SIMONE SUMMIT CARE HOME

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 by having medication in an unlocked drawer located in the kitchen which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 05/21/2026 Plan of Correction Administrator had staff removed medications from the drawer and dispose of them. Caregiver removed medications and disposed of them. DEFICIENCY CLEARED DURING VISIT.

Official classification

Type B

Official code

87355(d)(3)

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. (3) The licensee shall submit these fingerprints to the California Department of Justice, along with a second set of fingerprints for the purpose of searching the records of the Federal Bureau of Investigation, or comply with Section 87355(c), prior to the individual's employment, residence, or initial presence in the facility. 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 by having an individual working in the facility who was not fingerprint cleared which poses an immediate health and safety risk to persons in care. LPA asked that staff member leave the facility and not return until they are fingerprinted and associated.

Official plan of correction

POC Due Date: 05/29/2026 Plan of Correction Administrator agreed to submit a plan to obtain fingerprint clearance for individuals in the facility and send to CCLD by POC date. Civil penalty of $200.00 is being assessed today.

Official classification

Type B

Official code

87309

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 (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to residents shall be stored where inaccessible which poses a potential health and safety risk to residents in care.

Official plan of correction

POC Due Date: 05/27/2026 Plan of Correction Administrator agreed to lock shovels in storage and provide the Department with photos of shovels being removed and locked in storage by the POC date

Official classification

Type A

Official code

87643(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain a resident who requires the use of an indwelling catheter under the following circumstances: This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by not having a care plan for resident who require use of an indwelling urinary catheter, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to obtain a plan of care from appropriate Home Health Agencies and email CCLD copies of plan by POC date.

Deadline recorded: Nov 6, 2025. 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 by having unlocked washing detergent, matches, and a fire place lighter located in the garage and kitchen drawer which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2025 Plan of Correction Administrator agreed to have staff lock washing detergent in the garage by the POC date.

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 by having unlocked medication in the unlocked garage which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2025 Plan of Correction Administrator agreed to have staff lock their medications at all times and submit photos of cabinet licked to the department by the POC date.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

Medical assesment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. 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 by not having a medical assessment for R1 which poses a potential health and safety to persons in care.

Official plan of correction

POC Due Date: 05/02/2025 Plan of Correction Administrator agreed to provide a copy of R1's medical assessment (LIC-602) to the department by the POC date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

CCR

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 by not conducting disaster drills quarterly which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2025 Plan of Correction Administrator has agreed to conduct a disaster drill and submit a written statement regarding how often disaster drills should be conducted and submit the statement to CCLD by POC date.

Official classification

Type B

Official code

87203

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic 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 not having a fire extinguisher without purchase receipt or service tag which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/23/2025 Plan of Correction Administrator agrees to submit photos of updated fire extinguisher tag by the POC date.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (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, health. Personnel with evidence of physical illness or emotional instability 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 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: Based on record review, the licensee did not comply with the section cited above by not having health screening documents for three(3) out of five (5) staff members which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator has agreed to obtain health screening for S1,S2 and S5 and submit a copy of health screening to CCLD by POC date.

Deadline recorded: Jan 16, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above in notifying CCLD of any alterations which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agreed to remove wall and beds or submit a LIC200 and updated facility sketch to CCLD by POC date.

Deadline recorded: Jan 23, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 not having Knives and Scissors stored inaccessible to the residents with which poses an immediate health, safety risk to persons in care.

Official plan of correction

POC Due Date: 04/30/2024 Plan of Correction Caregiver immediately locked drawer with Knives and Scissors during visit. Deficiency cleared.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (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 not having medications stored and inaccessible to residents which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/30/2024 Plan of Correction caregiver immediately locked cabinet with medications during visit. Deficiency cleared

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608(a)(3) Postural Supports. (a) Based on the individual's preadmission appraisal, ... 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 ... 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, LPA observed a full bedrail on R1's bed, LPA did not observe a physician's report for the full bed rail which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/07/2023 Plan of Correction Administator will contact R1's physician and obtain a writted order for the full bed rail or replace the full rail with a half rail and submit order to CCL by POC date.