COUNTRY CREST ASSISTED LIVING

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement LPA observed pine needles and debris collected on exposed roofing areas from the second and third floors which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/04/2026 Plan of Correction Licensee agrees to remove the debris from these areas and any other areas of the facility roof where debris is present. Licensee shall submit photographs of the areas to LPA once completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 (a) 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 was not met as evidenced by: LPA observed common area to be too warm, gnats flying in all areas of the facility, dead and alive cock roaches in common area, memory care kitchen and utility room, 1 resident room flooring in disrepair, sewage smell in the main kitchen, flood damage in the elevator utility room sticky floor throughout the facility.

Official plan of correction

Licensee agrees to submit timeline in which all repairs will be completed to LPA as proof of correction by 10/14/2025. As the repairs are completed the licensee shall update LPA by submitting invoices and photographs of the repairs. Licensee agrees to remediate the gnat and cockroach infestation immediately and will submit pest control invoices to LPA as proof of correction. LPA will follow-up with visits to ensure the repairs / pest control / cleaning have been completed.

Deadline recorded: Oct 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(c)

Regulation authority

CCR

What the official deficiency says

87355(c) Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility. This requirement is not met as evidenced by: Based on file review the licensee did not comply with the section cited above as S1 was working in but was not associated to the facility which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee is to submit in writing the date and details of S1 being terminated from employment. Additionally, the licensee shall review this regulation and submit a statement of understanding of the regulation. Both of these requirements are to be submitted to LPA by 11/28/2024. A civil penalty in the amount of $500.00 is being issued on 11/14/2024

Deadline recorded: Nov 28, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(8) Additional Personal Rights of Residents in Privately Operated Facilities (a)(8) 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 document review and interviews the licensee did not protect R1 from being financially abused by S1 resulting in significant financial loss to R1. This poses an immediate Health, Safety and Personal Rights risk to clients in care.

Official plan of correction

Licensee agrees to conduct staff training for all current staff regarding the penalties for perpetrating financial abuse of a resident and the consequences and penalties they will face if they do so. Additionally licensee agrees to hold staff training regarding accepting gratuities and gifts from residents and consequences of doing so. Licensee shall submit staff training sign in sheet as proof of correction.

Deadline recorded: Oct 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation the licensee did not comply with the section cited above in 3 of 10 bathroom lightbulbs and 1 of 10 bathroom fans which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2024 Plan of Correction Licensee agrees to inspect all resident bathrooms to ensure that there are no lightbulbs that need to be replaced and also inspect all bathrooms fans to ensure that all are operating properly. Licensee agrees to submit inpection list with room numbers, inspection results and date of any required repair/replacement to LPA as proof of correction.

Official classification

Type B

Official code

87411

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 LPA record review the licensee did not comply with the section cited above in 4 of 4 staff files which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2024 Plan of Correction LIcensee agrees to audit all staff files and determine which staff have not received first aid training or have expired training. In additiona licensee shall provide training to all staff who are not current and will submit proof of staff.

Official classification

Type B

Official code

87303(b)(2)

Regulation authority

CCR

What the official deficiency says

87303(b)(2) Maintenance and Operation - (b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement is not met as evidenced by: Based on observation, interviews, and records review it was determined that the licensee was aware that the air conditioning units were in need of repair / replacement in Summer 2022 and did not replace or repair the units until Summer 2023 which poses a potential health and safety risk to residents in care.

Official plan of correction

The facility replaced the non-functioning air conditioning units in the kitchen and anteroom to the kitchen and completed the trouble shooting of the new units. The installation and repair is complete. LPA Knight toured the facility during the visit and confirmed that the air conditioning units were functioning properly. This POC is complete.

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

Official classification

Type B

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the section cited above in 2 of 4 resident rooms which poses a potential health, safety risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2023 Plan of Correction Licensee agrees to inspect all resident rooms and ensure that non-skid mats or strips are installed in all resident showers/ bathtibs. Licensee shall submit inspection report including dates of inspection and room numbers confimring that all resident rooms meet this requirement.