A OHANA HOME FOR SENIORS, LLC

Official classification

Type B

Official code

87468.2(a)(19)

Regulation authority

CCR

What the official deficiency says

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... - This requirement is not met as evidenced by: Based on interviews and record review, the authorized representative has not received records in two months since the initial request.

Official plan of correction

On or before plan of correction due date, Licensee will send an email of the requested documents to the RP and will include CCL in the email as proof

Deadline recorded: Feb 24, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(j)

Regulation authority

CCR

What the official deficiency says

Upon the death of a resident, all cash resources, personal property, and valuables of that resident shall immediately be safeguarded. -This requirement is not met as evidenced by: Based on record review and staff interviews, the resident's belongings were thrown away two days after the resident's passing.

Official plan of correction

On or before plan of correction due date, Licensee will submit proof to CCL that all caregivers have participated in an inservice/training on the handling of a resident's belongings.

Deadline recorded: Feb 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000)...or neglect by, the licensee or its employees. -This requirement is not met as evidenced by: Based on records review, the liability insurance was outdated.

Official plan of correction

Licensee shall submit the proof of renewed liability insurance to CCL by the POC date.

Deadline recorded: Feb 27, 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

87309(a) Storage Space and Access(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects... locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: The licensee did not comply with the section cited above by having unlocked items such as paint, ladder, drill, screwdriver, disinfectant deodrozier, dayquill, laxaclear, and knives all around the kitchen which poses an immediate health and safety risk to person in care.

Official plan of correction

The Administrator agrees to self-certify the regulation, lock the items, and send proof to CCLD by POC date.

Deadline recorded: Feb 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(d)(3)

Regulation authority

CCR

What the official deficiency says

87411(d)(3)Personnel Requirements - General (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above when S1 was left alone in the facility with a language barrier which posed a potential safety risk to persons in care.

Official plan of correction

By POC date, the Administrator agrees to self-certify the regulation and ensures that a staff member is always present that can communicate with the residents. Proof of correction will be sent to CCLD by POC date.

Deadline recorded: Feb 13, 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

87303(a) Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by: The licensee did not comply with the section cited above by having items such as mattress, furniture, carpet, boxes, window panel, and other items in the backyard, the kitchen drawer in disrepair, and multiple bugs such as spiders found in the kitchen pantry, which poses a potential safety risk to persons in care.

Official plan of correction

The Administrator agrees to schedule a bulk pick up to remove the items, fix the kitchen drawers, and clean the kitchen pantry. Proof of correction will be sent to CCLD by POC date.

Deadline recorded: Feb 13, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87505(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as the facility does not have a certified administrator, which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

A civil penalty of $250.00 is assessed for a repeat violation. On or before plan of correction due date, licensee will find a certified administrator to be associated with the facility and ensure they are on site a sufficient amount of hours. Licensee will send LPA the up to date administrator certificate, updated LIC308, updated LIC500, LIC501, and fingerprint clearance information.

Deadline recorded: Jan 30, 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

87464 Basic Services (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 is not met as evidenced by: -Based on record review and interviews, the licensee did not comply with the section cited above by leaving the residents unattended.

Official plan of correction

On or before plan of correction due date, licensee will submit an updated LIC500 and staff schedule that will mitigate gaps of coverage in case of staff running behind.

Deadline recorded: Dec 22, 2025. 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

87355 Criminal Record Clearance (e) All individuals...shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as there is a staff member working while the background check is still in process, which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Before LPAs left the facility, the staff member in question left the facility. In addition, licensee will contact Guardian to see why there is a delay, and will provide LPA an update via email for proof of this occurance. A civil penalty of $400.00 is assessed for the failure to complete the caregiver background check.

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

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as the facility does not have a certified administrator, which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

On or before plan of correction due date, licensee will find a certified administrator to be associated with the facility and ensure they are on site a sufficient amount of hours. Licensee will send LPA the up to date administrator certificate, updated LIC308, updated LIC500, LIC501, and fingerprint clearance information. A civil penalty of $250.00 is assessed for a repeat violation.

