MORI MANOR

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... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not as evidence by: Based on record review and interview, the licensee did not comply with the section above by not obtaining medication refills in a timely manner for R1 which poses an immediate health and personal rights risks the persons in care.

Official plan of correction

By POC date, the Administrator agrees to submit proof of R1's medication obtained to CCLD.

Deadline recorded: Feb 4, 2026. 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 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to [...] This requirement is not met as evidenced by: Based on record review and interview the Licensee did not comply with the section cited above by not calling 9-1-1 when R1 was complaining of pain which poses a potential personal rights risk to persons in care.

Official plan of correction

The Administrator has agreed to review regulation and self certify with signatures by POC date.

Deadline recorded: Sep 4, 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

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. Based on observation, the licensee did not comply with the section cited above by having a pair of scissors unlocked in a residents room and unlocked laundry room which poses an immediate health and safety rights risk to persons in care.

Official plan of correction

Administrator removed the scissors and locked them up in a locked closet during the visit. Administrator locked the laundry room containing cleaning disinfectants and cleaners during visit. Deficiency cleared.

Deadline recorded: Jun 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(g)

Regulation authority

CCR

What the official deficiency says

(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following: Based on record review, the Licensee did not comply with the section cited above by not providing the documentation required for administrator change which poses a potential personal rights risk to persons in care.

Official plan of correction

The Administrator has agreed to provide the required documentation for the change of administrator on or before the POC date.

Deadline recorded: Jun 27, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87156(a)

Regulation authority

CCR

What the official deficiency says

87156 Licensing Fees (a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section above by not paying the late/licensing fees which poses an immediate health and safety risk to persons in care.

Official plan of correction

Administrator agreed to make payment and provide proof of that payment to CCL on or before the POC date.

Deadline recorded: Jun 20, 2025. 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

87465 Incidental Medical and Dental Care (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. Based on observation, the licensee did not comply with the section cited above in having unlocked medications in refridegerator and a resident's room which poses an immediate health and safety risk to persons in care.

Official plan of correction

Administrator has agreed to obtain lock boxes for medications in the refrigerator and resident's room. Administrator will submit picture proof to CCL on or before the POC date. Civil Penalty of $250 is being assessed for repeat violation.

Deadline recorded: Jun 20, 2025. 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

87465 Incidental Medical and Dental Care (h)The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by not locking R1's medication which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2024 Plan of Correction S1 locked R1's medication during the visit.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interviews, the licensee did not comply with the section cited above by not providing window screens in the kitchen, bedrooms and common areas which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/11/2024 Plan of Correction Licensee to update CCLD with a quote and provide photos when the screens are installed on or before POC date.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties:(a).....The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section.... -This requirement is not met as evidenced by: Based on records review, NCC and interview, the licensee did not comply wth the section above in administrator not in the faciity for 40 hours/week which poses a potential health, safety and/or personal rights risks to persons in care. This is repeat violation,

Official plan of correction

Administrator to devote 40 work hours/week and submit copy of LIC500 Personnel Report by 5/22/24. A $250.00 civil penalty is assessed.

Deadline recorded: May 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: -Based on observation, the licensee did not comply wth the section above in overgrown weeds in the backyard, and bed frame, head board and bed rails in the side yard which pose a potential safety risks to persons in care. Ths is a repeat violation

Official plan of correction

Administrator to have the yards cleaned and submit pictures by 5/22/24. A $250.00 civil penalty is assessed.

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

Official classification

Type B

Official code

87219(d)

Regulation authority

CCR

What the official deficiency says

87219 Planned Activities (d) In facilities licensed for seven (7) or more persons, notices of planned activities shall be posted in a central location readily accessible to residents, relatives, and representatives of placement and referral agencies........... -This requirement is not met as evidenced by: -Based on observation and interviews, the licensee did not comply with the section above for not having planned activites for residents.

Official plan of correction

Administrator to do the following, and submit proof by 5/22/24: 1. Come up with resident appropriate activities schedule. 2. Ensure that the planned activities are conducted.

