OAKLAND HEIGHTS SENIOR LIVING

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. Based on records review and interview, R1 and R2 left the facility unassisted on 07/25/2026, became lost, and were observed traveling along the shoulder of the freeway. The licensee did not update R1 and R2's appraisals following the incident which can cause a potential health and safety risk to the residents.

Official plan of correction

Licensee shall complete updated reappraisals for R1 and R2 and submit copies to CCLD by the POC due date.

Deadline recorded: Aug 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(b)

Regulation authority

CCR

What the official deficiency says

(b) The licensee shall obtain an updated medical assessment when required by the Department. Based on records review, R1's Physician's Report is dated 03/05/2024 and R2's Physician's Report is dated 02/10/2020. Following the incident on 07/25/2026, in which R1 and R2 left the facility unassisted, and were observed walking along the shoulder of the freeway, the facility did not obtain updated medical assessments for R1 and R2 as required by the Department which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee shall obtain updated medical assessments/Physician’s Reports for R1 and R2 and submit copies to CCLD by the POC due date.

Deadline recorded: Aug 26, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days...(D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. Based on records review and interview, R1 and R2 left the facility on 07/25/2026, became lost, and were observed walking along the shoulder of the freeway. The facility did not submit a written incident report to CCLD regarding the incident within seven days of the occurrence which posed a potential risk to the health and safety of residents in care.

Official plan of correction

Licensee shall submit the incident report for R1 and R2 to CCLD, review the regulation, and provide a letter of attestation to LPA by the POC due date.

Deadline recorded: Aug 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 was not met as evidence by: Based on observations, the licensee did not comply with the section cited above by having unlocked sharps and chemicals in resident common areas which posed an immediate safety risk to persons in care.

Official plan of correction

By POC facility agrees to conduct a formal training to all care staff and house keepers in relation to storage space and access and provide training materials to CCLD. $250 Civil Penalty Issued For Repeat Violation in 12month Period.

Deadline recorded: Aug 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h)The following requirements shall apply to medications which are centrally stored:(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met as evidence by: Based on observations and record review, the licensee did not comply with the section cited above by having medications that are required to be centrally stored accessible to residents R7, and R8 which posed an immediate safety risk to persons in care.

Official plan of correction

By POC facility agrees to conduct a formal training to all care staff in relation to medication management and assistance and provide training materials to CCLD.

Deadline recorded: Aug 27, 2026. 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

(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, the licensee did not comply with the section cited above by facility being unclean and unsanitary throughout (the main living room floor/carpet covered with debris, trash, and crumbs, floors, surfaces, unsanitary ie hallway floors with spills and sticky, in dining spills that have turned sticky, in kitchen/dining splatters of unknown substances on floor and wall, doors with dirt, crumbs of food throughout facility) which poses a potential personal rights risk to persons in care.

Official plan of correction

By POC facility agrees to develop and implement daily checks and cleanings of common areas and notify CCLD to reinspect

Deadline recorded: Sep 3, 2026. 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

(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. This requirement was not met as evidence by: Based on observation, the licensee did not comply with the section cited above by facility being unclean and unsanitary throughout (the main living room floor/carpet covered with debris, trash, and crumbs, floors, surfaces, unsanitary ie hallway floors with spills and sticky, in dining spills that have turned sticky, in kitchen/dining splatters of unknown substances on floor and wall, doors with dirt, crumbs of food throughout facility) kitchen staff not ensuring proper food storage which poses a potential health and personal rights risk to persons in care.

Official plan of correction

By POC facility agrees to conduct a formal training with all kitchen staff regarding proper food preparation and storage and provide training materials used to CCLD as well as notify CCLD to reinspect

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

Official classification

Type B

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

(b)The following food service requirements shall apply: (27)All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement was not met as evidence by: Based on observations the licensee did not comply with the section cited above by an alive roach being in the cabinet located in the resident dining kitchen area which poses a potential personal rights risk to persons in care.

Official plan of correction

By POC facility agrees to have pest control come and treat facility perimeters as well as kitchen area and submit proof of service to CCLD

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

Official classification

Type B

Official code

87506(c)(1)

Regulation authority

CCR

What the official deficiency says

(c)All information and records obtained from or regarding residents shall be confidential.(1)The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not met as evidence by: Based on observations the licensee did not comply with the section cited above by having resident files accessible and unlocked exposing confidential information in common hallway in the downstairs, main building which poses a potential personal rights risk to persons in care.

