copy of updated LIC602A by 8/28/25.

Deadline recorded: Aug 28, 2025. 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.....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, interviews and observation, the licensee did not compy with the section above in retaining R1 who is dependent on all ADLs which poses a potential health and/or personal rights risks to person in care,

Official plan of correction

Administrator stated she'll submit request for exception. Signed written request with supporting documents to be submitted by 8/28/25.

Deadline recorded: Aug 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(c)(5)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment: (c) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101, ..The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition, or both.... -This requirement is not met as evidenced by: -Based on record review and observation, the licensee did not comply with the section above in R2's LIC602A not consistent with R2's ambulatory status

Official plan of correction

Administrator to have the LIC602A updated and submit copy by 8/28/25.

Deadline recorded: Aug 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(h)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (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: -Based on records review, the licensee did not comply with section above in R1 and R2's LIC602A more than a year old which pose a potential health and/or personal rights risks to persons in care.

Official plan of correction

Administrator agreed to make appointments and submit copies of LIC602A by 5/15/25.

Deadline recorded: May 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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 health, safety and/or personal rights risk to persons in care: unlocked pocket utility knife, skin protector, razor, cleaning supplies, construction tool, pails and gallons of paint and staff medications. This is a repeat violation. A $250.00 civil penalty is assessed.

Official plan of correction

POC Due Date: 03/06/2025 Plan of Correction Staff locked the items and the gate to the side yard. In addition, administrator to in-service the staff and submit proof by 3/07/25.

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 in the following which pose an immediate health and/or personal rights risks to persons in care: rotten mushrooms, Serrano peppers, radish, celery and carrots with mold in the refrigerator

Official plan of correction

POC Due Date: 03/06/2025 Plan of Correction Administrator discarded the items. In addition, administrator to do the following and submit proof by 3/07/25: 1. Have all the food supplies checked. 2. In-service the staff.

Official classification

Type A

Official code

87555(b)(9)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. 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 poses an immediate health and/or personal rights risks to persons in care: food items in the refrigerator still in the shopping bags and box packaging materials; sausage links and Bologna in open plastic packaging material.

Official plan of correction

POC Due Date: 03/06/2025 Plan of Correction Staff removed the shopping bags and put the sausage links in a Ziplock and threw away the Bologna. In addition, administrator to in-service the staff and submit proof by 3/06/25.

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 the following which pose a potential health, safety and/or personal rights risks to persons in care: rusted dirty dining chairs and trash cans; cracked cement in between transition and heavily scratched door post in the common bathroom; broken night stand door & heavily soiled upholstered chair in resident's room; stained stairs carpet covering; shower door with mildew and water damaged lavatory with stained faucet; debris/garbage in the backyard and ramp; dusty exit door. A $250.00 civil penalty assessed for repeat violation.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction Administrator to have following done and submit proof by 3/19/25: (1) Purchase trash cans and dining chairs; (2) Repair/fixed the cement cracks; (3) Repaint; (4) Repair or replace the night stand; (5) Purchase and replace the chair in the resident's room; (6) Deep cleaned the stairs's steps; (7) Clean the shower; (8) Replace/repair the lavatory; (9) Clean the yard, ramp and door.

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 record review, the licensee did not comply with the section cited above in not having CPR certified staff which poses a potential health, safety and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction Administrator stated she'll have the staff complete CPR training. Proof to be submitted by 3/19/25.

Official classification

Type B

Official code

1569.696(a)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: 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 S5 not having restricted health conditions training for 2024 which pose a potential health and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction Administrator stated she'll have the staff complete the training. Proof to be submitted by 3/19/25.

Official classification

Type B

Official code

1569.69(a)(2)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two 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 and S5 not having the required/ complete number hours of medication training which pose a potential health and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction Administrator stated she'll have the staff complete the training. Proof to be submitted by 3/19/25.

Official classification

Type B

Official code

87456(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. 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 R1 not having a pre-placement appraisal which posed a potential health, safety and/orr personal rights risks to persons in care.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction Administrator to complete the appraisal and submit copy by 3/19/25.

Official classification

Type B

Official code

87457(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall document, at a minimum: (A) An evaluation of the prospective resident's functional capabilities, mental condition, and social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors. 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 R1 not having a LIC9172 Functional Capability Assessment which poses a potential health, safety and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction Administrator to complete the LIC9172 and submit copy by 3/19/25.

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 records review, the licensee did not comply with the section cited above in R3, R4 and R5's LIC625 missing 2 pages and R3 and R4's not signed by the residents and/or residents's responsible person which posed a potential health, and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction Administrator to complete the LIC625s, review with the resident and/or residents' responsible person and have the documents signed. Self-certification to be submitted by 3/19/25.

