Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(f)
- Regulation authority
- CCR
What the official deficiency says
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: 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 having S3 and S5 available for review which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/20/2026 Plan of Correction House Manager agreed to complete files and submit self-cetification to CCLD by POC date.
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87608(a)(5)(B)
- Regulation authority
- CCR
What the official deficiency says
(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 R4 having a full bed rail which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/20/2026 Plan of Correction House Manager agreed to have full bed rail changed to half-rail and submit photo to CCLD by POC date.
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87633(b)
- Regulation authority
- CCR
What the official deficiency says
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: 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 having a hospice care plan for R6 which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/20/2026 Plan of Correction House Manager agreed to obtain a copy of the hospice care plan for R6 and submit a copy to CCLD by POC date.
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87307(a)(2)(C)
- Regulation authority
- CCR
What the official deficiency says
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet. 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 bedroom #5 as a passageway to storage closet for facility which poses a potential personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/20/2026 Plan of Correction House Manager agreed to remove all items from closet and submit photo to CCLD by POC date.
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, the licensee did not comply with the section cited above in having pills in cup sitting on microwave in kitchen which poses an immediate health and safety risk to persons in care..
Official plan of correction
POC Due Date: 05/14/2026 Plan of Correction Caregiver locked pills away immediately during inspection. Deficiency cleared during inspection.
Background checksType A
- Official classification
- Type A
- Official code
- 87355(d)
- Regulation authority
- CCR
What the official deficiency says
(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. 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 having S5 fingerprinted and associated before working in the facility which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/14/2026 Plan of Correction House Manager agreed to get S5 fingerprinted and submit documentation to CCLD by POC date
Not classified in the sourceType B
- Official classification
- Type B
- Official code
- 87632(d)(2)
- Regulation authority
- CCR
What the official deficiency says
(d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver as necessary to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements: (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. 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 submitting an initiation to hospice services to CCLD which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/20/2026 Plan of Correction House Manager agreed to submit a hospice notification for R6 to CCLD by POC date.
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.1(a)(6)
- Regulation authority
- CCR
What the official deficiency says
(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: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in having locks on the outside of doors for R2 and R5 which poses a potential safety and personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/20/2026 Plan of Correction House Manager agreed to remove locks and submit a photo to CCLD by POC date.