Official plan of correction

By POC facility agrees to ensure all files of residents current and past are in a secure location to ensure confidentiality and provide CCLD with the new location/ area of storage.

Deadline recorded: Aug 27, 2026. 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

(3)Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C)Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. This requirement was not met as evidence by: Based on observations the licensee did not comply with the section cited above by R9 and R10 having inadequate linens for their respective beds which poses a potential personal rights risk to persons in care.

Official plan of correction

By POC facility agrees to dispose of all ripped linens, ensure all residents linens are clean, ensure all residents have readily accessible all required linens, and notify CCLD to reinspect.

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

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a)The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement was not met as evidence by: Based on record review the licensee did not comply with the section cited above by S2's file being incomplete in missing their job application/start date, health screening, and TB test results) which poses a potential personal rights risk to persons in care.

Official plan of correction

By POC facility agrees to audit all staff files and ensure completion then notify CCLD.

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

Official classification

Type B

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

(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 This requirement was not met as evidence by: Based on record review the licensee did not comply with the section cited above by S2-S5 not having required annual training's which poses a potential personal rights risk to persons in care.

Official plan of correction

By POC facility agrees to audit all staff files and ensure completion od all required training's for care staff by a CCLD approved vendor and notify CCLD.

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

Official classification

Type B

Official code

87303(i)(B)

Regulation authority

CCR

What the official deficiency says

Facilities shall have signal systems which shall meet the following criteria: Transmit a …auditory signal to a…location…loud enough to summon staff. This requirement was not met as evidence by Based on observation, the licensee did not comply with the section cited above by not having the supplied pendent functioning which posed a potential health and safety risk to persons in care.

Official plan of correction

By POC date Executive Director agrees to check all batteries for all pendents and create a system to regularly check the batteries.

Deadline recorded: May 12, 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(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... This requirement is not met as evidenced by: Based on observations and record review, the licensee did not comply with the section cited above by having unlocked medications such as polyethylene glycol in R1’s room in memory care and unlocked bug spray in the common area which posed an immediate safety risk to persons in care.

Official plan of correction

Staff removed the items and locked it. Deficiency cleared during today's visit.

Deadline recorded: Apr 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303(e)(2) Maintenance and Operation (2)... 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: Based on observation, the licensee did not comply with the section cited above by having the water temperature measured at 100.1 degrees Fahrenheit which poses a potential safety risk to persons in care.

Official plan of correction

By POC date, the Executive Director agrees to have the water temperature within range and send proof to CCLD.

Deadline recorded: Apr 10, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(h)(2)

Regulation authority

CCR

What the official deficiency says

Admission Agreements. (h) The admission agreement shall not contain the following: (2) Written or oral agreements to waive facility responsibility or liability for the health, safety or the personal property of residents, or the provision of safe and healthful facilities, equipment and accommodations. This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by including bed bug appendix in the admission agreement which poses a personal rights violation to the persons in care.

Official plan of correction

Licensee will remove the noncompliant language from the Admission Agreement, including Appendix J (Bed Bug Addendum), that could be interpreted as waiving or shifting facility responsibility or liability for resident health, safety, personal property, or provision of safe and healthful accommodations. The revised Admission Agreement will be sent to CCLD by POC date. Civil penalty of $250 is being assessed for a repeat violation.

Deadline recorded: Mar 11, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.269(a)(5)

Regulation authority

HSC

What the official deficiency says

Enumerated rights: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. Based on record review the licensee did not comply with the section cited above. Licensee added a bed bug addendum to the admissions agreement requiring residents to pay for bed bug eradication, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to send a notice to all residents notifying them of the removal of the bed bug addendum, licensee to reimburse any residents for costs of bed bug treatments and send letter of self-attestation of completion to LPA by POC date.

Deadline recorded: Dec 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The admission agreement shall not contain the following: (2) Written or oral agreements to waive facility responsibility or liability for the health, safety or the personal property of residents, or the provision of safe and healthful facilities, equipment and accommodations. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above. Licensee added a bed bug addendum to the admissions agreement requiring residents to pay for bed bug eradication, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to send a notice to all residents notifying them of the removal of the bed bug addendum, licensee to reimburse any residents for costs of bed bug treatments and send letter of self-attestation of completion to LPA by POC date.

