QCARE RESIDENTIAL FACILITY III

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... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having Lysol Wipes unlocked in R1’s room and the tool shed with chemicals which poses an immediate safety risk to persons in care.

Official plan of correction

Administrator agrees to lock the items and send proof to CCLD by POC date.

Deadline recorded: Jan 23, 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

(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 observations, the licensee did not comply with the section cited above by having one of the kitchen cabinets loose and the smoke alarm missing in the hallway which poses a potential safety risk to persons in care.

Official plan of correction

The Assistant Administrator agrees to repair the items and send proof to CCLD by POC date.

Deadline recorded: Jan 30, 2026. 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

(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by not having sufficient food and snacks for the residents in care which poses a potential safety risk to persons in care.

Official plan of correction

The Assistant Administrator will purchase more food and send proof of corrections by POC date.

Deadline recorded: Jan 25, 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

(a) 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: Based on observation and interview, the licensee did not comply with the section cited above by only having one staff per shift which poses a potential safety risk to persons in care.

Official plan of correction

The Assistant Administrator agrees to obtain more staffing to cover staff during break and update the LIC500. Proof of correction will be sent to CCLD by POC date.

Deadline recorded: Jan 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. 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 hot water measuring to 128.0 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/12/2025 Plan of Correction Administrator will adjust the water heater and send photo proof of the lowered temperature to the LPA 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 in part to the cleaning chemicals, such as bleach and bathroom cleaner, being found under the unlocked sinks in both bathrooms, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/12/2025 Plan of Correction Staff will remove the chemicals from the bathrooms and move them to a locked cabinet. Administrator will also create a sign-in sheet for training on this matter 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 observation, the licensee did not comply with the section cited above due to junk and debris found in the pathway, discarded furniture on the side of the house, and a hole in the wall next to the front door, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/18/2025 Plan of Correction Administrator will submit photo proof of the fixes to the facility on or before POC date.

Official classification

Type B

Official code

87468.2(a)

Regulation authority

CCR

What the official deficiency says

(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: 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 which there was a camera installed pointed to a room and locks on the fridge + pantry which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/18/2025 Plan of Correction Camera was fixed on site and removed from the area. Administrator will submit photo proof of the removal of the fridge/pantry locks on or before POC date.

Official classification

Type A

Official code

87355(e)(3)

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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) 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 one staff member not being associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/12/2025 Plan of Correction Administrator had staff member move off site until the staff can be properly associated to the facility. In addition, a civil penalty of $500 was issued.

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.... 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). -This requirement is not met as evidenced by: -Based on record review and Guardian Portal look-up, the licensee did not comply with the section above for not having S1 associated to this facility which poses a potential safety and/or personal right risks to persons in care.

Official plan of correction

Administrator to have the staff associated, and submit proof by 5/02/24.

Deadline recorded: May 2, 2024. 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 record review and interview, the licensee did not comply with the section above for not having R1's documents readily avalable for review.

Official plan of correction

Administrator to complete the resident's file, and submit self-certification by 5/02/24.

Deadline recorded: May 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 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: -Based on observation and interviews, the licensee did not comply with the section above in installing lock on the front door which poses an immediate safety and/or personal rights risks to persons in care. Civil penalty is assessed.

Official plan of correction

Administrator to do the following, and submit proof by 4/19/24: 1. Remove the lock and submit picture. 2. Ensure there's an awake/night staff and submit LIC500 Personnel Report. 3. In-service the staff and submit copy of in-service training with attendees signatures, A $500.00 civil penalty is assessed.

Deadline recorded: Apr 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87628(a)

Regulation authority

CCR

What the official deficiency says

87628(a) Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above by staff (S1) performing glucose testing for resident (R1) which poses/posed a potential health, safety or personal rights risk to persons in care. LPAs were informed that S1 performs testing for R1, R1 is not on hospice or receiving care from home health

Official plan of correction

POC Due Date: 10/06/2023 Plan of Correction Administrator will review regulation and submit a plan to address R1 diabetic care needs and submit a copy to CCL by POC date.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency... within seven days of the occurrence... This requirement was not met as evidence by: Based on LPA's interview and record review the Licensee did not comply with the section cited above in reporting incidents, which poses a potential health and safety risk to clients in care.

Official plan of correction

Administrator agreed to submit a self-certification that the regulation 87211 has been reviewed and administrator will abide by the regulation. Self-certification will be submitted by the POC date.

Deadline recorded: Nov 9, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(16)

Regulation authority

CCR

What the official deficiency says

87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services This requirement was not met as evidence by: Based on LPA interviews and record reviews Licensee did not comply with the section cited above in having R1's seen by podiatrist, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to submit a self-certification that the regulation 87468.1 has been reviewed and administrator will abide by the regulation. Self-certification will be submitted by the POC date.

Deadline recorded: Nov 9, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)(2)

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). (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: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by having a broken drawer with knives, scissors accessible located in a bookshelf and the keys to the medication closet hanging in the door of the closet and the knob broken which makes the medication accessible to residents in care which poses an immediate health and safety to persons in care.

Official plan of correction

POC Due Date: 09/08/2022 Plan of Correction Administrator agreed to repair the kitchen sharps drawer and repair or replace the door know to the medication closet and email photos to CCLD no later then the POC date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation 87303(a) (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 observation, the licensee did not comply with the section cited above by having dresser, weed eater, chair, lamp, rake, shovel, hoe, pick, pitch fork lawn mower, pressure washer, mattress, stove top and leaning fence which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/28/2022 Plan of Correction Administrator agreed to lock tools weed eater, rake, shovel, hoe, pick, pitch fork and lawn mower in the locked shed and remove the dresser, chair, lamp, mattress, stove top and repair fence by POC date and email photo copies to CCLD no later then POC date.

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

87305(a) Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by alternating the existing building which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/28/2022 Plan of Correction Administrator will submit approved permit from the local county department along with a new facility sketch to CCL no later than the POC date.