TODOS SANTOS ASSISTED LIVING AND MEMORY CARE

Official classification

Type B

Official code

87207

Regulation authority

CCR

What the official deficiency says

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility This requirement is not met as evidenced by; based on interviews staff 2 lied about using a photo of a resident in group messages as a " meme " This poses as a personal rights violation to resident in care.

Official plan of correction

Administrator agrees to submit a letter to CCLD disscusing what training and counciling will be occuring with S2 as well as a self certified letter stating that the administrator has gone over the regulation. Proof of correction will be sent to CCLD by POC date

Deadline recorded: Jul 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Resident 2 (R2) physicians report was found in R1 medical file.

Official plan of correction

The facility agrees to remove R2's physicians report from R1 file and check all other resident files. The administrator agrees to review Tilte 22 and send in a self certified letter about resident files. Proof of correction will be sent in to CCLD by POC date.

Deadline recorded: May 21, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87156(a)

Regulation authority

CCR

What the official deficiency says

An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. provides ....after initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license. -This requirement is not met as evidenced by: -Based on review, the licensee did not comply with the section above in not paying the annual fee which was due on 11/26/25.

Official plan of correction

Board Director to pay the annual fee and submit proof by 5/15/26.

Deadline recorded: May 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)....(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by: The administrator stating " but those are just physical plant thing, why would that prevent us from passing " when not being granted a new license and asked to make corrections.

Official plan of correction

The administrator agrees to review Tilte 22 and send in a self certified letter about kadministrator qualifications. Proof of correction will be sent in to CCLD by POC date.

Deadline recorded: Apr 8, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: The facility finding an Illegal substance in a residents room and not reporting it to licensing.

Official plan of correction

The administrator agrees to review Tilte 22 and send in a self certified letter about reporting requirements. Proof of correction will be sent in to CCLD by POC date. This is a repeat violation and a civil penalty of $250 is assesed

Deadline recorded: Apr 15, 2026. 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 the provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: LPA observed the cabinet in the assisted living " Bistro " to be dirty.

Official plan of correction

The facility agrees to clean the cabinets inside and out, assisted living Bistro. Proof of correction will be sent to CCLD by POC date. This is a repeat violation an immediate civil penalty of $250 is assessed

Deadline recorded: Apr 8, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

All window screens shall be clean and maintained in good repair. This requirement was not met as evidenced by: At least one windows in memory care was missing a screens and another was broken

Official plan of correction

The facility agrees to replace the missing screens and replace or repair the broken screens. Proof of correction will be sent to CCLD by POC date. This is a repeat violation an immediate civil penalty of $250 is assessed

Deadline recorded: Apr 8, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(4) Additional Personal Rights Residents in all residential care facilities for the elderly shall have the following personal rights: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and record review the licensee did not comply with the section cited above in by to ensure that Resident (R1)’s request for assistance through the call pendant system was responded to promptly. This resulted in R1 remaining on the floor after a fall and unable to get up for approximately 26 minutes until staff responded. This poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator agreed to conduct an In-Service training on answering the call light buttons with all staff, on all shifts in assisted living and memory care and will send sign-in sheet to CCLD by POC due date.

Deadline recorded: Mar 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)

Regulation authority

CCR

What the official deficiency says

87465(a) Incidental Medical and Dental Care Services A plan for incidental medical and dental care shall be developed by each facility to ensure that residents receive necessary medical and dental services. This requirement is not met as evidenced by: Based on interviews, and record review the licensee did not comply with the section cited above in by to ensure that Resident (R1) received appropriate medical evaluation or follow-up after sustaining an open wound to their hand. This failure resulted in R1 not receiving timely medical assessment following an injury. This poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator agreed to conduct an In-Service training on medical care for all residents with all staff, on all shifts in assisted living and memory care and will send sign-in sheet to CCLD by POC due date.