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

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

87705 (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. -This requirement is not met as evidenced by -Based of observation, the licensee did not comply with the section above in entrance/exit doors auditory signals turned off which posed immediate risk to persons in care, This is a repeat violation within 12 month period. First citation was issued on 6/28/23.

Official plan of correction

Auditory signals were turned on while LPA was at the facility. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 5/09/24.

Deadline recorded: May 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Based on observation, the facility did not have sufficient supply of non perishable foods which poses a potential risk to health and safety of clients under care.

Official plan of correction

Administrator agreed to purchase food and submit photos of food and receipts to CCLD by POC date.

Deadline recorded: May 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87311

Regulation authority

CCR

What the official deficiency says

87311 Telephones All facilities shall have telephone service on the premises... This requirement is not met as evidence by: Based on interview the licensee did not have telephone service for the residents which poses/posed a potential Health, Safety or Personal Rights risk to persons in care. Administrator stated that the phone was in disrepair for about 5 (five) days due to internet problems

Official plan of correction

Deficiency cleared during visit, Administrator stated that the facility telephone was repaired about 3 (three) days ago and is operable. LPA called the facility telephone and confirmed it is working.

Deadline recorded: Nov 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. -This requirement is not met as evidenced by: -Based on observation and interview, the licensee did not comply with the section above for smoke detectors in R1's room removed which poses immediate safety risk to person in care. Civil penalty is assessed.

Official plan of correction

Administrator stated he'll have smoke detectors installed, Pictures to be submitted by 10/25/23. A $1,000.00 civil penalty is assessed today.

Deadline recorded: Oct 25, 2023. 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

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications..(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. -This requirement is not met as evidenced by: -Based on observation. the licensee did not comply with the section above for medications unlocked in R1's room which poses immediate health and/or personal rights risks to persons in care. This is a repeat violation.

Official plan of correction

Staff took and locked the medications. Administrator to in-service the staff and submit copy of training topic with attendees signatures by 10/25/23. A $250.00 civil penalty is assessed,

Deadline recorded: Oct 25, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for unlocked storage, shovel in the side yard, weed killer in cabinet without lock in the foyer, wound cleanser in cabinets without lock, and scissors. These pose immediate health and safety risks to persons in care. This is a repeat violation.

Official plan of correction

Staff put shovel and weed killer in the storage and lock the storage, In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 10/25/23. A $250.00 civil penalty is assessed,

Deadline recorded: Oct 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 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 mouse droppings and protruding drain pipe which pose potential safety risks to persons in care. This is a repeat violation.

Official plan of correction

Administrator called Pest Control company to provide service. Proof of service to be submitted by 11/07/23. In addition, administrator to do the following and submit proof by 11/07/23: 1. Have the mouse droppings cleaned-up and submit picture. 2. Have the protruding pipe fixed and submit picture. A $250.00 civil penalty is assessed,

Deadline recorded: Nov 7, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (a) ....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....... -This requirememt is not met as evidenced by: -Based on record review, the licensee did not comply with the section above for R2's half bed rails without doctor's order on file which poses potential personal rights risk to person in care.

Official plan of correction

Administrator to obtain doctor's order and submit copy by 11/07/23.

Deadline recorded: Nov 7, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff -This requirement is not met as evidenced by: -Based on record review, the licensee did not comply with the section above for R2's LIC9172 and Appraisal indicated ambulary, which are not consistent with LIC602A which showed bedridden. These pose potential safety and/or personal rights risks to person in care. This is a repeat violation.

Official plan of correction

Administrator to have R2 seen by primary care physician (pcp) and update the documents accordingly. Copies of updated Appraisal and LIC9172 to be submitted by 11/07/23. A $250.00 civil penalty is assessed.

Deadline recorded: Nov 7, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(b)(5)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (b) The medical assessment shall include, .. (5) The determination whether the person is ambulatory or nonambulatory ... The assessment shall indicate whether nonambulatory status is based upon the resident’s physical condition, mental condition or both. -Based on record review, the licensee did not comply with the section above for R2's LIC602A indicated bedridden which poses potential safety and/or personal rights risks to persons in care. This is a repeat violation,

Official plan of correction

Administrator to have R2 seen by pcp and have the LIC602A updated and copy to be submitted by 11/07/23. A $250.00 civil penalty is assessed.

