PACIFICA SENIOR LIVING UNION CITY

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above by having unlocked prescription of topical cream in R1's room which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 07/15/2025 Plan of Correction The Executive Director agrees to lock the ointment and send proof to CCLD by POC date.

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by not properly storing and labeling food which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/29/2025 Plan of Correction The Administrator will self-certity the regulation and send proof to CCLD by POC date.

Official classification

Type B

Official code

87463(h)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not having updated medical assessment for residents in care which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 08/05/2025 Plan of Correction The Executive Director agrees to obtain medical assessments for R1, R3, R4, R5, and R6 and send proof to CCLD by POC date.

Official classification

Type A

Official code

87465(a)(2)

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......... (2) The licensee shall provide assistance in meeting necessary medical and dental needs……... -This requirement is not met as evidenced by: -Based on records review and interviews, the licensee did not comply with the section in not seeking immediate medical assistance for resident (R1) which posed an immediate risk to the health risk to person in care.

Official plan of correction

Executive Director to in-service the staff and submit copy of training topic with attendees signatures by 1/10/25.

Deadline recorded: Jan 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

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 7 days of the occurrence... evidence by: This requirement was not met as evidence by: Based on interview and observation the Licensee did not comply with the section cited above by notifying the responsible party, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator submitted reporting and abuse training that was completed on 7/27/2024, to LPA during visit. Deficiency cleared during visit.

Deadline recorded: Dec 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87208

Regulation authority

CCR

What the official deficiency says

“…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 B

Official code

87468.2(a)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities. 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... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by charging R1 for services not rendered which poses a potential personal rights violation to the persons in care.

Official plan of correction

Facility has agreed to update R1 detail ledger and refund R1 for the difference according to the updated detail ledger if necessary. Facility will submit the updated ledger to CCLD by POC date.

Deadline recorded: Sep 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

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: S1 stated that the gate that was supposed to be lock was not lock that led to an elopement. During the time resident was led outside by Activity assistance for an activity. The staff didn’t notice that the resident had went outside the gate.

Official plan of correction

Administrator will keep a record of staff that are checking the gate prior to bringing residents outside the yard. Administrator will conduct an in-service training topic: Elopement in Dementia with all the staff signature and submit to CCLD by POC date.

Deadline recorded: Aug 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(6)

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: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for locking residents inside their room in memory care unit.

Official plan of correction

Administrator will unlock all the residents room in memory care. In service training of all staff in memory care will sign off that they understand the regulation under resident personal rights.

Deadline recorded: Jul 26, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above by 5 out of 5 staff did not have first aid or CRP on files, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2024 Plan of Correction Administrator will provided proof of all staff with current first aid and CPR to CCLD by POC date.

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 by having unlocked disinfectants and cleaning solutions accessible which poses an immediate health and safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/28/2024 Plan of Correction Administrator agreed to keep the disinfectants and all cleaning solutions inaccessible to residents in care at all times. Deficiency cleared during visit.

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 is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not having files for the staff avaliable for review which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 03/04/2024 Plan of Correction Administrator agreed to read understan regulation self certify and send a sample of Administrator file to CCL by the POC date.

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 interviews and documentation review the facility has/had mold in various resident apartments which poses/posed an immediate/potential Health, Safety or Personal Rights risk to persons in care

Official plan of correction

Administrator will submit their mold treatment plan and prevention plan to ensure no mold outbreak in the future to CCL by POC date

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

Official classification

Type B

Official code

87211(a)(1)(A)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency....(1) A written report shall be submitted to the licensing agency ... within seven days of the occurrence of any of the events......(A) Death of any resident from any cause regardless of where death occured -This requirement is not met evidenced by: -Based on record review, the licensee did not comply with the section above for not submitting the death report within 7 days which posed potential personal rights risk to person in care.

Official plan of correction

Corrected. Executive Director provided copy of Death Report while LPA is at the facility.

Deadline recorded: Dec 12, 2023. 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

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency....(1) A written report shall be submitted to the licensing agency ... within seven days of the occurrence of any of the events.....(D) Any incident which threatens the welfare, safety or ........ ......health of any resident...... -This requirement is not met evidenced by: -Based on record review, the licensee did not comply with the section above for not submitting an incident report within 7 days which posed potential personal rights risk to person in care.

