SUNSHINE ASSISTED LIVING- THE COTTAGE

Official classification

Type B

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

87412(d) Personnel Records. The licensee shall maintain documentation that an administrator has met...the recertification requirements in Section 87407, Administrator Recertification Requirements. The licensee did not comply with the section above as evidenced by: Record review and the administrator does not have a current and renewed administrator certificate. Which poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator will complete the administrator recertification process and obtain a up to date administrator certificate. Administrator will submit proof of correction to LPA by POC due date.

Deadline recorded: Jul 15, 2026. 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 observation and record review, the licensee did not comply with the section cited above in 5 out of 6 staff members which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/06/2026 Plan of Correction Administrator will have all staff recieve CPR training by POC due date Administrator will submit proof of correction to LPA by POC due date

Official classification

Type B

Official code

87412(a)(11)

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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 in 2 out of 6 staff members, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/06/2026 Plan of Correction Adminstrator will get the health screen records for the missing staff members and put it in their files. Administrator will submit proof of correction to LPA by POC due date

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 in two of four staff files were missing record of a tuberculosis test and health screening, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/11/2025 Plan of Correction Administrator agrees to send proof of health screening and TB test to licensing by end of business on 08/11/2025.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. 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 in one out of four resident files was missing proof of a tuberculosis test which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/11/2025 Plan of Correction Administrator agrees to provide proof of tuberculosis test to LPA by end of business, August 11, 2025.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(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 not required 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 record review, the licensee did not comply with the section cited above in one of four emergency disaster drils was conducted and/or documented within the last 12 months which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/27/2024 Plan of Correction The Administrator will create and implement a plan to ensure that emergency disaster drills are conducted at least quartlerly. The administrator will share this plan with the LPA by 6/27/24.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(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 observation, interview and record review, the licensee did not comply with the section cited above in four out of six resident files reviewed had bed rails with not order from a doctor in the file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/27/2024 Plan of Correction The Administrator will request updated medical orders for the bed rails for residents who have bed rails, or remove the bed rails from the resident beds who have the bed rails. The Administrator will inform the LPA of which of the two options above the facility will take. The Administrator will provide the LPA with documentation.

Official classification

Type B

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. 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 that two residents who have oxygen did not have the appropriate signage posted on the residents door which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/27/2024 Plan of Correction Administrator will ensure that the proper signage is posted on residents door when oxgen is in use. Adminstrator inform the LPA that the signage is posted.