Deadline recorded: Dec 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(e)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (e) If the resident is an SSI/SSP recipient, then the basic services shall be provided and/or made available at the basic rate at no additional charge to the resident. This requirement was not met as evidence by: Based on interviews and record review the Licensee did not comply with the section cited above in providing basic service at no additional rate for an SSI/SSP recipitent, which poses a potential risk to persons in care.

Official plan of correction

Executive Director agreed to recind the eviction notice to R1 and submit proof to CCLD by POC date.

Deadline recorded: Jul 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.269(a)(22)

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:(22) To be protected from involuntary transfers, discharges, and evictions in violation of state laws and regulations. Facilities shall not involuntarily transfer or evict residents for grounds other than those specifically enumerated under state law or regulations, and shall comply with enumerated eviction and relocation protections for residents. For purposes of this paragraph, “involuntary” means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident.

Official plan of correction

Administrator to review PIN 24-13 and send LPA self-attestation by 8/01/25.

Deadline recorded: Aug 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(H)(2)

Regulation authority

CCR

What the official deficiency says

87507 Admission Agreements(h)The admission agreement shall not contain the following: (2) Written or oral agreements to waive facility responsibility or liability for the health, safety or the personal property of residents, or the provision of safe and healthful facilities, equipment and accommodations. This requirement is not met as evidenced by: the facility waiving it's responsibility to provide a safe and healthy facility by requiring residents to pay the cost of bed bug removal.

Official plan of correction

Administrator to submit a revised bed bug addendum to CCL and residents by POC date.

Deadline recorded: Nov 22, 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 the facility did not ensure the R1’s apartment was kept free of bed bugs.

Official plan of correction

Facility administrator shall develop a plan for routine maintenance, including checks for bed bugs, and submit to CCL by POC date. LPA also requests all bed bug reports for R1's Apartment be sent to LPA by POC date.

Deadline recorded: Nov 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1

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: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, This requirement is not met as evidenced by the facility threatening R1 with eviction if they did not sign the addendum to the admission agreement.

Official plan of correction

Facility to conduct a Residents Rights training by POC date and submit proof to CCL by POC date.

Deadline recorded: Nov 15, 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 the facility did not ensure the R1’s apartment was kept free of bed bugs.

Official plan of correction

Facility administrator shall develop a plan for routine maintenance, including checks for bed bugs, and submit to CCL by POC date. LPA also requests all bed bug reports for R1's Apartment be sent to LPA by POC date.

Deadline recorded: Nov 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1

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: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, This requirement is not met as evidenced by the facility threatening R1 with eviction if they did not sign the addendum to the admission agreement.

Official plan of correction

Facility to conduct a Residents Rights training by POC date and submit proof to CCL by POC date.

Deadline recorded: Nov 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

87208(a) Plan of Operation…Any significant changes in the plan of operation…shall be submitted to the licensing agency for approval. This requirement is not met as evidenced by: Based on observations, interviews and record review, the licensee did not comply with the section cited above in by changing the plan of operation without CCLD approval which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

By POC date, the facility will submit to CCLD for review a new, detailed plan of operation describing the changes that the Licensee wishes to implement.

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

Official classification

Type A

Official code

87303(2)

Regulation authority

CCR

What the official deficiency says

(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. Hot water in the hallway bathroom was measured at 147.2 degrees F which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/17/2024 Plan of Correction Administrator will submit a photo of the hot water temperture in the hallway bathroom within regulation by POC date.

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

87465(h)(5) Incidental Medical and Dental Care. Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the section cited above. LPA observed several days of pre-poured medication s in the med room which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/19/2024 Plan of Correction Administrator will submit training records for all staff who pass medications in the proper storage and management of meds by POC date.

Official classification

Type B

Official code

87412(f)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. -This requierment is not met as evodenced by: -Based on interview, the licensee did not comply with the above for not having staff file available for review.

Official plan of correction

Executive Director to read the Regulation, and self-certify that records wiill be made reacily available for inspection. Self-certification to be submitted by 3/03/23..

Deadline recorded: Mar 3, 2023. 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. In facilities licensed for sixteen or more, sufficient support staff shall be employed ........... -This requirenent is not met as evidenced by: -Based on interviews, the licensee did not comply with the section above for not having sufficient staff.

Official plan of correction

Executve Director stated they are in the process of hiring memory care coordinator. Proof that this postiion is filled-up tp be submitted by 3/24/23.

Deadline recorded: Mar 24, 2023. 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 inspection, observation and inteview, the licensee did not comply with the section above for having rat infestation.