Deadline recorded: Nov 7, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(24)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements: (b) The following food service requirements shall apply: (24) Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas, or where kitchen equipment or utensils are stored. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for keeping the weed killer in the cabinet where food supplies are kept which poses potential health and/or personal right rsks to persons in care,

Official plan of correction

Staff removed and locked the weed killer. Administrator to in-service the staff and submit copy of training topic with attendees signatures by 11/07/23.

Deadline recorded: Nov 7, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (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. -This requiement is not met as evidenced by: -Based on records, the licensee did not comply with the section above for R2's LIC602A signed by PA-C not consistent with MD's assessment. R2 was not followed-up with his MD. These pose potential health, safety, and/or personal rights risks to person in care. This is a re-citation.

Official plan of correction

Administrator to do the following and submit proof by 11/07/23. 1. Have an appointment schedule with R2's doctor. 2. Obtain an updated LIC602A.

Deadline recorded: Nov 7, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(1)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for having shovel and shave cream unlocked which poses an immediate safety risks to persons in care,

Official plan of correction

LPA had the items locked by the staff. Administrator to in-service the staff and submit copy of training topic with attendees signatures by 9/30/23.

Deadline recorded: Sep 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to.....(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for weed and grass killer unlocked which poses an immediate risk to persons in care,

Official plan of correction

LPA had the item locked by the staff. Administrator to in-service the staff and submit copy of training topic with attendees signatures by 9/30/23.

Deadline recorded: Sep 30, 2023. A deadline is not proof that correction was completed.

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..... -This requirement is not met as evidenced by: -Based on records review, the licensee did not comply with the section above for not having doctor's order for R1's 8 medications which poses immediate health risk To person in care.

Official plan of correction

Administrator to obtain doctor's order and submit copy by 9/30/23. A $250.00 civil penalty is assessed.

Deadline recorded: Sep 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

CONTINUATION OF THE ABOVE: This is a repeat violation within 12 months. First citation was issued on 7/27/23.

Deadline recorded: Sep 29, 2023. A deadline is not proof that correction was completed.

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......... (4) The licensee shall assist residents with self-administered medications as needed. -This requirement is not met as evidenced by: -Based on records review, the licensee did not comply with the section above for not having 3 of R2's medications and 2 medications dosage and stregth different from the order which poses immediate risks to person in care.

Official plan of correction

Administrator to obtain the medications and submit pictures by 9/29/23.

Deadline recorded: Sep 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (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. -This requiement is not met as evidenced by: -Based on records, the licensee did not comply with the section above for R2's LIC602A signed by PA-C not consistent with MD's assessment. R2 was not followed-up with his MD. These pose potential health, safety, and/or personal rights risks to person in care.

Official plan of correction

Administrator to do the following and submit proof by 10/13/23. 1. Have an appointment schedule with R2's doctor. 2. Obtain an updated LIC602A.

Deadline recorded: Oct 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(e)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative,,,, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467...... -This requirement is not met as evidenced by: -Based on record review, the licensee did not comply with the section above for R2's LIC625 Appraisal/Needs and Services Plan more than a year old which poses potential health and/or personal rights risks to person in care.

Official plan of correction

Administrator to have the appraisal updated and submit copy by 10/13/23.

Deadline recorded: Oct 13, 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. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the ... ...premises a sufficient number of hours to permit adequate attention to the management and administration of the facility. -This requirement is not met as evidenced by: -Administrator failed to demonstrate ....

Official plan of correction

Administrator to take the following training from Department's vendors: 1. Dementia Care - 8 hours 2. Criminal Record - 2 hours 3. Medication Administration - 8 hours 4. Administration including but not limited to hiring practices, record keeeping. staffing and maintenance - 8 hours Proof to be submiitedby 9/14/23.

