ANGEL CARE HOME

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... This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having the kitchen drawer that contained medications locked, which poses an immediate health and safety risk to persons in care.

Official plan of correction

Caregiver S2 immediately locked kitchen drawer during visit. Deficiency cleared during visit.

Deadline recorded: Aug 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container...This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having medications for R1 in it's original container, which poses a potential health and safety risk for persons in care.

Official plan of correction

Administrator agreed to read and review regulation 87465 and submit self-certification that the facility will abide by the regulation going forwarded to CCLD by POC date.

Deadline recorded: Aug 26, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(b)

Regulation authority

CCR

What the official deficiency says

(b) A comfortable temperature for residents shall be maintained at all times. This requirement was not met as evidence by: Based on observation the licensee did not comply with the section cited above in having a comfortable temperature for residents, which poses a potential personal rights issue to persons in care.

Official plan of correction

Administrator agreed to have air condition serviced and submit a repair invoice to CCLD by POC date.

Deadline recorded: Aug 26, 2026. 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

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 and to the person responsible for the resident within seven days of the occurrence... This requirement was not met as evidence by: Based on observation and record review the Licensee did not comply with the section above in submitting an incident report for R2's hospitalization, which poses a personal rights issue to person in care.

Official plan of correction

Administrator agreed to submit a complete incident report for R2's hospitalization to CCLD by POC date.

Deadline recorded: Aug 26, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement was not met as evidence by: The Licensee did not comply with the section cited above in having a medical assessment for R1 which poses a potential health and safety risk to persons in care.

Official plan of correction

The administrator agreed to obtain a medical assessment for R1 and submit a copy to CCLD by POC date.

Deadline recorded: Aug 26, 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 in having knives in unlocked kitchen drawer upon arrival which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/08/2026 Plan of Correction Caregiver immediately locked kitchen drawer. Deficiency cleared during visit.

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 observation, interview, and record review, the licensee did not comply with the section cited above in having all staff complete the required yearly trianing which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2026 Plan of Correction Administrator agreed to get all staff trained and submit documentation to CCLD by POC date.

Official classification

Type A

Official code

87628(a)

Regulation authority

CCR

What the official deficiency says

(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... 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 was not met as evidence by: Based on interviews the Licensee did not comply with the section cited above in having a skilled professional conduct glucose testing and administering insulin, which poses a potential health and safety risk to persons in care

Official plan of correction

House Manager agreed to implement a plan to have R2, R3, and R4 glucose tested and insulin given, and submit plan to CCLD by POC date.

Deadline recorded: Mar 20, 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) ... (b), the licensee shall ensure that disinfectants, cleaning solutions... knives, matches, tools, sharp objects... are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having sharps inaccessible to residents, which poses a safety risk to persons in care.

Official plan of correction

Caregiver removed sharps from kitchen drawer and locked them outside in the garage during visit. Deficiency cleared during visit.

Deadline recorded: Mar 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: This requirement is not met as evidence by: Based on observation licensee did not comply with the section cited above in having refrigerated medication for R2, R3, and R4 locked and inaccessible, which poses a possible health and safety risk to persons in care.

Official plan of correction

House Manager agreed to lock refrigerated medications and submit photos to CCLD by POC date.

Deadline recorded: Mar 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(1)

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: (1) Nonambulatory persons. 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 having a fire clearance for five (5) non-ambulatory residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2025 Plan of Correction Administrator agreed to submit an updated facility sketch and an LIC200 to CCLD by POC date.

Official classification

Type A

Official code

87465(h)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: 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 diabetic medication unlocked in refrigerator which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2025 Plan of Correction Administrator agreed to lock up diabetic medication and submit a photo to CCLD by POC date.

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 observation, interview, and record review, the licensee did not comply with the section cited above in having training for all staff which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/12/2025 Plan of Correction Administrator agreed to get all staff trained and submit certifications and/or sign-in sheets to CCLD by POC date.

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 observation and record review, the licensee did not comply with the section cited above in conducting a quarterly fire drill which poses a potential health, or safety risk to persons in care.

Official plan of correction

POC Due Date: 06/12/2025 Plan of Correction Administrator agreed to conduct a fire drill and submit documentation to CCLD by POC date.