Official plan of correction

Corrected. Faciliy hired pest control company. Proof of service obtained by LPA on this same day, 2/24.23.

Deadline recorded: Mar 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(l)(8)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (l):(8) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. -This requirement is not met as evidenced by: -Based on records review and interview, the licensee did not comply with the section above for not having completed fire drills which poses potential safety risks to persons in care.

Official plan of correction

Executive Diector (ED) to have fire drill conducted and submit proof by 3/03/23.

Deadline recorded: Mar 3, 2023. 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 inspection and observation, the licensee did not comply with the section above for trash in the stairwell which ppsed potential health and personal rights risks to persons in care.

Official plan of correction

The garbage was removed on the day LPA observed. In addition, ED will in-service the staff and submit by 3/03/23.

Deadline recorded: Mar 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269(a)(5)

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: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. -This requirement is not met as evidenced by: -Based on records review and interviews. the licensee did not comply with the section above for staff not responding to residents' calls in timely manner which poses immediate health, safety and personal right risks to persons in care.

Official plan of correction

Executive Director (ED) stated he and/or Care Service Directors will review the call button records periodically to ensure timely response. In additiionm, ED will conduct in-service training, and submit copy of training topic with attendees signatures by 2/25/23.

Deadline recorded: Feb 25, 2023. 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 interviews and inspection. the licensee did not comply with the section above. LPA observed a clothes washer in the Salem Building with an out or order sign on it which poses a potential safety risk to person in care.

Official plan of correction

Administrator to do the following: Have the necessary repairs completed or replace the washer with an operational unit by the POC date.

Deadline recorded: Feb 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects... All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Licensee failed to keep the facility clean and free of pests which posed a potential health and safety risk to residents in care

Official plan of correction

The facility covered part of the kitchen wall where the vermin/rodents had access to the facility, sticky traps for rodents were set up and checked weekly. Previous LPA requested a permanent plan on how to prevent rodents/vermin entering the facility. POC was cleared on 04/07/2021

Deadline recorded: Jan 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87755(c)

Regulation authority

CCR

What the official deficiency says

87755 Inspection Authority of the Licensing Agency (c)The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand... Records may be removed if necessary for copying... This requirement was not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not providing records requested by the department which poses a potential health and safety risk to the persons in care.

Official plan of correction

Administrator agreed to provide documents to the department when requested and provide and in-service training explaining regulation 87555 and submit a verification of training with signatures to CCLD by POC date.

Deadline recorded: Jan 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

87465 (g) The licensee shall immediately telephone 9-1-1 if an injury... has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis... This requirement was not met as evidence by: Based on investigation the Licensee did not comply with the section cited above in telephoning 9-1-1 immediately for an injury, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agrees to have an authorized vendor conduct in-service staff retraining on timely addressing residents’ medical needs. Administrator agrees to submit completed staff retraining certifications to CCLD by POC date.

Deadline recorded: Jan 16, 2023. A deadline is not proof that correction was completed.

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. This requirement is not met as evidenced by… Based on record review, the licensee did not comply with the section cited above. LPA observed facility does not have an active certified Administrator associated in the month of January and February 2022 which poses a potential health and safety concern to persons in care.

Official plan of correction

Executive Director agreed to review the regulation and submit a self-certification of understanding regulation to CCL by the POC due date.

Deadline recorded: Sep 6, 2022. 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.... This requirement is not met as evidenced by… Based on record review, the licensee did not comply with the section cited above. LPA observed key fobs on Salam Woods Building did not operate to open the door which poses a potential health and safety concern to persons in care.

Official plan of correction

Defeciency Cleared. ED has awarded the contract of repairing key fobs system on 8/23/22, the project starting date is pending, and also, ED proactively keeps CCL updated.

Deadline recorded: Sep 6, 2022. A deadline is not proof that correction was completed.

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. This requirement is not met as evidenced by… Based on record review, the licensee did not comply with the section cited above. LPA observed facility does not have an active certified Administrator associated in the month of January and February 2022 which poses a potential health and safety concern to persons in care.

Official plan of correction

Executive Director agreed to review the regulation and submit a self-certification of understanding regulation to CCL by the POC due date.

Deadline recorded: Sep 6, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(4)

Regulation authority

CCR

What the official deficiency says

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: (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. This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, facility staff failed to respond to residents pendant call for assistance in a timely manner which poses a potential risk to the health and safety of resident under care.

