Fire safety and emergency preparednessType A
- 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 evidence by: Based on observation, the licensee did not comply with the section cited above in having locks on the front yard gate which poses an immediate health and safety risk to persons in care.
Official plan of correction
The Administrator removed the locks from the gate. Deficiency Cleared During Visit. *An immediate civil penalty of $500.00 will be assessed*
Deadline recorded: Apr 22, 2026. A deadline is not proof that correction was completed.
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87307(a)
- Regulation authority
- CCR
What the official deficiency says
87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function..privacy for the residents, staff, and others who may reside in the facility.. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in having a staff member utilizing part of the common area for residents as a live-in space for staff which poses an immediate health and safety risk to persons in care.
Official plan of correction
By POC date, the Administrator agrees to Revert back to the approved Physical plant and send photo proof of the arrangement to CCLD.
Deadline recorded: May 5, 2026. A deadline is not proof that correction was completed.
Hazardous items and storageType A
- Official classification
- Type A
- Official code
- 87309(A)
- Regulation authority
- CCR
What the official deficiency says
87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools... This requirement is not met as evidence by: Based on observation, the licensee did not comply with the section cited above in having unlocked chemicals in a residents room such as a multi-purpose cleaner, and disinfectant spray which poses an immediate health and safety risk to persons in care.
Official plan of correction
By POC date, the Administrator removed the chemicals and put them in a locked cabinet. Deficiency cleared during visit.
Deadline recorded: Apr 22, 2026. A deadline is not proof that correction was completed.
Medication handling and storageType B
- Official classification
- Type B
- 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... This requirement is not met as evidence by: Based on observation, the licensee did not comply with the section cited above in having unlocked medications in a residents room such as Clotrimazole and unlocked medications in the refrigerator such as Insulin Glargine-yfgn which poses an immediate health and safety risk to persons in care.
Official plan of correction
By POC date, the Administrator removed the medications and put them in a locked cabinet. Deficiency cleared during visit.
Deadline recorded: Apr 28, 2026. A deadline is not proof that correction was completed.