Official classification

Type A

Official code

87705(f)

Regulation authority

CCR

What the official deficiency says

(f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: 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 exit gate unlocked. LPA observed locked padlock which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2025 Plan of Correction Caregiver immediately removed padlock during visit. Deficiency cleared during visit.

Official classification

Type B

Official code

87307(a)(3)(B)

Regulation authority

CCR

What the official deficiency says

(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. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. 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 all required furniture in residents bedrooms which poses personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/12/2025 Plan of Correction Administrator agreed to purchase required furniture for residents bedrooms and 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 outdoor passageways cleared which poses a potential health or safety risk to persons in care.

Official plan of correction

POC Due Date: 06/12/2025 Plan of Correction Administrator agreed to have all items removed from passageways and submit photo to CCLD by POC date.

Official classification

Type B

Official code

87307(3)(c)

Regulation authority

CCR

What the official deficiency says

(3) Equipment and supplies necessary for personal care... shall be readily available to each resident. (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often... clean linen is in use by residents at all times. This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having suffiencient linen for residents, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to purchase towels and enough linen for each resident. Administrator will submit photo to CCLD by POC date.

Deadline recorded: Feb 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors. This requirement was not met as evidence by: Based on observation the Licensee did not comply wiht the section cited above in having a non slip mat in the shared bathroom tub, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to purchase non skid mat and submit photo to CCLD by POC date.

Deadline recorded: Feb 6, 2025. 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

(a) Each licensee shall furnish to the licensing agency such reports... (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... This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section above in reporting incidents for R1 and R2 to CCLD, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to submit incident reports for R1 ad R2 to CCLD by POC date.

Deadline recorded: Feb 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(6)

Regulation authority

CCR

What the official deficiency says

(a) Residents... shall have all of the following personal rights: (6) To... not be locked into any room... by day or night. This does not prohibit a licensee... locking doors at night to protect residents... This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in R1 having a reversed door knob and being locked inside bedroom, which poses a potential health and safety risk for persons in cae.

Official plan of correction

Administrator agreed to have a new door knob placed without a lock or reverse the door knob with the lock being inside the room for resident.

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

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: Based on LPA record review the licensee did not comply with the section cited above in having R1's file completed, which poses a potential health and safety risk for persons in care.

Official plan of correction

Administrator agreed to obtain admission agreement, consent for medical treatment, emergency contact and identification, and submit forms to CCLD by POC date.

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

Official classification

Type B

Official code

87465(d)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription... and is unable to communicate... facility staff ... shall be permitted to assist the resident with self-administration provided all of the following requirements are met: This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having 3 prescribed medications available for R1 for administration which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to obtain medication for and submit a copy of the prescription and the bottle of medication to CCLD by POC date

Deadline recorded: Nov 25, 2024. 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

(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 and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement was not met as evidence by: Based on record review and interview the Licensee did not comply with the section cited above in report R1's hospitalization, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to submit an LIC624 for R1's hospitalization to CCLD by POC date.

Deadline recorded: Nov 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(d)

Regulation authority

CCR

What the official deficiency says

(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement was not met as evidence by: Based on record review and interview the Licensee did not comply with the section cited above in have a S4 residing in facility with a clearance, which poses an immediate health and safety risk to persons in care.

Official plan of correction

Administrator agreed to get S4 fingerprinted or submit document stating S4 will not be residing in the facility to CCLD by POC date.

Deadline recorded: Nov 22, 2024. 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

87211 (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 and to the person responsible for the resident within seven days of the occurrence... This requirement was not met as evidence by: Based on observation and record review the Licensee did not comply with the section cited above in submitting an incident report for R1, which poses a potential health and safety risk for persons in care.

Official plan of correction

Administrator agreed to review regulation 87211 and submit self-certification that facility will abide by regulation going forward to CCLD by POC date.

Deadline recorded: Sep 13, 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 was not met as evidence by: Based on observation, interview, and record review the Licensee did not comply with the section cited above in having R1's file available for review, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to review regulation 87506 and submit self-certification that facility will abide by regulation going forward to CCLD by POC date.