Official plan of correction

Executive director agrees to conduct staff training will be conducted about the facility’s protocol on pendant call response and submit proof of training to CCL by POC date,

Deadline recorded: Aug 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 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 regulation is not being meet by observation of the doors to the independent living building. The doors must be manually opened manually which posed a potential threat to the safety of the residents in care.

Official plan of correction

Executive Director has agreed to provide LPA with bi-weekly updates on the progress of the door repair.

Deadline recorded: Jun 30, 2022. 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

Personal Rights (a) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (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. This requirement was not met as evidenced by resident sustaining pressure injuries while in care which posed a potential health & safety risk to resident in care

Official plan of correction

By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on proper incontinence care and will submit to CCLD copy of completed staff retraining.

Deadline recorded: May 26, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

Basic Services Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications… This requirement was not met as evidenced by staff failing to reposition resident in bed which posed a potential health & safety risk to resident in care

Official plan of correction

By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on proper repositioning techniques and will submit to CCLD copy of completed staff retraining.

Deadline recorded: May 26, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)(3)(B)

Regulation authority

CCR

What the official deficiency says

Personnel requirements - General 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 (3) The training shall include, but not be limited to, the following: (B) Importance and techniques of personal care services, including but not limited to, bathing, grooming, dressing, feeding, toileting, and infection control… This requirement was not met as evidenced by staff failing to reposition resident which posed a potential health & safety risk to resident in care

Official plan of correction

By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on proper repositioning techniques and will submit to CCLD copy of completed staff retraining

Deadline recorded: May 26, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations & Services: The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by non functioning building elevator, exterior doors & FOB keys which posed a potential Health & Safety risk to residents in care

Official plan of correction

By POC due date, Administrator agrees to submit to CCLD proof of repairs to permanently fix broken building elevator, exterior doors & FOB keys for residents in care.

Deadline recorded: May 26, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. General Food Service Requirements. All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Licensee failed to keep the facility clean and free of rodents which poses a potential health and safety risk to residents in care.

Official plan of correction

S2 states facility covered part of the kitchen wall where the vermin/rodents have access to the facility, sticky trap for rodents are set up which is being check weekly. LPA requested for a permanent plan on how to prevent rodents/vermin entering the facility. LPA discussed with S2 and Yidara about starting weekly monitoring documentation when staff check sticky trap. Staff will indicate the following information but not limited to; check date, if there is/are rodents captured, the action that was taken. This document and plan need to be submitted to CCL by POC date.

Deadline recorded: Apr 1, 2022. 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 evidenced by inaccessible elevator from garage to residential levels which posed a potential health & safety risk to residents in care.

Official plan of correction

Facility will submit a plan of maintenance service which needs to be approved by CCL by the POC due day.

Deadline recorded: Mar 31, 2022. 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

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 evidenced by inoperable exterior doors which posed a potential health & safety risk to residents in care

Official plan of correction

Administrator/Executive Director agreed to elevate the broken exterior doors with corporate to get the doors permanently fixed for the safety of all residents, visitors and staff. By POC due date, Administrator/Executive Director will submit to CCLD a copy of repaired exterior doors invoice certifying that the exterior doors are safely operable for residents, visitors & staff to use.

Deadline recorded: Feb 4, 2022. 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

Maintenance and Operation (e)Water supplies and plumbing fixtures shall be maintained as follows:(2) Faucets used by residents...Hot water temperature controls shall be maintained ... 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: Based on LPAs observation, Licensee did not comply with the regulation cited above. LPAs observed hot water temperature maintained at 123 and 96 degrees F which poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator will maintain hot water temperature between 105 to 120 degrees F and submit a self-certification letter to CCL by POC date.

Deadline recorded: Oct 12, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by: Based on LPAs observation, Licensee did not comply with the regulation cited above. LPAs observed a dresser blocking the exit in the memory care building which poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator will remove dresser and submit a photo to CCL by POC date. In addition, Administrator will review regulation and conduct training with staff and submit a copy of training to CCL by 10/29/2021

Deadline recorded: Oct 12, 2021. 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

Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not repairing the community gate which poses a potential health and safety risk to the residents in care.

Official plan of correction

Administrator will submit receipt to show the community gate was repaired by POC date. If administrator is unable to repair the community gate by POC date, a plan will be submitted to CCLD on how long it would take to repair the community gate to operable condition.

Deadline recorded: May 26, 2021. A deadline is not proof that correction was completed.