Deadline recorded: Dec 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

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, the licensee did not comply with the section cited above as a backyard passageway was obstructed by furniture and debris, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2025 Plan of Correction Administrator will submit proof to LPA that the passageway is cleared on or before POC date.

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 due to Pepto Bismol found unlocked in a bathroom and paint primer found unlocked in a closet, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2025 Plan of Correction Fixed on site. Administrator removed items and placed them in locked containers.

Official classification

Type A

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 as none of the staff have up to date CPR/First Aid training, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2025 Plan of Correction Administrator will submit proof to LPA that they and other staff are scheduled to do training on or before POC date

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 record review, the licensee did not comply with the section cited above due to doors heavily shutting themselves, window screens missing, a window being broken, and the freezer on the fridge not opening, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2025 Plan of Correction On or before POC date, administrator will submit proof to LPA that the issues found during inspection are fixed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. 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 with the issue of the language barrier between care staff and residents, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2025 Plan of Correction Administrator has agreed that staff with a language barrier with the residents will not be alone in the facility and that one staff member that can fluently communicate with residents will be present.

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 in not having complete staff files, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2025 Plan of Correction LPA explained the necessary forms that should be readily available in regards to staff.On or before POC date, administrator will submit proof that the staff have the required forms in their staff files.

Official classification

Type B

Official code

87506(b)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least 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 in not having complete resident files, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2025 Plan of Correction LPA explained the necessary forms that should be readily available in regards to residents. On or before POC date, administrator will submit proof that the residents have the required forms in their resident files.

Official classification

Type B

Official code

1569.695(b)

Regulation authority

HSC

What the official deficiency says

(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. 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 in not conducting quarterly emergency drills, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2025 Plan of Correction Administrator will create a form and give staff training for this quarter on or before POC date.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. 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 in failing to renew their administrator certificate, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/20/2025 Plan of Correction Administrator will submit proof to LPA that the process has begun to renew the certificate on or before POC date

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required..... -This requirement is not met as evidenced by: -Based on record review and interviews, the licensee did not comply with section above in allowing S1 worked without exemption which posed an immediate risk to persons in care. This is a repeat violation. A citation was issued on

Official plan of correction

Staff left while LPA was at the facility. Administrator stated she'll have the staff re-frigerprinted and request for exemption. Administrator not to allow the staff worked until exemption is approved. A $3,000.00 civil penalty is assessed.

Deadline recorded: Aug 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (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; -Based on interview, the licensee did not comply with the section in not having file/record for staff, S1, which poses a potential health, safety and/or personal rights risks to persons in care. This is a repeat violation. A citation was issued on 9/23/24.

Official plan of correction

Administrator to complete record and submit self-certification by 9/10/25. A $250.00 civil penalty is assessed.

Deadline recorded: Sep 10, 2025. 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

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required.. .....by the Department... -This requirement is not met as evidenced by: -Based on record review and interviews, the licensee did not comply with section above in allowing S1 worked without fingerprint clearance which posed an immediate risk to persons in care.

Official plan of correction

Administrator stated she'll have S1 fingerprinted. Proof to be submitted by 7/25/25.

Deadline recorded: Jul 25, 2025. 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

87506 Resident Records (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: -Based on records review and interview, the licensee did not comply with the section for not having Pre-placement Appraisals and LIC621 for residents which pose a potential personal rights risks to persons in care.

Official plan of correction

Administrator stated she'll complete the documents. Copies to be submitted by 8/07/25.

Deadline recorded: Aug 7, 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

87309 Storage Space and Access (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 residents.... -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above which posed an immediate health, safety and/or personal rights risks to persons in care: shovels; unlocked storage; pails of paint

Official plan of correction

Administrator to do the following and submit proof by 7/16/25: 1. Lock the items and submit pictures. 2. In-service the staff.

Deadline recorded: Jul 16, 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

87303 Maintenance and Operation (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: -Based on observation, the licensee did not comply with the section above for the following in the yard: soiled mattress; foam; hospital bed and board; hole in the kitchen door

Official plan of correction

Administrator to have the yard cleaned and repair the kitchen door. Pictures to be submitted by 729/25.

