Medication handling and storageType A
- 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 and interview, the licensee did not comply with the section cited above in having unlocked medication in mini refrigerator which poses an immediate health, safety risk to persons in care.
Official plan of correction
POC Due Date: 05/27/2026 Plan of Correction By POC date, licensee will purchase a locked box for medication to be properly stored in the refrigerator. Licensee will send a photo email to CCL.
Facility condition and maintenanceType B
- 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 Based on observation and interview, the licensee did not comply with the section cited above in having a broken kitchen drawer and missing knob on armoire closet in resident bedroom which poses a potential safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/02/2026 Plan of Correction By POC date, licensee will repair or replace broken kitchen cabinet and missing knob on resident's armoire closet and sent photo email to CCL.
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(e)(2)
- Regulation authority
- CCR
What the official deficiency says
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. 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 degrees C) and not more than 120 degree F (49 degrees C). 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 water temperature more than 120 degree F which poses a potential safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/02/2026 Plan of Correction By POC date, licensee will maintain water temperature in resident's shared restroom not less than 105 degree and not more than 120 degree F. licensee will send an email photo of temperature to CCL.
Facility condition and maintenanceType B
- Official classification
- Type B
- 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 and interview, the licensee did not comply with the section cited above in having sofas, television, toilet commodes, walkers, mattresses ,Hoyer lift, chairs and ladder in garage obstructing passageway which poses a potential safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/02/2026 Plan of Correction By POC date, licensee will removed items from garage and send photo email to CCL.
Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(h)(5)
- Regulation authority
- CCR
What the official deficiency says
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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 medications transferred between containers which poses a potential health, safety risk to persons in care.
Official plan of correction
POC Due Date: 06/02/2026 Plan of Correction By POC date, licensee will read regulation, provide staff with training on regulation and send a self-certifying email to CCL
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87608(5)(B)
- Regulation authority
- CCR
What the official deficiency says
B- 87608 Postural Supports (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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 in having resident in a hospital bed with bed rails to extend the entire length of bed which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/02/2026 Plan of Correction By POC date, licensee will remove full bed rail, obtain a physician order for half bed rail and send email to CCL
Fire safety and emergency preparednessType A
- 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 observation and interview, the licensee did not comply with the section cited above in having a latch lock on facility’s front door entrance/exit which poses an immediate safety risk to persons in care. *Civil penalty of $500 is being assessed*
Official plan of correction
POC Due Date: 05/27/2026 Plan of Correction By POC date, licensee agreed to remove latch lock from facility’s front door and send email photo to CCL.
Hazardous items and storageType A
- Official classification
- Type A
- Official code
- 87309(a)(b)
- 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 comet with bleach in an unlocked kitchen cabinet and tide laundry detergent pods in an unlocked cabinet in washroom which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/27/2026 Plan of Correction During visit caregiver immediately removed items and placed in a locked cabinet. Deficiency cleared.