Deadline recorded: Sep 14, 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

CONTINUATION: ability to comply with the Regulations as evidenced by multiple citations, civil penalties, issues such as physical plant, staffing, training, records keeping and failure to correct timely.

Deadline recorded: Sep 14, 2023. 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 or a criminal record exemption as required.... ... by the Department -This requirement is not met as evidenced by: -Based on observation, interview and Guardian Portal check, the licensee did not comply with section above for having S1 work without fingerprint clearance. This is a repeat violation.

Official plan of correction

Administrator have the staff go for fingerprinting while LPA is still at the facility. Administrator to read the Regulation and will not allow the staff to work until claared and associated. Proof to be submitted by 7/28/23.

Deadline recorded: Jul 28, 2023. A deadline is not proof that correction was completed.

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..... -This requirement is not met as evidenced by: -Based on observation and interview, the licensee did not comply with the section above for R4 who has insulin but no file and/or record of doctor's order. Insulin was not administered and facility does not have discontinued order. It's not clear it the med is still needed.

Official plan of correction

Administrator to check with the resident's physician if the medication is still needed. If still needed, to have a licensed professional administer; otherwise, obtain a discontinued order. Proof to be submitted by 7/28/23.

Deadline recorded: Jul 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87355(e)(2)

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: (2) Request a transfer of a criminal record clearance ... This requirement is not met as evidenced by: -Based on records review, the licensee did not comply with the section above for S2 who is not associated to this facility. This is a repeat violation within 12 month period. First violation was issued on 7/18/23.

Official plan of correction

Corrected. Administrator submitted the LIC9182 on this day. A $250.00 is assessed on this day,

Deadline recorded: Aug 10, 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. -This requirement is not met as evidenced by: -Based on records review, the licensee did not comply with the section above for staff affixing initial on R4's MAR but the medication was not administered.

Official plan of correction

Administrator to in-service the staff, and submit copy of traing topic with attendees signatures by 8/10/23.

Deadline recorded: Aug 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87470(c)

Regulation authority

CCR

What the official deficiency says

87470 Infection Control Requirements (c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. -This requirement in not met as evidenced by: -Based on interview and records review, the licensee did not comply with the section above for not having an Infection Control Plan which poses potentiall health risk to persons in care.

Official plan of correction

Administrator to developed a plan and submit copy by 8/10/23.

Deadline recorded: Aug 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.605

Regulation authority

CCR

What the official deficiency says

§1569.605 Liability insurance; coverage requirements: On and after July 1, 2015, all residential care facilities for the elderly, .... shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate..... -This requirement is not met as evidenced by: -Based on records review and interview, the licensee did not comply with the section for not having insurance coverage under licensee's name.

Official plan of correction

Licensee to obtain insurance coverage, and submit proof by 8/10/23.

Deadline recorded: Aug 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569

Regulation authority

CCR

What the official deficiency says

§1569.69 Employees assisting residents with self-administration of medication; training requirements (b) Each employee who received training and passed the examination... and who continues to assist with the self-administration of medicines, shall also complete four hours.. of in-service training on medication-related issues in each succeeding 12-month period. -This requirement is not met as evidenced by: -Based on records review and interview, the licensee did not comply with the section for S3 not having the required hours of annual medication training,

Official plan of correction

Administrator to have the staff trained and submit proof by 8/10/23.

Deadline recorded: Aug 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.312(a)

Regulation authority

CCR

What the official deficiency says

§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. -This requirement is not met as evidenced by: -Based on interviews and review of police reports, the licensee did not comply with the section above for R1 who was able to AWOL which posed immediate safety risk to person in care.

Official plan of correction

Administrator to do the following, and submit proof by 7/28/23: 1. Complete Appraisal/Needs and Services Plan. 2. In-service the staff.

Deadline recorded: Jul 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above for not having LIC9020 Register of Facility Clients/Residents which poses/posed a potential health,or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2023 Plan of Correction Administrator to complete a LIC9020 and submit copy by 8/01/23.