Deadline recorded: Mar 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(d)

Regulation authority

CCR

What the official deficiency says

87506(d) Resident Records (d) All resident 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: Based on record review and interview, the licensee did not comply with the section cited above in by not ensuring that complete and former resident records were maintained and available for review as required. Specifically, the financial records for R1 from the year 2022 were not available during the visit on 11/19/25 and 03/11/26. In which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee shall ensure that R1’s records including but not limited to financial, billing statements from admission in 2022 are retrieved and maintained in the facility files. The Executive Director shall submit proof of record retrieval (copies or verification of access) to the Department by due date.

Deadline recorded: Mar 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211(a)(1) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in by not reporting the fall incident with R1 to Licensing which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agreed to conduct In-Service training will a staff, on all shifts in assisted living and memeory care and will send sign in sheet to CCLD by POC due date.

Deadline recorded: Mar 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)(b)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition…(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in by not updating reappraisals for R1 with the frequent falls which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agreed to conduct In-Service training with all 3 clinical leaders and including Administrator. Administrator will send sign-in sheet to CCLD by POC due date.

Deadline recorded: Mar 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(19)(2)

Regulation authority

CCR

What the official deficiency says

87468.2 (a)(19) Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (19) To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in by not giving R1 and/or R1's representative copies of R1's records as requested which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agreed to obtain records and send to R1. Administrator will advise CCLD via email when records have been submitted to resident.

Deadline recorded: Mar 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

87465(g) Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with section above by not activating 9-1-1 if an injury or other circumstance which poses a potential health and safety risk to the persons in care.

Official plan of correction

Administrator will conduct In-Service training with all staff on all shifts in assisted living and memory care and will send a copy of sign in sheet to CCLD by POC due date.

Deadline recorded: Mar 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(d)

Regulation authority

CCR

What the official deficiency says

(d)If the resident is unable to determine...all of the following requirements are met: This requirement is not met as evidence by: Based on observation and record review the facility did not comply with the section above by having an inaccurate MAR which poses a potential health and safety violation for residents in care.

Official plan of correction

By POC Facility agrees to update and maintain the MAR as well as provide additional training to staff and notify CCLD.

Deadline recorded: Mar 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidence by: Based on interviews and record reviews the Licensee did not comply with the section cited above in charging R1 for a higher level of services than they were in.

Official plan of correction

The administrator corrected R1's billing and documentation to show that R1 was level 2 instead of level three and retroactivly paid back the over charged amount to R1. POC is cleared

Deadline recorded: Feb 26, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(a)(1)(B)

Regulation authority

CCR

What the official deficiency says

(a)(1) (B) The text of the admission agreement,... shall be: Written in clear, understandable, coherent, and unambiguous language, using words with common and everyday meanings, and shall be appropriately divided with each section appropriately titled. This requirement was not met as evidenced by: Based on interviews and record reviews the Licensee did not comply with the section cited above by the facility not having in their admissions agreement if residents are agreeing to pay for a shared or single room.

Official plan of correction

The facility agrees to add an addendum to all admissions agreements of shared occupancy rooms stating that they agree to the shared room and the associated rate. The facility also agrees to add an addendum to all admissions agreements of single occupancy rooms stating that they agree to the single... room and the associated rate. Proof of correction will be sent to CCLD by POC date.

Deadline recorded: Mar 12, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance. All individuals subject to a criminal record review... Obtain a California clearance...as required by the Department... This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not having one staff fingerprint cleared which poses an immediate health and safety risk to the persons in care.

Official plan of correction

Facility has agreed to obtain fingerprint clearance S4. House manager will submit a plan to obtain fingerprint clearance for S4 by POC date.

Deadline recorded: Jan 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance. All individuals subject to a criminal record review...Request a transfer of a criminal record clearance... This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not having two staff associated to the facility which poses a potential health and safety risk to the persons in care.

Official plan of correction

S7 has been associated to the facility. The facility has agreed to associate S5 and S6 to the facility and submit proof of association by POC date.

