GRAND OAK MANOR SUITE II LLC

Official classification

Type B

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, the licensee did not comply with the section cited above by having storage rooms as a resting room for staff, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/15/2026 Plan of Correction The licensee shall immediately discontinue the use of storage rooms as staff resting or break areas. The Administrator will ensure storage rooms are used only for their intended purpose and will conduct an in-service training with all staff regarding appropriate use of facility space. Documentation of the training and a signed self-certification of compliance shall be submitted to CCLD by the POC due date.

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, the licensee did not comply with the section cited above by not having a completed R1 physician report avalible at the facility during files review.

Official plan of correction

The Administrator should ensure that all resident records, including physician reports, are complete, current, and maintained in full. A standardized file review process should be implemented to verify that all required pages are present upon admission and during periodic audits. Missing or incomplete documents should be promptly obtained from the appropriate healthcare provider. The Administrator agrees to obtain the missing pages (including pages 5 and 6) of R1’s physician report and ensure the document is complete and up to date. The Administrator agrees to review the cited regulation in its entirety and complete a self-certification attesting to their understanding of the requirements. Documentation of the completed self-certification will be submitted to CCLD by the specified POC due date.

Deadline recorded: Mar 31, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: This requirement is not met as evidenced by: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on information obtained through interviews, it was determined that the staff did not provide adequate care and supervision for a resident. Witness statements from W1 and W9 indicated that they observed and heard that staff member S6 did not respond when R1 called for assistance.

Official plan of correction

Administrator(ADM) agree that ADM will review and re-train all staff on supervision requirements and resident care needs to ensure compliance with regulations. Submit attance and traning topic to CCLD by POC date.

Deadline recorded: Mar 24, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Base on information obtained through these interviews determined that staff engaged in verbal abuse toward a resident. Witness statements from W1 and W9 indicated that they observed and heard staff member S6 speak in an inappropriate and verbally aggressive manner toward R1.

Official plan of correction

Administrator (ADM) agree to provide Proof of training, updated supervision plan, and a statement of understanding will be submitted to CCLD by the POC due date.

Deadline recorded: Mar 24, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.269(a)(2)

Regulation authority

HSC

What the official deficiency says

§1569.269(a)(2)Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (2) To be granted a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the internet, and meetings of resident and family groups. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above by

Official plan of correction

Administrator agree to submit confirmation from vivint company confirming that those camera located in the common area do not have audio submitted via email to CCLD by POC date.

Deadline recorded: Mar 24, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87355(d)(3)

Regulation authority

CCR

What the official deficiency says

87355(d)(3) Criminal Record Clearance (d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury (3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by having staff working without finger print clearance which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to have staff printed and cleared before S1 can return to work. Administator will provide CCLD with clearance for S1 by POC date.

Deadline recorded: Mar 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)(1)

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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Based on observations by the Department, Licensee did not comply with the regulation cited above by the facility is not clean and sanitary due to rodent droppings in all of the resident room including but not limited to corners, closets, and also in the garage. In additional there was a black cockroach found in a pest glue trap.

Official plan of correction

Administrators agree to clean all rodent droppings in all residents' rooms, including but not limited to behind the furniture, closets, and all corners. Send pictures of POC to CCLD by POC dates.

Deadline recorded: Jan 1, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.651(b)

Regulation authority

HSC

What the official deficiency says

1569.651(b) Preadmission fee or deposit for elderly at residential care facilities; written statement describing costs and stating whether fee is refundable; conditions for refund; refund rate schedules (b) If a licensee charges a preadmission fee, the licensee shall provide the applicant or his or her representative with a written general statement describing all costs associated with the preadmission fee charges and stating that the preadmission fee is refundable. The statement shall describe the conditions for the refund as specified in subdivision (g). A licensee shall only charge a single preadmission fee as defined in subdivision (e) per resident admission. This requirement is not met as evidenced by: Based on record review and interviews by the Department, Licensee did not comply with the regulation cited above buy collecting a collected an additional security deposit of $6500, and first month's rent in the amount of $ 6500, and a preadmission fee in the amount of $ 3250.

Official plan of correction

ADM agree to refund the amount of $5850 to resposible party. ADM agree to review the LIC 604A and facility admission agreement and submit an adendum to changes chages that is being made. ADM agree to send in confirmation once ADM paid the amount to CCLD by POC date.

Deadline recorded: Dec 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.651(h)(3)

Regulation authority

HSC

What the official deficiency says

1569.651(h)(3) Preadmission fee or deposit for elderly at residential care facilities; written statement describing costs and stating whether fee is refundable; conditions for refund; refund rate schedules (h) Unless subdivision (g) applies, preadmission fees in excess of five hundred dollars ($500) shall be refunded according to the following: (3) If the resident leaves the facility for any reason during the second month of residency, the resident shall be entitled to a refund of at least 60 percent of the preadmission fee This requirement is not met as evidenced by: Based on record review and interviews by the Department, Licensee did not comply with the regulation cited above, by not refunding to FR. LPA interviewed with ADM and recorded reviews, showing that ADM took a security deposit amount of $6500 and a preadmission fee amount of $3250, minus 60 percent of the FR stated and minus excess cost of 500 a refund of the amount $1650 to FR.

Official plan of correction

ADM agree to refund the amount of $1650 to resposible party. ADM agree to send in confirmation once ADM paid the amount to CCLD by POC date.

Deadline recorded: Dec 31, 2025. A deadline is not proof that correction was completed.