Facility condition and maintenanceType B
- 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 in by not having the back yard clear of window screens, blinds, wood, mirror, rusted paint can etc.. which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2026 Plan of Correction Administrator agreed to clean the back yard and submit a photo to CCLD by POC due date.
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468(c)
- Regulation authority
- CCR
What the official deficiency says
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. 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 by not having personal rights and non-discrimination posted in prominent area of the facility to be seen which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2026 Plan of Correction Administrator agreed to send a photo of personal rights and non-discrimination in RCFE facilities posted to CCLD by POC due 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 in by not having 20hrs annual training, including but not limited to 8hrs dementia and 4hrs specific to postural support, restricted health conditions and hospice care completed by S1-S4 which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2026 Plan of Correction Administrator agreed to send training certificates of complettion for S1-S4 to CCLD by POC due dat.
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468(b)(1)(A)
- Regulation authority
- CCR
What the official deficiency says
(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record. 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 by not having completed signed personal rights (LIC 613C) for R1, R3 and R4 which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2026 Plan of Correction Administrator agreed to submit proof of signed personal rights for R1, R3 and R4 to CCLD by POC due date.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(a)
- Regulation authority
- CCR
What the official deficiency says
(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, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. 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 by not having an Appraisal Needs and Services (ANS/LIC 625) on file for R1-R4 which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2026 Plan of Correction Administrator agreed to send copies of completed ANS to CCLD by POC due date.
Fire safety and emergency preparednessType B
- 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 and record review, the licensee did not comply with the section cited above in by not conducting quarterly emergency drills with staff which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2026 Plan of Correction Administrator agreed to send In-Service emergency drills sign-in sheet with participants to CCLD by POC due date.
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87608(a)(5)(A)
- Regulation authority
- CCR
What the official deficiency says
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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 by not having a dr's order on file for 1/2 rail for postural support/mobility for R3 which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2026 Plan of Correction Admiistrator agreed to send copy of Dr's order to CCLD by POC due date.