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 record review, the licensee did not comply with the section cited above in S5 not First Aid certified which poses a potential health, safety and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction Administrator stated she'll have the staff trained. Copy of certificate to be submitted by 3/19/25.

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 record review, the licensee did not comply with the section cited above in not having doctor's orders for R1 and R3's bed rails which pose a potential safety and/or personal rights risks to persons in care. This is a repeat violation. A $250.00 civil penalty is assessed.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction Administrator stated she'll obtain doctor's orders. Copies to be submitted by 3/19/25.

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: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in R5's two medications incorrectly recorded on LIC622 which pose potential health and/or personal rights risks to persons in care. This is a repeat violation. A $250.00 civil penalty is assessed.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction Administrator to have the record corrected and in-service the staff. Proof to be submitted by 3/19/25.

Official classification

Type B

Official code

87411(d)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (1) Principles of good nutrition, good food preparation and storage, and menu planning. 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 S4, a cook, not having the required training which poses a potential health and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction Administrator to have the staff trained and submit proof by 3/19/25.

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. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents…….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 S4 not having LIC503 and S3's LIC503 incomplete which pose a potential health and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 03/19/2025 Plan of Correction Administrator to have the staff health screened and submit copies of LIC503 by 3/19/25.

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 record review and interview, the licensee did not comply with the section above in not completing the record when R1's medication was received and administered which posed a potential personal rights risk to person in care.

Official plan of correction

Administrator to do the following and submit proof by 2/28/25: 1. Complete the LIC622. 2. In-service the staff.

Deadline recorded: Feb 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 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: -Based on observation, the licensee did not comply with the section above for the following which pose a potential health and/or personal rights risks to persons in care: strong smell of urine in the bathroom; mouse droppings; dusty air vents; stain and dusty floor

Official plan of correction

Staff cleaned and removed the mouse droppings. In addition, administrator to do the following and submit proof by 2/28/25: 1. Have the bathrooms cleaned thoroughly. 2. Have all the vents and flooring cleaned properly. A $250.00 civil penalty is assessed for repeat violation. A citation was issued on 9/04/24.

Deadline recorded: Feb 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (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: (1) Obtain a California clearance ............ -This requirement is not met as evidenced by: -Based on observation and interviews, the licensee did not comply with the section in S1 working without fingerprint clearance which poses an immediate risk to persons in care. Civil penalty assessed.

Official plan of correction

Administrator stated she'll have the staff fingerprinted. Proof by 9/05/24. In addition, administrator not to allow S1 to work until cleared and associated. $100.00 civil penalty assessed.

Deadline recorded: Sep 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 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 -Based on observation, the licensee did not comply with the section above in the following which pose a potential health and/or personal rights risks to persons in care: untidy refrigerators; bathroom cabinet in disrepair; clogged lavatory; flies. This is a repeat violation within 12 month.

Official plan of correction

Staff cleaned the refrigerators while LPA was at the facility. In addition, administrator to do the following and submit proof by 9/18/24: 1. Have the bathroom cabinet repaired. 2. Have the lavatory unclogged. 3. Eradicate the flies and install door mesh. A $250.00 civil penalty is assessed.

Deadline recorded: Sep 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.269(a)(1)

Regulation authority

HSC

What the official deficiency says

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. -This requirement is not met as evidenced by -Based on interviews, the licensee did not comply with the section when staff made an inappropriatec comment toward resident which posed personal rights risk to person in care. This is a repeat violation. The first citation was issued on 3/08/24.

Official plan of correction

Administrator to in-service the staff and submit copy of training topic with attendees signatures by 9/18/24. A $250.00 civil penalty is assessed.

Deadline recorded: Sep 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (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: (1) Obtain a California clearance ............ -This requirement is not met as evidenced by: -Based on observation and interviews, the licensee did not comply with the section in S1 working without fingerprint clearance which poses an immediate risk to persons in care. Civil penalty assessed.

Official plan of correction

Staff left while LPA was at the facility. Administrator to have the staff fingerprinted and submit proof by 8/07/24. In addition, administrator not to allow S1 to work until cleared and associated. $200.00 civil penalty assessed.

Deadline recorded: Aug 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)

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, ........ -This requirement is not met as evidenced by: -Based on observation and interviews, the licensee did not comply with the section above in making the resident's room storage for staff's belongings/beds. This is a repeat violation within 12-month period. The first citation was issued 3/08/24.

Official plan of correction

Staff removed the items. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 8/20/24. $250.00 civil penalty is assessed.

Deadline recorded: Aug 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202a

Regulation authority

CCR

What the official deficiency says

87202(a) Alll 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 Marshall........ -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section cited above in converting the storage into staff bedroom which poses an immediate safety and/or personal rights risk to persons in care.