Official plan of correction

Corrected. Executive Director provided copy of incident reportt while LPA is at the facility.

Deadline recorded: Dec 12, 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 records review and interviews, the licensee did not comply with the section above for not having records in the emergency binder for 3 out of 4 residents which pose potential health and personal rights risks to persons in care.

Official plan of correction

Executive Director to check the emergency binder and have the documents completed for all residents, Self-certification to be submitted by 12/12/2023.

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

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights .... (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities.... (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, the licensee did not comply with the section above when staff consumed alcohol while in the facility which posed a potential safety and/or personal rights risks to persons in care.

Official plan of correction

ED stated the 3 staff were terminated. In addition, ED to in-service the staff. and submit copy of training topic with attendees signatures by 11/06/23.

Deadline recorded: Nov 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(24)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements. Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas... This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by storing chemicals in the kitchen area which poses an immediate health and safety risk to the persons in care.

Official plan of correction

Staff removed the chemicals to the cleaning supplies room during inspection. Deficiency cleared

Deadline recorded: Oct 5, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(23)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements. All readily perishable foods... shall be stored in covered containers... This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by storing foods without covered container which poses a potential health and safety risk to the persons in care.

Official plan of correction

Executive Director has agreed to conduct training with all kitchen staff regarding storing food items and submit staff sign-in sheet & materials to CCLD by POC date.

Deadline recorded: Oct 20, 2023. 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

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such report... (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. This requirement is not met as evidenced by: R1 who has dementia and is not allowed to leave facility unassisted wandered out of the facility on 5/23/2022 but facility failed to report incident to CCL which poses a potential threat to safety of clients in care.

Official plan of correction

Memory Care Director will review Sec 87211 Reporting Requirements and submit self certificate of understanding of said section.; proof of completion will be submitted to CCL by POC date.

Deadline recorded: Jul 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269(a)(10)

Regulation authority

HSC

What the official deficiency says

(a) Residents of residential care facilities for the elderly shall have all of the following rights: (10) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: This requirement is not met as evidenced by: On May 23, 2022, R1 wandered out of the building. R1 has dementia and medical records indicate R1 is not allowed to leave the facility unassisted.

Official plan of correction

Director will review records of all residents who have wandering behavior and update needs and services plan to address exit seeking behavior. A copy of the updated plan will be submitted to CCL by POC date.

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

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465(a)(4) 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 review of MAR for May 2022, R1 was given Donepezil for only 9 days.

Official plan of correction

MCD will review all MARs and medications to ensure all residents are taking medications accordingly and submit self certification of completion to CCL by POC date.

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

Official classification

Type A

Official code

1569.269(a)(6)

Regulation authority

HSC

What the official deficiency says

§1569.269 Enumerated rights: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered... This requirement is not met as evidenced by: Based on records review and interviews conducted, the licensee did not comply with the section above when R1 developed Stage 2 pressure injuries on left posterior thigh and Stage 1 pressure injury on coccyx which posed an immediate health

Official plan of correction

R1 has moved out of the facility. Director will submit a plan to CCL on how to prevent residents from developing pressure injuries. Plan needs to be submitted to CCL by 5/8/2023.

Deadline recorded: May 5, 2023. 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

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...(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient… This requirement is not met as evidenced by: Based on records reviewed, facility staff failed to respond to pendants in timely manner, based on records review, at least nine calls from R1 & R2 that staff responded within 30 minutes or more, which poses a potential risk to the health and safety of resident under care.

Official plan of correction

Administrator agreed that staff training will be conducted about the facility’s protocol on pendant call response. A proof of training needs to be submitted to CCL by POC date.

Deadline recorded: May 15, 2023. 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

87303 Maintenance and Operation (e)(2) 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: -Based on observation, the licensee did not comply with the section above for water temperature tested and measured at 80 degrees Fahrenheit which poses ummediate safety & personal right risks to persons in care.