Deadline recorded: Jan 12, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall... by compliance with the following:(2)The licensee shall provide assistance in meeting necessary medical and dental needs... This requirement is not met as evidenced by: The facility staff did not call for refill in timely manner which resulted in residents missing medication dosages. This poses an immediate health risk to resident in care.

Official plan of correction

Licensee to review facility's procedure in ordering medication refill. Proof to be submitted by 01/07/2026

Deadline recorded: Jan 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.... This requirement is not met as evidenced by: The facility not having enough staff at that time to preform all resident ADL's

Official plan of correction

The facility has sence hired addtional staff in all departments.

Deadline recorded: Jan 6, 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 by having unlocked paints and detergents in the laundry room which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/21/2025 Plan of Correction Staff either threw away or locked up the items during inspection. Deficiency cleared.

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, 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: 12/05/2025 Plan of Correction Executive Director has agreed to conduct disaster drill and submit documents to CCLD by POC date.

Official classification

Type B

Official code

87555(b)(21)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (21) Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degrees F (4 degrees C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures. 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 freezer temperature at 16 degrees F which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 12/05/2025 Plan of Correction Executive Director (ED) has agreed to repair the freezer door and maintain freezer temperature at 0 degrees F. ED will submit picture proof and/or work order to CCLD by POC date.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87565 Incidental Medical and Dental Care. (a) A plan for incidental medical shall be developed by each facility...... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by: -Based on review of records and interview, the licensee did not comply with the section above by not obtaining medication refills in a timely manner for R1 and order for one of R2's medications which pose an immediate health and personal rights risks the persons in care. This is a repeat violation.

Official plan of correction

Administrator to do the following and submit proof by 9/19/25: 1. Have the order for R2's medication obtained. 2. Ensure residents' medications are refilled timely and self-certify. A $250.00 civil penalty is assessed.

Deadline recorded: Sep 19, 2025. 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 the provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: The facility not clean a residents room after rodent droppings were found.

Official plan of correction

The facility agrees to clean R2/R3's room and sanitize the room. The facility also agrees to read the regulation and submitted a letter of self certification to CCLD by POC date.

Deadline recorded: Sep 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(d)

Regulation authority

CCR

What the official deficiency says

The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement was not met as evidenced by: The facility refusing to take a resident back after they eloped and addmitted to a hsopital.

Official plan of correction

Executive Director (ED) will review " Eviction Procedures " regulation and submitted email notice to CCLD by POC date.

Deadline recorded: Sep 18, 2025. 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 the provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: The facility has a rodent in room 124 and dropings to prove it.

Official plan of correction

Licensee to within 7 days have a pest control specialist conduct an inspection of the premises and take appropriate measures, and submit proof to LPA by POC date.

Deadline recorded: Sep 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(a) In addition...the elderly shall have all of the following personal rights:(4) To care, supervision... that meet their individual needs ... This requirement was not met as evidence by: Based on interviews the facility did not meet the requirement above by not having enough staff which lead to two residents in memory care eloping from the facility which posed an immediate safety risk to residents in care.

Official plan of correction

By POC date, Licensee will hire an additional staff member for the memory care unit. Proof of correction will be sent to CCLD by POC date. A civil penalty of $250 has been assesed on this day for a repeat violation

Deadline recorded: Sep 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care. A plan for incidental medical...shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by: Based on records review and interviews, licensee did not comply with the section cited above by given a resident the incorrect medication.

Official plan of correction

By POC date, Licensee will hire an additional Med Tech. Proof of correction will be sent to CCLD by POC date. A civil penalty of $250 has been assesed on this day for a repeat violation

Deadline recorded: Sep 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(a) In addition...the elderly shall have all of the following personal rights:(4) To care, supervision... that meet their individual needs ... This requirement was not met as evidence by: Based on interviews the facility did not meet the requirement above by not having enough staff which lead to multiple elopements by of residents in memory care which posed an immediate safety risk to residents in care.

