Facility condition and maintenanceType A
- Official classification
- Type A
- 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 degree C) and not 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 the hot water temperature measured at 132.5 degrees Fahrenheit which poses an immediate health risk to persons in care.
Official plan of correction
POC Due Date: 11/20/2025 Plan of Correction The Administrator agrees to lower the temperature within range and send proof to CCLD by POC date.
Hazardous items and storageType A
- 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 medications such as Multivitamin Gummies, Tylenol, Triamcinolone Acetonide, etc and all purpose cleaning wipes which poses an immediate safety risk to persons in care.
Official plan of correction
POC Due Date: 11/20/2025 Plan of Correction The Administrator agrees to lock the items and send proof to CCLD by POC date.
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, the licensee did not comply with the section cited above by having a key lock on the only emergency side gate which poses an immediate safety and personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/20/2025 Plan of Correction The Administrator agrees to remove the lock and send proof to CCLD by POC date.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(a)
- Regulation authority
- CCR
What the official deficiency says
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: 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 the Health Screening (LIC503) for S2 and S3, and TB test for S3 which poses a potential safety risk to persons in care.
Official plan of correction
POC Due Date: 12/03/2025 Plan of Correction Administrator agrees to obtain the health screening and TB test for staff. Proof of correction will be sent to CCLD by POC date.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 1569.625(b)(2)
- Regulation authority
- HSC
What the official deficiency says
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 staff training for all staff which poses a potential personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/03/2025 Plan of Correction Administrator agrees to obtain staff training and send proof to CCLD by POC date.
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87608(a)(3)
- Regulation authority
- CCR
What the official deficiency says
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. 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 doctor's order for all the residents' half bed rail which poses a potential safety and personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/03/2025 Plan of Correction Administrator agrees to obtain a doctor's order for all the residents' half bed rail and send proof to CCLD by POC date.