Official plan of correction

Corrected. LPA observed the storage is converted back to it's original use.

Deadline recorded: Apr 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

8730787307 Personal Accommodations and Services: (d)(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section cited above in stairway on the second floor from resident's room going to the backyard blocked with rusted lamp and commode which poses an immediate safety and/or personal rights risk to persons in care.

Official plan of correction

Administrator to in-service the staff, and submit proof by 4/27/24.

Deadline recorded: Apr 27, 2024. 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 cited above in .... the following: unlocked staff medications, scissors, razors, cleaning supplies, tools cart, shovel, pails of paint, bleach, rubbing alcohol, Hydrogen Peroxide; bread toaster in one of the residents' rooms, These pose an immediate health, safety and/or personal rights risks to persons in care.

Official plan of correction

Administrator to in-service the staff, and submit training topic with attendees signatures by 4/27/24.

Deadline recorded: Apr 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (1) The facility has a nonambulatory fire clearance for each room that will be used to accommodate a resident with dementia who is unable to or unlikely to respond either physically or mentally to oral instructions relating to fire or other dangers and to independently take appropriate actions during emergencies or drills. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, interviews and observation, the licensee did not comply with the section cited above in 2 residents (R3 and R4) in bedrooms not fire cleared for non-ambulatory which poses an immediate safety and/or personal rights risks to persons in care. A $500.00 civil penalty is assessed.

Official plan of correction

POC Due Date: 04/27/2024 Plan of Correction Administrator contacted the residents' responsible persons and stated she will have the residents move out. Proof to be submitted by 4/27/24.

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 records review, the licensee did not comply with the section cited above in staff (S2, S3, S4, S5) not having the complete required number of hours of annual training which poses potential health, safety and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 05/10/2024 Plan of Correction Administrator to have the staff complete the required training and submit self-certification by 5/10/24.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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 R5 not having medical assessment (LIC602A) which poses a potential health and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 05/10/2024 Plan of Correction Corrected.

Official classification

Type B

Official code

87458(b)(5)

Regulation authority

CCR

What the official deficiency says

(b) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101(a) or (n), or bedridden as defined in Section 87455(d). The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition or both. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interviews and record review, the licensee did not comply with the section cited above in R3 and R4's ambulatory status not consistent with mental/medical condition (non-ambulatory) which pose a potential health, safety and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 05/10/2024 Plan of Correction Administrator to obtain updated LIC602A and submit copies by 5/10/24

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 record review, the licensee did not comply with the section cited above in not having doctor's order for R1, R3 and R5's bedrails which pose a potential safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/10/2024 Plan of Correction Administrator to obtain doctor's order and submit copies by 5/10/24.

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 R1,R2 & R3’s LIC602A Physician's Reports 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: 05/10/2024 Plan of Correction Administrator to have the residents medically assessed and submit self-certification by 5/10/24 that LIC602As are obtained.

Official classification

Type B

Official code

87411(c)

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 in S1's first aid certificate expired and S2, S3, S4 & S5 not having first aid certificates on file which pose a potential health, safety and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 05/10/2024 Plan of Correction Administrator to have the staff register and complete the training and submit copies of certificates by 5/10/24.

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. 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 order which pose an immediate health, and/or personal rights risks to persons in care for the following: R`1's 10 medications; R2's 5 medications; 2 of R5's medications;

Official plan of correction

POC Due Date: 04/27/2024 Plan of Correction Administrator stated she'll obtain doctor's orders. Copies to be submiitted by 4/27/24.

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......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: -Based on review of records and interviews, the licensee did not comply with the section above when R1's cream run out and did not obtain nor follow-up with the doctor for the other cream.

Official plan of correction

One of the cream is delivered on 4/18/24. Administrator to check with the doctor if the other cream is still needed and submit proof by 4/20/24.

Deadline recorded: Apr 20, 2024. 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

(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: 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 converting the storage into staff bedroom which poses an immediate safety and/or personal rights risk to persons in care. At $500.00 civil penaty is assessed.

Official plan of correction

POC Due Date: 03/09/2024 Plan of Correction Administrator stated she'll have the room converted to it's original use as storage. Picture to be submitted by 3/09/24.

Official classification

Type A

Official code

87303(i)

Regulation authority

CCR

What the official deficiency says

(i) Facilities shall have signal systems which shall meet the following criteria: 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 2 exit doors with no auditory signals which pose an immediate health, safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/09/2024 Plan of Correction Administrator to have signals installed, and submit pictures by 3/09/24.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. 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 stairway on the second floor from resident's room going to the backyard blocked with rusted lamp and commode which poses an immediate safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/09/2024 Plan of Correction Staff removed the items. In addition, administrator to in-service the staff, and submit proof by 3/09/24.

