CAREFRONT RESIDENTIAL LIVING, LLC

Official classification

Type A

Official code

87465(h)(2)

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. Based on observation the licensee did not comply with the section cited above by having unlocked medication, including but not limited to MiconazorbAF 2% which was unlocked in R2's bedroom, which poses an immediate health and safety risk to persons in care.

Official plan of correction

Administrator agreed to obtain a dr's order for the medication and will conduct an In-Service training with caregivers. Administrator will submit documents and sign-in sheet to CCLD by POC due date. Administrator removed the medication from resident's room during visit.

Deadline recorded: Feb 4, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, maintained in the residents file, Both the physician's order and the label shall contain at least all of the following information. Based on file review the licensee did not comply with the section cited above by not having on a file a doctor's order for R2's MiconazorbAF 2% which poses an health, safety risk and personal rights to persons in care.

Official plan of correction

Administrator agreed to obtain a doctor's order for the medication for R2 and will submit a copy to CCLD by POC due date. During visit Administrator obtained doctor's order for R2's Miconazole Powder prescription. Deficiency cleared during visit.

Deadline recorded: Feb 4, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(3)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (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. Based on file review and observation the licensee did not comply with the section cited above by not having on a file a doctor's order for R3, R4, R5 and R6 1/2 bed rails which poses an health, safety risk and personal rights to persons in care.

Official plan of correction

Administrator agreed to remove 1/2 bed rails. During visit caregiver removed 1/2 rails from R3, R4, R5 and R6's beds. Deficiency cleared.

Deadline recorded: Mar 4, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. Based on observation the licensee did not comply with the section cited above by not having backyard cean and cleared of window frames, paint cans, bags of cement mix, stroller, infant car seat, wood, reindeer Christmas decorations located outside which poses an health, safety risk and personal rights to persons in care.

Official plan of correction

Administrator agreed to clear, remove and clean the backyard and will submit photos to CCLD by POC due date. Repeat Violation. Civil penalty $250.00 assessed.

Deadline recorded: Feb 11, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87609(b)(4)

Regulation authority

CCR

What the official deficiency says

87609 Allowable Health Conditions and the Use of Home Health Agencies (b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s). Based on observation and record review, the licensee did not comply with the section cited above in not having a home health care plan for R1's foley catheter which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agreed to obtain a copy of home health care plan for R1 and submit copy to CCLD by POC due date.

Deadline recorded: Feb 4, 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 as cleaning chemicals were found in an unlocked cabinet under the kitchen sink and scissors in an unlocked drawer in the kitchen, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/05/2025 Plan of Correction Fixed on site. Cabinet underneath the sink was locked and the scissors were moved to a storage area that was inaccessible to residents in care

Official classification

Type B

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 due to the emergency exit gates in the backyard being broken and tied with a rope, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/11/2025 Plan of Correction On or before the plan of correction date, licensee will submit photos to LPA of the gates being fixed, and able to open and close with ease.

Official classification

Type B

Official code

87555(b)(23)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate 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 in having expired fruits in the fridge in the kitchen, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/11/2025 Plan of Correction Fixed on site. Expired fruit was removed from the fridge, and staff ensured understanding to double check all foods.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(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 having knives in kitchen unlocked kitchen cabinet and shed in back yard unlocked which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/16/2024 Plan of Correction Administrator agreed to lock shed and make knives inaccessible to residents and submit photos to CCLD by POC date.

Official classification

Type A

Official code

87615(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (2) Gastrostomy tubes. 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 in having an approved exception for R1, R2, and R3 prohibited health condition which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/16/2024 Plan of Correction Administrator agreed to submit exception request for R1, R2, and R3 prohibited health condition to CCLD by POC date.

Official classification

Type B

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 observation and record review, the licensee did not comply with the section cited above in having any of the staff first aid or CPR certified which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2024 Plan of Correction Administrator agreed to have all staff first aid certified and at least one staff per shift CPR certified. Certificates will be submitted to CCLD by POC date.

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. 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 in having appraisal needs and services plan for each resident which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2024 Plan of Correction Administrator agreed to fully fill out an appraisal needs and services plan for each resident and submit plan to CCLD by POC date.

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in having doctor's orders for R1, R2, and R3 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2024 Plan of Correction Administrator agreed to obtain a doctor's order for full bed rail for R1, R2, and R3 and submit order to CCLD by POC date.