Deadline recorded: Sep 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(3)(C)

Regulation authority

CCR

What the official deficiency says

(3) ...supplies necessary for personal care and maintenance... shall be readily available to each resident. ...if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall... at least once per week or more often... This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having sufficent linen for residents, which poses a possible health and safety risk to persons in care.

Official plan of correction

Administrator agreed to purchase additonal linen including towels and submit receipt and photo of new items to CCLD by POC date.

Deadline recorded: Sep 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(f)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (f) All personnel 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 evidence by: Based on observation and record review the Licensee did not comply with the section cited above in having S3's file available for review, which poses a potential health and safety risk to persons in care..

Official plan of correction

Administrator agreed to have S3's file readily for review at facility ad submit a self certification to CCLD by POC date.

Deadline recorded: Sep 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (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 was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having knives locked and inacessible to residents, which poses a health and safety risk to persons in care.

Official plan of correction

Caregiver locked kitchen drawer containing knives. Deficiecency cleared.

Deadline recorded: Aug 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(e)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidence by: Based on observartion the Licensee did not comply with the section cited above in having R1's records available for review, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to implement a plan on how and where records will be retained following termination of a resident to CCLD by POC date.

Deadline recorded: May 28, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(A)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish to the licensing agency such reports... including, but not limited to... (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven day... This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment... A) Death of any resident from any cause regardless of where the death occurred...This requirement was not met as evidence by: Based on observation the Licensee did not comply with the seciton cited above in reporting R1's death to CCLD, which poses a potential health and safety risk to person in care.

Official plan of correction

Adminstrator agreed to submit a complete death report for R1 to CCLD by POC date.

Deadline recorded: May 28, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(c)(3)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. Based on observation and record review the Licensee did not comply with the section cited above in having an accurate MAR for each resident, which poses a potential health and safety risk for persons in care.

Official plan of correction

Administrator agreed to have an in-service training regarding record keeping for medication and submit complete training to CCLD by POC date.

Deadline recorded: May 28, 2024. 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) 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 in having cleaning supplies accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/01/2024 Plan of Correction Caregiver immediately locked away disinfectants in garage. Deficiency cleared during visit.

Official classification

Type A

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 observation and record review, the licensee did not comply with the section cited above in having an administrator employed at facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/01/2024 Plan of Correction Administrator agreed to implement plan or submit documents showing recertification to CCLD by POC date.

Official classification

Type A

Official code

87633(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act (Health and Safety Code Section 1569 et seq.), all other requirements of Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver. 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 having only 2 residents residing in facility on hospice which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/01/2024 Plan of Correction Administrator will implement a plan to accommodate more than two (2) hospice residents, and submit plan to CCLD by POC date.

Official classification

Type A

Official code

87705(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (1) The facility has a nonambulatory fire clearance for each room that will be used to accommodate a resident with dementia who is unable to or unlikely to respond either physically or mentally to oral instructions relating to fire or other dangers and to independently take appropriate actions during emergencies or drills. 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 a resident with dementia in a ambulatory room only per fire clearance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/01/2024 Plan of Correction Administrator will implement a plan to have R4 in correct room and submit plan to CCLD by POC date.

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 and scissors inaccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/01/2024 Plan of Correction Caregivers immediately locked knives and scissors in drawer. Deficiency cleared during visit.

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, interview, and record review, the licensee did not comply with the section cited above in having a full bedrail for R4 and no doctor's order which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/07/2024 Plan of Correction Administrator will obtain order for full bedrail and submit copy to CCLD by POC date.

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 in having outdoor passageways clear of obstruction which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/07/2024 Plan of Correction Administrator agreed to have all items removed and submit photos to CCLD by POC date.

Official classification

Type A

Official code

87202(a)(1)

Regulation authority

CCR

What the official deficiency says

87202(a) All facilities shall maintain a fire clearance approved by the city, county... department, or district providing fire protection services... Prior to accepting or retaining... licensee shall notify the licensing agency and obtain an appropriate fire clearance... (1) Non ambulatory persons. This requirement was not met as evidence by: Based on observation and record review the Licensee did not comply with the section cited above in have 3 non-ambulatory residents in ambulatory rooms, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to either move residents to non-ambulatory or submit updated facility sketch and LIC200 to have a new fire clearance to CCLD by POC date.

