KARO MINA CARE HOME

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 a pair of scissors with a blue handle acessible to residents located in the kitchen on top of the microwave which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 01/13/2026 Plan of Correction Administrator removed and locked the scissors in a cabinet. DEFICIENCY CLEARED DURING VISIT.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 that the administrator stated that they have a leg injury that requires surgery which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 01/19/2026 Plan of Correction By POC date, the Administrator agrees to appoint an additional staff member to assist the facility during their shifts and notify CCLD.

Official classification

Type B

Official code

87412(a)(4)

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: (4) Written verification that the employee is at least 18 years of age, including, but not necessarily limited to, a copy of his/her birth certificate or driver's license. 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 that S2's personnel file is missing their identifying document and LIC501 which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/19/2026 Plan of Correction By POC date, Administrator agrees to complete S2's personnel file including their identifying documents and LIC501 and notify CCLD.

Official classification

Type B

Official code

87468(c)(2)(A)

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. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. 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 that the PUB475 is the incorrect size which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/19/2026 Plan of Correction By POC date, the administrator agrees to obtain the correct 20 X 26 PUB475 poster and notify CCLD.

Official classification

Type B

Official code

87219(a)

Regulation authority

CCR

What the official deficiency says

(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in the facility not having any planned activities or an activity calendar which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/19/2026 Plan of Correction By POC date, the Administrator agrees to create an activity calendar that details planned activities for residents and notify CCLD.

Official classification

Type B

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 that there was Vicks formula 44DM cough syrup on R1's bedside table accessible which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 01/19/2026 Plan of Correction Administrator removed the Vicks formula 44DM cough syrup and locked it in the medication cabinet. DEFICIENCY CLEARED DURING VISIT.

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 PRN medication, and is unable to 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: 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 that the facility did not have proper documentation of the PRN, notification to the physicians or a log of the dosages being taken which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 01/19/2026 Plan of Correction By POC date, the Administrator agrees to review the procedure, update files accordingly and notify CCLD.

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 that R1's Appraisal needs and Services Plan was incomplete which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/19/2026 Plan of Correction By POC date, the Administrator agrees to complete R1's Appraisal needs and services plan and notify CCLD.

Official classification

Type B

Official code

87623(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain a resident who requires the use of an indwelling catheter under the following circumstances: This requirement is not met as evidence by: Based on record review, interview with W1 and Licensee, and text messages Licensee did not have the proper requirements met to retain a resident with a catheter which posed a potential health risk to resident in care

Official plan of correction

By POC Licensee agrees to review regulation and notify CCLD

Deadline recorded: Nov 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(b)(1)

Regulation authority

CCR

What the official deficiency says

(b) A comfortable temperature for residents shall be maintained at all times.(1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). This requirement is not met as evidence by: Based on observation facility temperature was 66 degrees F which posed a potential health risk to resident in care

Official plan of correction

By POC facility agrees to set the thermostat to not allow the temperature to go below 68 degrees F and notify CCLD

Deadline recorded: Nov 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

(a)In addition to the rights listed in Section 87468. … the elderly shall have all of the following personal rights: (8)To be free from neglect… or sexual abuse. The following requirement was not met as evidence by: Based on interviews with W1 and review of text messages R1 sustained pressure injuries due to staff neglecting to ensure proper movement which poses an immediate health and personal rights violation to resident in care.

Official plan of correction

By POC Licensee agrees to review the regulation, develop a poster on how to prevent pressure injuries, have poster posted for staff, provide a copy of poster to CCLD via certified mail and notify CCLD.

Deadline recorded: Nov 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

(a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. The following requirement was not met as evidence by: Based on interviews with W1, photos, text messages with home health, and observations made at the facility by LPAs the facility is not providing quality food due to having expired foods in use for residents such as potatoes, pre-cooked meals, and produce as well as not following R1’s no salt diet which led to them swelling which poses an immediate health and personal rights violation to resident in care.

Official plan of correction

By POC Licensee agrees to review the regulation, develop a poster on how to inspect for expired food, when to discard, food life, and identifying and how to adhere to special diets, have poster posted for staff, provide a copy of poster to CCLD via certified mail and notify CCLD.

Deadline recorded: Nov 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.655(a)

Regulation authority

HSC

What the official deficiency says

(a) If a licensee .. increases the rates… the licensee shall provide no less than 90 days’ prior written notice… including a description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident. The following requirement was not met as evidence by: Based on interviews with Licensee, W1, and review of text messages the Licensee raised the rent without proper notice twice which poses a potential personal rights violation to resident in care.

Official plan of correction

By POC Licensee agrees to review the regulation, register and complete a training related to rate increases/admission agreements by an approved CCLD vendor that they have not used before, and notify CCLD.

Deadline recorded: Nov 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(3)(D)

Regulation authority

CCR

What the official deficiency says

(a)Living accommodations …shall apply: (3)Equipment and supplies necessary for personal care …the licensee shall assure provision of: (D)Hygiene items of general use such as soap and toilet paper. The following requirement was not met as evidence by: Based on interviews with R1, R2, and W1 the facility was not providing basic hygiene needs by not readily providing toilet paper which poses a potential personal rights violation to resident in care.