Official plan of correction

Corrected. Business Office Manager called the plumbing company while LPA is at the facility. Water temperature was adjusted to 105. 2 degrees Fahrenheit.

Deadline recorded: Feb 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(1)(B)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h):(1) Medications shall be centrally stored ....:(B)Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed -This requirement is not met as evidenced by: -Based on inspection, the licensee did not comply with the section above for R1's medications unlocked which pose immediate health risk to person in care.

Official plan of correction

Staff locked the items immediately. In addition, an in-service training to be conducted, and proof with attendees signatures to be submitted by 2/14/23.

Deadline recorded: Feb 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269(a)(10)

Regulation authority

HSC

What the official deficiency says

§1569.269(a)(10) Enumerated rights; severability (10) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on records review, Licensee did not comply with the regulation cited above. R1 sustained one Stage 2 coccyx pressure ulcer and one Stage 1 pressure injury on right hip which poses an immediate health and safety risk to residents in care.

Official plan of correction

By POC date, Administrator agrees to review Personal Rights with all caregivers and submit proof of training to CCL.

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

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

87465(a)(5) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility.....(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications…. This requirement is not met as evidenced by: Based on records review, the Licensee did not comply with the regulations cited above when R1 was not given Donepezil from 5/30/2021 to 6/22/2021 which poses an immediate health and safety risk residents in care.

Official plan of correction

By POC date, Administrator agrees to review Incidental Medical and Dental care regulation with all caregivers and submit proof of training to CCL.

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

Official classification

Type A

Official code

87355(a)

Regulation authority

CCR

What the official deficiency says

The Department shall conduct a criminal record review of all individuals ...any adults other than a client, residing in the facility shall have a criminal record clearance or exemption. This requirement was not met as evidenced by staff (S1) not having criminal record clearance prior to employment which posed an immediate health & safety risk to residents in care.

Official plan of correction

Immediate civil penalty of $500 assessed during visit due to employment of a non-cleared individual on 03/27/22. Deficiency corrected during visit. Administrator submitted copies of S1 termination documents dated 08/29/22. Administrator also updated Guardian Portal and disassociated S1 from employment list effective 12/08/22.

Deadline recorded: Dec 8, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (b)(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. -This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section above for retaining R1 with dementia. R1 was able to AWOL which posed immediate safety risk to person in care.

Official plan of correction

R1 is no longer in the facility. In-Service Training has been completed on 5/25/22. Memory Care Director will provide a detail planning of preventing AWOL in the memory care unit, and submit it to CCL by the POC due date.

Deadline recorded: May 27, 2022. 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

(b) In addition to Section 87611, General Requirements for Allowable... the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that ...incontinence. This requirement is not met as evidenced by: Based on investigation: During the televisit conducted by LPA on 2/5/2021, former RSD confirmed with LPA that there was urine smell and stains on the carpet in R1’s room which poses a potential risk to health and safety of client

Official plan of correction

Administrator will conduct training with caregivers and housekeepers on Sec 87625 Managed Incontinence and submit proof of training to CCL by 5/05/2022.

Deadline recorded: May 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia. Each resident with dementia shall have an annual medical assessment...at least annually... This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not having an updated medical assessment for R1 which poses a potential health and safety risk to the persons in care.

Official plan of correction

Executive director has agreed to obtain current medical assessment for R1 and submit a copy to CCLD by POC date.

Deadline recorded: Mar 4, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements. A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events... This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not reporting COVID positive cases and submit death reports which poses a potential health and safety risk to the persons in care.

Official plan of correction

Executive director has agreed to review reporting requirements and submit self-certification to CCLD by POC date.

Deadline recorded: Feb 25, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(19)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities. To have prompt access to review all of their records and...Photocopied records shall be provided within two (2) business days... This requirement was not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not providing a copy of care plan to R1's responsible party which poses a potential health and safety risk to the persons in care.

Official plan of correction

Executive Director has agreed to provide a copy of the care plan to R1's responsible party and submit self-certification/proof to CCLD by POC date.

Deadline recorded: Feb 25, 2022. A deadline is not proof that correction was completed.