Deadline recorded: Feb 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(d)(3)

Regulation authority

CCR

What the official deficiency says

87355 (d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement... (3) The licensee shall submit these fingerprints... for the purpose of searching the records... prior to the individual's employment, residence, or initial presence in the facility. This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having S3 fingerprinted before working at facility which poses a potential immediate health and safety risk to persons in care.

Official plan of correction

Administrator agreed to get S3 fingerprinted and submit proof to CCLD by POC date.

Deadline recorded: Feb 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (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 was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having knives and scissors accessible to residents, which poses/posed an immediate health and safety risk to persons in care.

Official plan of correction

Administrator locked knives away making them inaccessible to residents. Deficiency cleared during visit.

Deadline recorded: Feb 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303

Regulation authority

CCR

What the official deficiency says

87303 (e)Water supplies and plumbing fixtures shall be maintained as follows: (2)Faucets used by residents... Hot water temperature controls shall be maintained... to attain a temperature of not less than 105 degree F and not more than 120 degree F. This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in have hot water between 105-120, which poses/posed an immediate health and safety risk to persons in care.

Official plan of correction

Administrator agreed to adjust water temperature between 105 - 120 and submit photo to CCLD by POC date.

Deadline recorded: Feb 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 (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... This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited in have medications locked and inaccessible, which poses/posed a potential health and safety risk to persons in care.

Official plan of correction

Caregiver locked put away medication and locked closet immediately during visit. Deficiency cleared during visit.

Deadline recorded: Feb 14, 2024. 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

87211 (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 and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement was not met as evidence by: Based on interview and record review the Licensee did not comply with the section cited above in reporting incidents to CCLD, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to submit incident reports/death report for R1, R4, and R5 to CCLD by POC date.

Deadline recorded: Feb 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87632

Regulation authority

CCR

What the official deficiency says

87632 (d) ...a hospice care waiver it shall stipulate terms and conditions of the waiver... to ensure the well-being of terminally ill residents... which shall include..., the following requirements: (2)The licensee shall notify the Department in writing within five working days of the initiation of hospice care... or within five working days of admitting a resident already receiving hospice care services... This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in notifying CCLD about hospice residents, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to submit a hospice notification for R3 and R4 to CCLD by POC date.

Deadline recorded: Feb 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

877405(a)

Regulation authority

CCR

What the official deficiency says

87405 (a) All facilities shall have a qualified and currently certified administrator...The administrator shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility... When the administrator is not in the facility, there shall be coverage by a designated substitute... This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above by not having adequate attention to the management and administration of the facility , which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to review regulation 87405 and submit a self-certification that the regulation have been reviewed and the facility will abide by the regulation going forward to CCLD by POC date.

Deadline recorded: Feb 20, 2024. 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 was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having all personnel records complete and current, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to complete all personnel files and have them available for review, and will submit Health screenings, First aid, and TB test to CCLD by POC date.

Deadline recorded: Feb 20, 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 (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 was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in have complete and current records for residents, which poses a potential health and safety risk to persons in care.

Official plan of correction

The administrator agreed to complete all resident files and submit a copy of the physician's report, admission agreement, and the appraisal needs and services plan for each resident to CCLD by POC date.

Deadline recorded: Feb 20, 2024. 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

87555 (b) The following food service requirements shall apply: (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 was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in have 1 week perishable and 2-day non perishable foods for residents, which poses a potential health and safety risk to persons in care

Official plan of correction

Administrator agreed to purchase food and submit photo and receipts to CCLD by POC date.

Deadline recorded: Feb 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

87411 (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having annual training for staff, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to have all staff with required training and submit certifications to CCLD by POC date.

Deadline recorded: Feb 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87633(a)(4)

Regulation authority

CCR

What the official deficiency says

87633 (a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon... to reside in the facility and receive hospice services from a hospice agency... (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident... This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having a hospice plan for R3 and R4, which poses a potential health and safety risk for persons in care.