Official plan of correction

By POC Licensee agrees to review the regulation, register and complete a training related to personal accommodations and services by an approved CCLD vendor that they have not used before, provide all required hygiene supplies with extra supply available for resident use in the bathroom, and notify CCLD.

Deadline recorded: Nov 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

(f)Basic services shall at a minimum include:(4)Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. The following requirement was not met as evidence by: Based on interviews with W1, record review, observations made during visits the facility was not following the careplans’ for R3 by not assisting them with repositioning every 2 hours, and not following R1’s careplan which poses a potential personal rights violation to resident in care.

Official plan of correction

By POC Licensee agrees to review the regulation, register and complete a training related to basic services by an approved CCLD vendor that they have not used before, update all needs and services plans for existing residents, provide copies of the plans to CCLD via certified mail, and notify CCLD.

Deadline recorded: Nov 19, 2025. 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…facility require such additional staff for the provision of adequate services. The following requirement was not met as evidence by: Based on interviews with S1, and record review staff were not up to date on their training or competent to provide the required care and assistance which poses a potential personal rights violation to resident in care.

Official plan of correction

By POC Licensee agrees to provide copies of all current trainings to CCLD via certified mail, and notify CCLD.

Deadline recorded: Nov 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)

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: This requirement is not met as evidenced by: Based on record review and observation, the licensee did not comply with the section cited above by having S1 at the facility without fingerprint clearance which posed an immediate safety risk to persons in care.

Official plan of correction

Individual left the facility POC clear

Deadline recorded: Jul 16, 2025. 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 ...knives...are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having unlocked knives which posed an immediate safety risk to persons in care.

Official plan of correction

Knives locked durring visit POC clear

Deadline recorded: Jul 16, 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...as follows:(5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement was not met as evidence by: Based on observation, the licensee did not comply with the section cited above by not having non-skid mats in the showers which poses a potential safety risk to persons in care.

Official plan of correction

By POC Administrator agrees to buy and install the mats and notify CCLD

Deadline recorded: Aug 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87406(b)

Regulation authority

CCR

What the official deficiency says

(b) Each resident’s record shall contain at least the following information: This requirement was not met as evidence by: Based on observation and record review the licensee did not comply with the section cited above by all residents files are incomplete which poses a potential personal rights risk to persons in care.

Official plan of correction

By POC Administrator agrees to update all records according to regulation and notify CCLD

Deadline recorded: Aug 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. 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 not having a valid administrators certificate which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/01/2025 Plan of Correction By POC Administrator agrees to submit proof of pending Admistrator certificate application to CCLD

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 all staff not being up to date on trainings which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/01/2025 Plan of Correction By POC Administrator agrees to submit proof of updated trainings to CCLD

Official classification

Type B

Official code

87616(b)(1)

Regulation authority

CCR

What the official deficiency says

(b) Written requests shall include, but are not limited to, the following: (1) Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition. 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 R3 missing an updated physicians report which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 03/01/2025 Plan of Correction By POC Licencee agrees to get R3 a new phycicians report and notify CCLD

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 record review, the licensee did not comply with the section cited above in having expired cpr/first aid for all staff which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/19/2024 Plan of Correction By POC date administrator agrees to get all staff first aid and CPR certified and self certify to CCLD

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. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. 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 untrained staff working solo with residents which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/19/2024 Plan of Correction By POC date administrator agrees to either train new care staff or reschedule trained staff to be on the premises at all times and self certify to CCLD.

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 record review, the licensee did not comply with the section cited above in 4 out of 4 persons not having complete or missing personnel files which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/19/2024 Plan of Correction By POC date administrator agrees to review and complete all staff files and self certify to CCLD.

Official classification

Type A

Official code

87355(e)(1)

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: (1) Obtain a California clearance or a criminal record exemption as required by the Department 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 not fingerprint cleared which poses an immediate health and safety risk to person in care.

Official plan of correction

POC Due Date: 05/17/2022 Plan of Correction Effectively immediately, Administrator will discontinue S1 from providing care to residents and remove S1 from facility until fingerprint cleared. Administrator will review regulation and submit a self-certification letter and a copy of live scan for S1 by POC date. $500 CIVIL PENALTY IS ASSESSED

Official classification

Type B

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Deficient Practice Statement Based record review and interview,, the licensee did not comply with the section cited above. LPAs observed 3 staff are not fully vaccinated and does not have an exemption on file nor is conducting weekly COVID-19 testing which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/23/2022 Plan of Correction By POC date, Administrator agrees to obtain an exemption and conduct weekly COVID-19 for all staff who are not classified as " fully vaccinated " in accordances to Local County Health Order and PIN 22-05.1-ASC or be fully vaccinated and submit proof to CCL.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure....... 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 and S2 does not have a health screening and TB test on file which poses a potential health and safety risk to residents in care.

Official plan of correction

POC Due Date: 05/30/2022 Plan of Correction By POC date, Administrator agrees to obtain a health screening and TB test for both S1 and S2 and submit a copy to CCL.