Official classification

Type B

Official code

1569.153(a)

Regulation authority

HSC

What the official deficiency says

(a) Establishment and posting of the facility’s policy regarding theft and investigative procedures. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above for not posting facility's Theft and Loss Policy which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2023 Plan of Correction Administrator to post the policy, and submit picture by 8/01/23.

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 for the following: (a) pieces of carpet, wood, metal, rolled carpet, piece of glass, fitted bedsheet in the side yard; (b) mattress, window screen, hoyer lift, pieces wood, bedsheet, grinder in the backyard; (c) broken window blinds and protruding cable wires in room # 2. These pose a potential safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2023 Plan of Correction Administrator had the yards clean. Administrator to have the window blinds replaced with new one and removed the protruding cable. Pictures to be submiited by 8/01/23, A $250.00 civil penalty is assessed for repeat violation. First citation was issued on 6/28/23.

Official classification

Type B

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 for resident not having signal system or call button which pose a potential health, safety and/orr personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2023 Plan of Correction Administrator to purchase call button, and submit by 8/01/23 proof of purchase and pictures.

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, licensee did not comply with the section cited above for not posting Complaint poster which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2023 Plan of Correction Administrator to post the poster in the prominent place and submit picture by 8/01/23.

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 or a criminal record exemption as required by the Department This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above for S1 not fingerprint cleared which poses an immediate safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/20/2023 Plan of Correction Administrator to have S1 fingerprinted and associated. In addition, administrator not to allow S1 to work until cleared and associated. Proof to be submitted by 7/20/23. A $500.00 civil penalty is assessed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above for the insulin in the refrigerator which poses an immediate health and safety risks to persons in care.

Official plan of correction

POC Due Date: 07/19/2023 Plan of Correction Staff locked the item. In addition, administrator to in-service the staff, and submit copy of training topic with attendees signatures by 7/19/23.

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, licensee did not comply with the section cited above for 1 staff with no CPR/First and 4 staff with expired CPR/First Aid certiicates on file which posed a potential safety and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 08/01/2023 Plan of Correction Corrected. Staff completed the training.

Official classification

Type B

Official code

87355(e)(2)

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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above for staff (S6) not associated to this facility which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2023 Plan of Correction Administrator to have the staff associated and submot proof by 8/01/23.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

§1569.695 Emergency Plans (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 notrequired during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and reord review, the licensee did not comply with the section cited above for not conducting disaster driill which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2023 Plan of Correction Administrator to conduct drills, and submit proof by 8/01/23.

Official classification

Type B

Official code

1569.269(a)(2)

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: (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: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above for having cameras installed that capture audio which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2023 Plan of Correction Corrected. Administrator removed all the camera.

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 This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and rord review, the licensee did not comply with the section cited above for R4 and R6 not having records which pose a potential health, safety and/or personal rights risks to persons in care.

Official plan of correction

POC Due Date: 08/01/2023 Plan of Correction Administrator to complete the records, and submit self-certification by 8/01/23 stating records were completed.

Official classification

Type B

Official code

87608(a)

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 interview and record review, the licensee did not comply with the section cited above for not having doctor's order for R2's half bed rails which poses a potential safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2023 Plan of Correction Administrator to obtain doctor's order, and submit copy by 8/01/23.

Official classification

Type B

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above for R5 not having TB test on file which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2023 Plan of Correction Administrator to schedule an appointment, and submit copy of test by 8/01/23.

Official classification

Type B

Official code

87458(b)(5)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (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 for R7 who is non-ambulatory but LIC602A Physician's Report indicated ambulatory which poses a potential health and safety riisks to person in care.

Official plan of correction

POC Due Date: 08/01/2023 Plan of Correction Administrator stated he'll have the LIC602 Physician's Report updated. Copy to be submitted by 8/01/23.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

§1569.625 Staff training; legislative findings; contents (b) (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.1569.69(a) This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above for 4 staff not having the required annual training which poses a potential health, safety and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2023 Plan of Correction Administrator to have the staff complete the training and submit proof by 8//01/23.

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..........Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview and review of staff schedule, the licensee did not comply with the section cited above for not having sufficient staff which poses a potential health, safety and/or rsonal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2023 Plan of Correction Administrator stated he'll have the staffing increased. Copy of staff schedule to be submitted by 8/01/23.