Official plan of correction

By POC date, Licensee will submit to CCLD a detailed written plan on how they will address incidents of elopement and safety and also how they plan to mitigate this type of situation. Facility will send sign in sheet for elopement inservice. Proof of correction will be sent to CCLD by POC date.

Deadline recorded: Aug 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87470(a)(2)(A)

Regulation authority

CCR

What the official deficiency says

Surfaces such as floors,... 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 was not met as evidenced by: The facility being informed on 7/7/25 that urine was found in the courtyard and not cleaning/sanitizing it until after 7/19/25.

Official plan of correction

The facility agrees to clean and sanitized the memory care outdoor space. Proof of correction will be sent to CCLD by POC date.

Deadline recorded: Aug 26, 2025. 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 the provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.This requirement was not met as evidenced by: LPA observed dirty dishes in the cabinet in the memory care rec room, as well as dirt on the walls and cabinets.

Official plan of correction

The facility agrees to clean the cabinets inside and out, in the memory care rec room. Proof of correction will be sent to CCLD by POC date.

Deadline recorded: Aug 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

All window screens shall be clean and maintained in good repair.This requirement was not met as evidenced by: four windows in memory care were missing screens and at least two more had rips in their screens.

Official plan of correction

The facility agrees to replace the missing screens and replace or repair the broken screens. Proof of correction will be sent to CCLD by POC date.

Deadline recorded: Aug 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87219(h)(2)

Regulation authority

CCR

What the official deficiency says

The licensee shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: Outdoor activity areas that are easily accessible to residents, protected from traffic, and have adequate shady areas. This requirement was not met as evidenced by: the memory care patio being locked from the inside not allowing access to residents in care.

Official plan of correction

The facility agrees to unlock the patio door during daylight hours (weather permitted). Proof of correction will be sent to CCLD by POC date.

Deadline recorded: Aug 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care. A plan for incidental medical...shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not obtaining medication refills in a timely manner which poses a potential health and safety risk to the persons in care.

Official plan of correction

Executive Director has agreed to create a new procedure for medication refills and conduct training for staff. ED will submit new procedure and staff sign in sheet to CCLD by POC date.

Deadline recorded: Aug 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

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:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Based on observation and interviews there was not adequate staffing to meet residents needs.

Official plan of correction

Executive Director has hired additional staff to meet care and hygiene needs of residents

Deadline recorded: Jun 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.17

Regulation authority

CCR

What the official deficiency says

Fingerprints and criminal records of individuals in contact with clients...record exemption from the State Department of Social Services before his or her initial presence in a residential care facility for the elderly.

Official plan of correction

Administrator will read the Regulation and send self certification of understanding to Community Care Licensing (CCL) by POC date. In addition, licensee will not allow any individual to work, reside, or volunteer prior to being finger print cleared and associated. Administrator will also forward a copy of S1 clearance and association to CCLD by POC date.

Deadline recorded: Mar 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. Based on LPAs interview licensee did not comply with the section above by the facility staff yelling at

Official plan of correction

The facility agrees to go over resident personal rights in the next staff meeting. A sign in sheet will be sent to CCLD by POC date

Deadline recorded: Jun 11, 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...This requirement in not met as evidenced by: Based on LPAs interview licensee did not comply with the section above in facility not being kept clean in the memory care uint, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to review regulation 87303 and submit a self-certification that the regulation has been reviewed. Self-certification shall be submitted to CCLD by POC date. Facility will also submit to CCLD by POC date house keeping staff schedules and evaluate the cleaning needs of the facility as a whole.

Deadline recorded: Nov 17, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

HSC

What the official deficiency says

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 degree C) and not more than 120 degree F (49 degree C).

Official plan of correction

Water temperature/ water heater will be adjusted to fall between 105 degree F and 120 degree F. proof will be sent via email

Deadline recorded: Nov 10, 2021. A deadline is not proof that correction was completed.