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

Official classification

Type B

Official code

87309(a)

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 Based on observation, the licensee did not comply with the section cited above by having chemicals unlocked in the laundry room and bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/30/2024 Plan of Correction The facility agrees to lock away chemicals and to read and review the regulation and submit a letter of self certification to CCLD by POC date.

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 having all staff records mixed together in one binder which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/30/2024 Plan of Correction The facility agrees to separate each staff record. Proof of correction will be sent to CCLD by POC date.

Official classification

Type B

Official code

87506(b)(15)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. 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 R4 did not have an admissions agreement in his file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/30/2024 Plan of Correction The facility agrees to get a signed admissions agreement for R4s file. Proof of correction will be sent to CCLD by POC date.

Official classification

Type B

Official code

87506(b)(16)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables. 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 record of residents Personal Property, and Valuables which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/07/2024 Plan of Correction The facility agrees to get a signed record of each residents Personal Property, and Valuables . Proof of correction will be sent to CCLD by POC date.

Official classification

Type B

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. 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 signs for the oxygen tank that is stored in R1's room which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/30/2024 Plan of Correction The facility agrees to post sign outside R1's room and at the front door stating " No Smoking-Oxygen in Use” Proof of correction will be sent to CCLD by POC date.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. 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 an updated medical assessment for R1 and R2 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/07/2024 Plan of Correction The facility agrees to get updated medical assessments for residents. Proof of correction will be sent to CCLD by POC date.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record ....exemption as required by the Department. -This requirement is not met as evidenced by: -Based on review of roster, checking of Guardian Portal and interviews, the licensee did not comply with the section in FM1 and FM2 not fingerprinted and cleared which pose an immediate safety risks to persons in care.

Official plan of correction

Administrator to have FM1 and FM2 fingerprinted and submit proof by 5/10/24. A total of $1,000.00 civil penalty ($500 for each) is assessed on this day.

Deadline recorded: May 10, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance... -This requirement is not met as evidenced by: -Based on review of staff roster, checking of Guardian Portal and interviews, the licensee did not comply with the section above for not having S1 and S2 associated to this faciltiy which poses a potential safety and/or personal right risks to persons in care.

Official plan of correction

Admiinistrator to have the staff assiociated and submit proof by 5./23/24.

Deadline recorded: May 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services: (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. -This requirement is not met as evidenced by: -Based on interviews, the licensee did not comply with the section above in FM1 sleeping in the common area of the facilty which poses a potential personal rights risk to persons in care.

Official plan of correction

Administrator to have the family member stop sleeping in the common area.

Deadline recorded: May 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.269(a)(6)

Regulation authority

HSC

What the official deficiency says

§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) 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, the licensee did not comply with the section above in not providing meals to residents in timely manner which poses a potential health and/or personal rights risks to persons in care.

Official plan of correction

Administrator to in-service the staff and submit copy of training topic with attendees signatures by 5/23/24.

Deadline recorded: May 23, 2024. 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

87468.2(a)(4) (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..(4)To care, supervision, and services that meet their individual needs ... Based on interview, the licensee did respond to R1's verbal call for help after they sustained a fall which poses/posed an immediate Health, Safety or Personal Rights risk to persons in care

Official plan of correction

Adminstrator will review regulation with staff and think of alternative methods that can be used for fall risk residents. Administrator will submit a self certification and list of alternatives to CCL by POC date

Deadline recorded: Oct 7, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in staff failed to lock a gallon of bleach, LPA observed a gallon of bleach at the kitchen counter which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator locked the bleach. Administrator agreed to train all the staff on the cited regulation above. A copy of training topic with staff signature and LIC500 will need to be submitted to CCL by POC due date.

Deadline recorded: Apr 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87203

Regulation authority

CCR

What the official deficiency says

Fire Safety 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 failure to have fire extinguishers serviced on an annual basis which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed that fire extinguishers were last serviced April 2021.

Official plan of correction

POC Due Date: 12/30/2022 Plan of Correction Administrator will have fire extinguishers serviced and send photographic proof to CCL by POC date.

