ROUNDHILL CARE HOMES, INC.

Official classification

Type B

Official code

87470(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in the facility being maloudorous, and Kitchen cluttered which poses a potential health and personal rights risk to persons in care.

Official plan of correction

By POC Facility agrees to organize and sanatize the facility and notify CCLD

Deadline recorded: Apr 23, 2026. A deadline is not proof that correction was completed.

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: Based on observation, the licensee did not comply with the section cited above in having expired and improperly stored food in the refrigerator which poses a potential health and personal rights risk to persons in care.

Official plan of correction

By POC Facility agrees to organize food and clean out the refridgerators and notify CCLD

Deadline recorded: Apr 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in in having accesable paint and scissors in the kitchen which poses an immediate safety risk to persons in care.

Official plan of correction

By POC Facility agrees to organize to ensure adequete space for dangerous items and notify CCLD

Deadline recorded: Apr 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

POC Due Date: 02/02/2026 Plan of Correction Facility agrees to conduct an inservice and notify CCLD

Official classification

Type B

Official code

87470(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: 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 the facility being unsanitary, maloudorous, and cluttered which poses a potential health and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2026 Plan of Correction By POC facility agrees to remove all clutter from all areas of the facility, deep clean all surfaces, and insure there is no maloudoros scents and notify CCLD

Official classification

Type B

Official code

87303(f)

Regulation authority

CCR

What the official deficiency says

(f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. 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 having trash improperly disposed of by stacking it on the waste receptical in the kitchen which poses a potential health and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2026 Plan of Correction By POC facility agrees to develop and implement a plan for proper disposal of waste and notify CCLD

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. 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 the common area flooring and toilet seat being in disrepair which poses a potential safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2026 Plan of Correction By POC facility agrees to make repairs and notify CCLD

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 in having expired and improperly stored food in the refridgerator which poses a potential health and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2026 Plan of Correction By POC facility agrees to store resident and staff food seperatly and disgard all expired food. Facility also agrees to create a reminder poster of kitchen expectations to be posted on the outside of the refridgerator and notify CCLD

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, the licensee did not comply with the section cited above in having unlocked scissors which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 02/10/2025 Plan of Correction Administrator locked away the scissors POC clear.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

POC Due Date: 02/11/2025 Plan of Correction By POC Administrator agrees to purchace a lockbox for the fridge and secure medications and notify CCLD.

Official classification

Type B

Official code

87470(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: 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 the facility being unsanitary and cluttered which poses a potential health and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/03/2025 Plan of Correction By POC Administrator agrees to clean off and de-clutter all surfaces, counters, tables, and accesible areas and notify CCLD

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 in having expired and improperly stored food in the refridgerator which poses a potential health and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/03/2025 Plan of Correction By POC Administrator agrees to clean, organize and dispose of spoiled/expired items in the refridgerator and notify CCLD.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: 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 R1 being bedridden without the facility being cleared for bedridden which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/02/2024 Plan of Correction By POC date administrator agrees to either get the resident re-assesed, or apply for a new fire clearence and notify CCLD

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 aboveby having dangerous items unlocked and accesable to residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/27/2024 Plan of Correction By POC date administrator agrees to remove and lock all items and notify CCLD.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

POC Due Date: 03/27/2024 Plan of Correction Administrator removed and locked away medication during visit.

Official classification

Type B

Official code

87470(a)(2)(A)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material. 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 having animal fecal matter smeared on the floor and also unsanitized surfaces which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/09/2024 Plan of Correction By POC date administrator agrees to be in compliance with regulation and notify CCLD.

Official classification

Type B

Official code

87470(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (B) Walls and window coverings in resident care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary and when they are visibly contaminated or soiled. 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 having a buildup of cobwebs and dirt throughout facility which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/09/2024 Plan of Correction By POC date administrator agrees to be in compliance with regulation and notify CCLD.

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 by facility being unclean which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/09/2024 Plan of Correction By POC date administrator agrees to be in compliance with regulation and notify CCLD.

Official classification

Type B

Official code

87303(a)(1)

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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited aboveby having ants and a mildew odor in laundry room which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/09/2024 Plan of Correction By POC date administrator agrees to be in compliance with regulation and notify CCLD.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

(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, the licensee did not comply with the section cited above by room 3 having a ripped screen door which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/09/2024 Plan of Correction By POC date administrator agrees to repair or replace screen door and notify CCLD.

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 in having spoiled and expired food which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/27/2024 Plan of Correction By POC date administrator agrees to dispose of spoiled food and restock refrigerator.

Official classification

Type B

Official code

87555(b)(29)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above inhaving the itchen oven in disrepair which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/09/2024 Plan of Correction By POC date administrator agrees to repair oven and notify CCLD.

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... (b) Medicines which are centrally stored shall be stored as specified in Section 87465 and separately from other items specified in (a) above... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by leaving: - Medication was left unlocked inside the First Aid cabinet. - Knife left out on the kitchen counter on the cutting mat. Knife left out by the sink. Dishwasher was left open knife was observed to be unlocked. - Chemical was left unlocked in the bathroom cabinet which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will review regulation and submit a self-certified stating that AD review and understand the regulation. Administrator will lock all chemical and medicine and submit proof to CCLD by the due date.