Official classification

Type B

Official code

87633(b)

Regulation authority

CCR

What the official deficiency says

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in having a hospice care plan at facility for R4 and R5 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2024 Plan of Correction Administrator agreed to obtain a hospice care plan for R4 and R5 and submit it to CCLD by POC date.

Official classification

Type B

Official code

87412(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in not having administrator file available for review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2024 Plan of Correction Administrator agreed to read regulation 87412, and submit self-certification that it has been read and agree to abide by regulation going forward to CCLD by POC date.

Official classification

Type B

Official code

87705(k)(3)

Regulation authority

CCR

What the official deficiency says

(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors or perimeter fence gates: (3) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. 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 in conducting a fire drill which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2024 Plan of Correction Administrator agreed to conduct a fire drill and fully complete document and submit to CCLD by POC date.

Official classification

Type B

Official code

87305

Regulation authority

CCR

What the official deficiency says

(a) Prior to construction or alterations, all facilities shall obtain a building permit. 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 in obtaining a building permit or contacting CCLD prior to construction which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2024 Plan of Correction Administrator agreed to submit an LIC200 and updated facility sketch to CCLD by POC date.

Official classification

Type B

Official code

87203

Regulation authority

CCR

What the official deficiency says

(c) 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 in having the fire extinguisher serviced or purchased, and changing the battery in the smoke detector which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2024 Plan of Correction Administrator agreed to have fire extinguishers serviced or purchase new ones and change battery or have smoke detector services. Also, to submit photos to CCLD by POC date.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(d) The following space and safety provisions shall apply to all facilities: (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 in having hoyer lifts, tray, wheelchair, and bed frame in back yard. Also R5 is blocking emergency exit in bedroom which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2024 Plan of Correction Administrator agreed to have items removed from back yard, change R5's position not to block exit, and submit photos to CCLD by 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 in having R1's medication locked in refrigerator which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/16/2024 Plan of Correction Administrator agreed to have medication made in accessible to residents and submit photo to CCLD by POC date.

Official classification

Type B

Official code

87468.1(a)(6)

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 leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement was not met as evidenced by the facility having an additional inside front door lock to prevent residents from leaving the facility which is in violation of Title 22 Section 87468.1 1 Personal Rights of Residents in all Facilities.

Official plan of correction

On 03/07/24 at 1:45PM, LPA observed staff (S2) remove the additional inside front door lock during visit. Deficiency cleared during visit.

Deadline recorded: Mar 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(2)

Regulation authority

CCR

What the official deficiency says

87615(a)(2) Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (2) Gastrostomy tubes. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview, the licensee did not comply with the section cited above by admitting residents (R1, R2, R3 and R4) with prohibited health condition which poses an immediate health, safety or personal rights risk to persons in care. LPA observed that residents (R1, R2, R3 and R4) have feeding tubes

Official plan of correction

POC Due Date: 11/07/2023 Plan of Correction Administrator will submit an Exception Request to retain residents via email by POC date. Administrator will also separately submit a letter of explanation how the facility will care for residents while awaiting approval, to ensure residents needs are being met.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

87412(a) Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. 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 maintaining staff records which poses/posed a potential health, safety or personal rights risk to persons in care. S1 and S2 records are missing LIC 501, LIC 503 and LIC 508. S3 record is missing LIC 503 and LIC 508

Official plan of correction

POC Due Date: 11/16/2023 Plan of Correction Administrator will obtain missing records from staff, provide proof to CCL by POC date that records have been completed and place files in staff designated folders

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) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 associating S1 to the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/22/2022 Plan of Correction Adminstrator will have another caregiver work instead of S1 until the complete a transfer. Administrator will email and call CCL to complete the criminal record clearance transfer and associate them to the facility. Administrator will send proof of transfer completion to CCL by POC date

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

(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 as specified in Section 87355(c) or 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. LPA observed S1 is cleared, however, not associated to facility which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/23/2021 Plan of Correction By POC, Administrator will review regulation and submit self-certification letter to CCL.

Official classification

Type A

Official code

87705(l)(2)

Regulation authority

CCR

What the official deficiency says

(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above with the pedestrian gate remained locked at the facility, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/23/2021 Plan of Correction The Licensee will remove the latch, and send proof by POC date.