Official classification

Type B

Official code

87633(d)

Regulation authority

CCR

What the official deficiency says

Hospice Care of Terminally ill residents (d) The licensee shall ensure that the hospice care plan is current, accurately matches the services being provided, and that the client’s care needs are being met at all times. This requirement was not met as evidenced by resident sustaining injury while in care which posed a potential health & safety risk to resident in care

Official plan of correction

By POC due date, administrator agreed to submit to CCLD a self-certification that staff has read, understood and will comply with Section 87633 regulations.

Deadline recorded: Jan 17, 2022. 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

Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement was not met as evidenced by missing resident roster (LIC 9020) for inspection which posed a potential health & safety risk to residents in care.

Official plan of correction

By POC due date, administrator agreed to submit to CCLD a self-certification that staff has read, understood and will comply with Section 87506 regulations.

Deadline recorded: Jan 17, 2022. 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

Reporting Requirements (a) (1) 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… This requirement was not met as evidenced by failure of staff to submit incident report to CCLD which posed a potential health & safety risk to residents in care.

Official plan of correction

By POC due date, administrator agreed to submit to CCLD a self-certification that staff has read, understood and will comply with Section 87211 regulations.

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

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance. All individuals subject to a criminal record review...prior to working, residing or volunteering in a licensed facility: Obtain a California clearance... This requirement is not met as evidence by: Based on observation and interview 5 adults visitors has been staying at the facility with no fingerprint clearance, this possess immediate health and safety risk for residents in care.

Official plan of correction

Administrator stated that F1 & F2 will get fingerprint clearance, F1 & F2 cannot be at the facility while waiting for fingerprint clearance, V1,V2,V3,V4 will leave the facility and will be staying at the hotel. Any repeat violation will be subject to civil penalty for repeat violation.

Deadline recorded: Dec 24, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87707(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances... This requirement is not met as evidence by: Based on observation, facility failed to keep cleaning supplies and disinfectant inaccessible to residents in care, This possess an immediate health and safety risk of residents.

Official plan of correction

Administrator placed disinfectant and cleaning supplies at the facility office which makes inaccessible to residents in care. Administrator cleared the deficiency immediately. Cleared on site.

Deadline recorded: Dec 23, 2021. 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

Maintenance and Operation (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 was not met as evidenced by Based on observation LPA observed facility sitting area (per facility sketch) is cluttered with clothes, shoes on the floor, bedroom #3 & bedroom #5 was observed to have a lot of unorganized clothes, shoes on the floor, pantry which is located at the dining area is unorganized with food supplies observed to be on the floor. This possess a potential health and safety risk of residents.

Official plan of correction

Administrator stated that the staff will clean the facility and de-clutter the facility rooms and floors, picture will need to be send to CCL as proof of correction by POC date.

Deadline recorded: Dec 31, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements Supplies of nonperishable foods for a minimum of one week.. shall be maintained on the premises This requirement was not met as evidenced by Based on observation and interview, 1.5 Gallon of milk and ¾ bag loaf of bread during the visit, LPA asked Adminsitrator if there are more perishable food for resident, Adminsitrator only showed eggs observed at the counter. This possess a potential health and safety risk of residents.

Official plan of correction

Adminsitrator stated that she will buy more food supplies (perishable), receipt and picture of food supplies will need to be send to CCL office or to LPA L.Ibo by POC date.

Deadline recorded: Dec 27, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

80019(e)(1)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance Obtain a California clearance or a criminal record exemption as required by the Department... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by having S2 who do not have fingerprint exemption clearance work at the facility which poses an immediate health and safety risk to the clients in care.

Official plan of correction

Administrator stated that S2 will get fingerprint clearance not later than 12/24/2021. Adminstrator stated that S2 will not be at the facility until fingerprint clearance is receive.

Deadline recorded: Dec 24, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

80072(a)

Regulation authority

CCR

What the official deficiency says

Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This requirement is not met as evidence by: Based on observation LPA observed staff not wearing mask this possess potentia health and safety risk for residents in care.

Official plan of correction

Adminsitrator stated that she will trained all staff for proper PPE use, a copy of training topic and staff signature will need to send to CCL office by POC date.

Deadline recorded: Dec 27, 2021. A deadline is not proof that correction was completed.