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

Official classification

Type A

Official code

87705(e)

Regulation authority

CCR

What the official deficiency says

(e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having an unlocked pool area which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

By POC date Administrator agrees to have items in backyard removed or placed in a locked storage and submit photographic proof to CCLD

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

Official classification

Type A

Official code

1569.32

Regulation authority

HSC

What the official deficiency says

1569.32 Spot inspections Any duly authorized officer, employee, or agent of the department may, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation of, this chapter. This requirement is not met as evidenced by: Volunteer staff refused to let LPA in when asked.

Official plan of correction

LPA went over the regulation with Administrator to provide education to informed AD upon regulation.

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

Official classification

Type A

Official code

1548(c)(3)

Regulation authority

HSC

What the official deficiency says

1548 (c)(3) Civil penalties; regulations setting forth appeal procedures for deficiencies This requirement is not met as evidenced by: LPA confirmed with Zella a voluneer at the facility that there was no staff present during the time LPA arrived.

Official plan of correction

Administrator will insure to hire more staff. Administrator will review the regulation and submit a self-certifiy that AD review the regulation to CCLD by POC date.

Deadline recorded: Feb 1, 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

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 cited above due to facility being unsanitary which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

By POC date Administrator agrees to have facility common areas sanitary, and laudry room clean. Administrator will submit photo to CCLD.

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

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... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having food of poor quality which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

By POC date Administrator agrees to discard all food of poor quality and submit photographic proof to CCLD

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

Official classification

Type B

Official code

87705(e)

Regulation authority

CCR

What the official deficiency says

(e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having an unlocked pool area with a fence shorter than five feet which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

By POC date Administrator agrees to install a fence that is in compliance with state and local building codes and submit photographic proof to CCLD

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

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(d) The following space and safety provisions shall apply to all facilities:(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. Based on observation, the licensee did not comply with the section cited above by having outdoor area obstructed

Official plan of correction

By POC date Administrator agrees to have items in backyard removed or placed in a locked storage and submit photographic proof to CCLD

Deadline recorded: Nov 20, 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

(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 by having unlocked medication in kitchen which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

LPAs observed Administrator locked away medicine during visit

Deadline recorded: Nov 4, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. 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 obstructing sliding door fire exit in R1's room which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/06/2023 Plan of Correction Licensee will remove hospital bed from outside of sliding glass door and submit photographic proof to CCL by POC date

Official classification

Type A

Official code

87618(b)(3)

Regulation authority

CCR

What the official deficiency says

(3) Ensuring that the use of oxygen equipment meets the following requirements: 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 retaining portable oxygen tanks without stands in R1's room and empty portable tanks in backyard and not having the approprate oxygen signs posted which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/06/2023 Plan of Correction Licensee will have unused portable tanks removed and submit photographic proof to CCL by POC date. Oxygen signs were posted durring visit.

Official classification

Type A

Official code

87705(e)

Regulation authority

CCR

What the official deficiency says

(e) Swimming pools and other bodies of water shall be fenced and in compliance with state and local building codes. 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 an unlocked pool area with a fence shorter than five feet which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/06/2023 Plan of Correction Licensee will cover pool with bolted down tarp or install a fence around pool that locks and is over five feet tall and provide photographic proof to CCL by POC Date

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 due to facility being clutterd throughout common areas inside and outside ( items include but are not limited to: boxes, tires, car parts, miscelaneous items, and debris), dust throughout inside of facility, and uneven flooring inside and outside which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/26/2023 Plan of Correction Licencee called haul away company to remove clutter and debris from outside backyard, also agreed to secure and lock away miscelaneous items in shed. Licensee agrees to organize and clean inside of the facility and provide photographic proof of inside and outside to CCL by POC date

Official classification

Type B

Official code

87307(d)(4)

Regulation authority

CCR

What the official deficiency says

(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. 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 outside deck being uneven and having loose planks and inside flooring in common areas being uneven which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/02/2023 Plan of Correction Licensee will repair adn restructure as needed for ouside deck and will replace inside flooring in the uneven areas and inform CCL of repairs by POC date

Official classification

Type B

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 raid under residents sink which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/06/2023 Plan of Correction Deficencie cleared durring visit. LPA observed administrator lock away RAID.

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 having moldy and expired food in fridge and pantry which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/09/2023 Plan of Correction Licensee agrees to dispose of all moldy and expired food and provide photographic proof to CCL by POC date.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (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: Deficient Practice Statement Based on observation, Licensee did not comply with the regulation cited above. LPAs observed unlocked over the counter medication in the kitchen counter which poses an immdiate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 03/22/2022 Plan of Correction Deficiency cleared during visit. LPA observed Administrator removed over the counter medications and locked it away in kitchen cabinet.

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 LPAs observation, the licensee did not comply with the section cited above. LPAs observed side gate is in disrepair. In addition, LPAs observed a clutter of random items is being stored on deck which poses potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2022 Plan of Correction Administrator agrees to repair side gate and remove all random items on deck and submit a photo to CCL by POC date.