Official plan of correction

Administrator obtain the hospice care plan for R3 and R4 during visit. Deficiency cleared during visit.

Deadline recorded: Feb 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465 (h) The following requirements shall apply to medications which are centrally stored: (6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having the medication administrator record (MAR) current and aligned with resident's medication, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to review and correct the MAR for each resident for the month of February and submit a copy to CCLD by POC date.

Deadline recorded: Feb 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

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... This requirement was not met as evidence by: Based on record review and interview the licensee did not comply with the section cited above in having complete records for residents, which poses a potential health and safety risk for persons in care.

Official plan of correction

Administrator agreed to complete each resident file and submit a self-certification the files are complete by POC date. A $250.00 civil penalty will be assessed immediately.

Deadline recorded: Sep 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 (h)... shall apply to medications which are centrally stored: 2) ...medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision... This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having medication inaccessible which poses an immediate health and safety risk to persons in care.

Official plan of correction

Administrator immediately removed and locked medicines in closet. Deficiency cleared during visit.

Deadline recorded: Sep 15, 2023. 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... This requirement was not met as evidence by: Based on record review and interview the licensee did not comply with the section cited above in having complete records for residents, which poses a potential health and safety risk for persons in care.

Official plan of correction

Administrator agreed to complete each resident file and submit a self-certification the files are complete by POC date.

Deadline recorded: Aug 29, 2023. 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 was not met as evidence by: Based on record review and interview the Licensee did not comply with the section cited above in having a complete file for S2 which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to complete S2 personnel file, and submit self-certification that the files are complete by POC date. *Immediate $250 civil penalty for repeat*

Deadline recorded: Aug 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 (h) The following requirements shall apply to medications which are centrally stored: (2) ... medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having medicine inaccessible to residents, which posed an immediate health and safety risk to persons in care.

Official plan of correction

Administrator locked medicine closet immediately upon arrival. Deficiency cleared during visit.

Deadline recorded: Aug 23, 2023. 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

87211 (a) 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 specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Based on interview and record review, the Licensee did not comply with the section cited above in submitting and death report and incident report for residents, which poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator agreed to review regulation 87211 and submit self-certification that the regulation has been reviewed and will be abided by going forward to CCLD by POC date.

Deadline recorded: Aug 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidence by: Based on observation and record review the Licensee did not comply with the section cited above in obtaining a permit which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to submit and updated LIC200 and facility sketch to CCLD by POC date.

Deadline recorded: Aug 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

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, interview, and record review, the licensee did not comply with the section cited above in not obtaining a fire clearance or contacting CCLD regarding alterations which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/25/2023 Plan of Correction Administrator agreed to submit and updated LIC200 and facility sketch to CCLD by POC date.

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 in having passageways free of obstruction which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/25/2023 Plan of Correction Administrator agreed to remove all items out of passageways and submit photo to CCLD by POC date.

Official classification

Type B

Official code

1569.618(a)

Regulation authority

HSC

What the official deficiency says

(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. 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 being present during normal working hours which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/25/2023 Plan of Correction Administrator agreed to review the section cited above and regulation 87404, and submit a self-certification that the section and regulation has been reviewed and Administrator will abide by the regulation going forward by the 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 observation, interview, and record review, the licensee did not comply with the section cited above in having the Administrator file at the facility and the staff file complete which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/25/2023 Plan of Correction Administrator agreed to complete personnel files, and submit self-certification that the files are complete by POC date.

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 observation, interview, and record review, the licensee did not comply with the section cited above in having resident files complete which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/25/2023 Plan of Correction Administrator agreed to complete each resident file and submit a self-certification the files are complete by POC date.

Official classification

Type B

Official code

87211(a)(D)

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, including, but not limited to, the following: (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident 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 reporting incidents of residents to CCLD which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/25/2023 Plan of Correction Administrator agreed to review regulation 87211 and submit self-certification that the regulation has been reviewed and will be abided by going forward to CCLD by POC date.

Official classification

Type A

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 in having disinfectants and cleaning supplies accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/19/2023 Plan of Correction Administrator agreed to lock cleaning supplies and disinfectants away and take photo of locked cabinet and submit photo to CCLD by POC date.