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: unlocked staff medications, scissors, razors, cleaning supplies, tools cart, shovel, pails of paint, bleach, rubbing alcohol, Hydrogen Peroxide; bread toaster in one of the residents' rooms, These pose an immediate health, safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/09/2024 Plan of Correction Staff locked the items.. In addition, administrator to in-service the staff, and submit training topic with attendees signatures.

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 the following which pose a potential personal rights risks to persons in care: toilet paper holder in 2 bathrooms broken; 2 bathroom doors with dilapidated paint; wood transition in bathroom flooring rotten.

Official plan of correction

POC Due Date: 03/22/2024 Plan of Correction Administrator to do the following, and submit pictures by 3/22/24: 1. Replace the toilet paper holder. 2. Repaint the bathroom doors. 3. Replace the wood transition.

Official classification

Type B

Official code

87303(f)(3)

Regulation authority

CCR

What the official deficiency says

(f) Solid waste shall be stored and disposed of as follows: (3) 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 is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in trash cans in residents' rooms with no lids which pose a potential health and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/22/2024 Plan of Correction Administrator to purchase trash bins with foot pedal operated lids, and submit proof of purchase and pictures by 3/22/24.

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 interviews, the licensee did not comply with the section cited above in not conducting drills which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 03/22/2024 Plan of Correction Administrator to have drills conducted, and submit proof by 3/22/24.

Official classification

Type B

Official code

1569.695(f)(1)

Regulation authority

HSC

What the official deficiency says

(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell, on or before July 1, 2019. 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 evacuation chair which poses potential safety risk to persons in care.

Official plan of correction

POC Due Date: 03/22/2024 Plan of Correction Administrator to purchase evacuation chair, and submit proof of purchase by 3/22/24.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (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 degree C) and not more than 120 degree F (49 degree 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 137.8 degrees Fahrenheit. which poses an immediate health, safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/09/2024 Plan of Correction Administrator to have the temperature adjusted within Regulations range, and submit proof by 3/09/24.

Official classification

Type B

Official code

87307(a)

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. 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 staff sleeping in the resident's room which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/22/2024 Plan of Correction Administrator to have the staff stop sleeping in resident's room immediately. In addition, administrator to in-service the staff, and submit proof by 3/22/24.

Official classification

Type B

Official code

1569.269(a)(1)

Regulation authority

CCR

What the official deficiency says

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. -This requirement is not met as evidenced by: -Based on interviews, the licensee did not comply with the section when staff made an inappropriatec comment toward resident which posed personal rights risk to person in care.

Official plan of correction

Administrator to in-service the staff, and submit proof by 3/22/24.

Deadline recorded: Mar 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs........ -This requirement is not met as evidenced by: -Based on interviews, observation and records review, the licensee did not comply to the section above in not having sufficient staffing to be able to redirect resident timely and properly which poses potential personal rights risks to persons in care.

Official plan of correction

Administrator stated she'll hire additional staff. Copy of staff schedule to be submitted by 3/22/24.

Deadline recorded: Mar 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(3)(c)

Regulation authority

CCR

What the official deficiency says

87307 (3) Equipment and supplies necessary for personal care... shall be readily available to each resident... C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads... The quantity shall be sufficient to permit changing at least once per week or more often when indicated... This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in have appropriate linen on bed, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to put appropriate linen on each resident bed and submit a self-certification that it has been completed to CCLD by POC date.

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

Official classification

Type A

Official code

87705(l)(6)

Regulation authority

CCR

What the official deficiency says

87705 (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors... (6)Locked exterior doors or perimeter fences.. shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited in using a lock on entry/exit door for wander residents, which poses an immediate health and safety risk to persons in care.

Official plan of correction

Administrator agreed to remove locks from entry/exit door and submit a photo to CCLD by POC date.

Deadline recorded: Feb 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 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 was not met as evidence by: Based on observation and interview the Licensee did not comply with the section cited above in having facility free of rodents, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to rehire Terminx and submit invoice to CCLD by POC date.

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

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on observation the Licensee did not comply with the section cited above. PIN 21-38-ASC states " Well-fitting face mask is required in indoor settings (double mask or surgical mask recommended), unless an N95 respirator is required pursuant to Title 8 regulations. " for all staff and Licensees. However, LPAs observed Administrator Mirriam Paras, S1, S2, and S3 in facility without a mask in common areas which which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

By POC date Administrator agrees to review PIN 21-38-ASC and send a copy of self-certification document to CCL.

Deadline recorded: Aug 31, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. Based on observation the licensee did not comply with the section cited above. LPAs observed moldy cantaloupe in cabinet which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agrees to dispose all expired and moldy food and send self-certification to CCL by POC date.

Deadline recorded: Aug 31, 2021. A deadline is not proof that correction was completed.