Official classification

Type B

Official code

87307(a)(3)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (a) ...... The following provisions shall apply (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. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above for not having paper towels for residents use for drying hands in 2 bathrooms which pose a potential health and/or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2023 Plan of Correction Administrator to provide paper towels in paper towel holders. Pictures to be submiitted by 8/01/23.

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 for Pine Sol & CALRes in the bathrooms and rake in the backyard which pose an immediate safety risks to persons in care. This is a repeat violation within 12 month. First citation as issued on 6/28/23. Civil penalty is assessed.

Official plan of correction

POC Due Date: 07/07/2023 Plan of Correction Staff locked the items. In addition, administrator to do in-service training and submit copy of training topic with attendees signatures by 7/07/23.

Official classification

Type A

Official code

87204(a)

Regulation authority

CCR

What the official deficiency says

87204(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, licensee did not comply with the section cited above for 2 non-ambulatory residents in ambulatory only rooms which poses an immediate safety risk to persons in care. Civil penalty is assessed.

Official plan of correction

POC Due Date: 07/07/2023 Plan of Correction Administrator stated he'll have the residents move to rooms fire cleared for non-ambulatory. Proof to be submitted by 7/07/23.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

Administrator stated will have auditory signals installed. Pictures to be submitted by 6/29/23,

Deadline recorded: Jun 29, 2023. 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 for having the storage in the side yard not locked which poses immediate safety risks to persons in care,

Official plan of correction

Administrator locked the storage, In addition, administrator to do in-service training, and submit copy of training topic with attendees signatures by 6/29/23,

Deadline recorded: Jun 29, 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, sthe safety and well-being of residents, employees and visitors.anitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety -This requirement is not met as evidenced by: -Based o observation, the licensee did not comply with the section above for the soiled mattress & carpet in the yard which pose potential risks to person in care,

Official plan of correction

Adminstrator to have the yard cleaned, and, submit pictures by 7/12/23.

Deadline recorded: Jul 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section for facility having a strong smell of urine which poses personal rights risk to persons in care,

Official plan of correction

Administrator stated will find placement for the resident. Proof to be submitted by 7/12/23. Staff to continue to encourage the resident to be assisted in incontinence care while placement is pending.

Deadline recorded: Jul 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. -This requirement is not met as evidenced byL -Based on observation and interview, the licensee did not comply with the section above for removing the smoke detectors in 5 residents rooms and family room. Civil penalty is assessed.

Official plan of correction

Administrator stated he'll have smoke detectors installed, Pictures to be submitted by 6/29/23. A $500.00 civil penalty is assessed today.

Deadline recorded: Jun 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

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 was not met as evidenced by missing resident’s written records at the facility which posed a potential health & safety risk to resident in care.

Official plan of correction

By POC due date, administrator agreed to submit to CCL completed in-service staff retraining on proper administration of residents' records ensuring all residents' files are readily available for licensing and other agencies' review and inspections.

Deadline recorded: Jun 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(28)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements - All foods shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by: Based on observation, there were multiple expired foods in the in the pantry, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee will ensure all expired foods are disposed, and submit certification of compliance to CCL by POC date.

Deadline recorded: Jan 27, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia (2) ...alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidenced by: Based on observation, interview and records review, the licensee did not comply with the section cited above. LPA observed unlocked detergent in the laundry room which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Staff locked the laundry room during visit. Administrator will retrain staff for regulations and submitted training agenda and sign-in sheet to CCL by POC due date.

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

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate.... This requirement was not met as evidenced by: Based on observation, interview and records review, the licensee did not comply with the section cited above. LPA observed appraisal/care plan has not been updated due to changing in condition.

Official plan of correction

Administrator will retrain staff for regulations and submitted training agenda and sign-in sheet to CCL In addition, facility will update notes of changing condition and appraisal/care plan for resident and submit copies to CCL by the POC due day.

Deadline recorded: Apr 22, 2022. A deadline is not proof that correction was completed.