FIVE STAR ASSISTED LIVING

Official classification

Type B

Official code

87465(c)(1)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: (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: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation. Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 6 residents records missing PRN medication statement which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/19/2026 Plan of Correction Licensee agrees to obtain doctor statements for R1 regarding the resident’s ability to determine/ communicate need for Prescription PRN Medication and submit copies of documents to CCLD by due date.

Official classification

Type A

Official code

87202(a)(2)

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: (2) Bedridden persons This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA interviews with staff and Licensee disclosing 2 residents are bedriddent and LPA observations. The licensee did not comply with the section cited above in 2 of 6 residents are bedridden. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/22/2025 Plan of Correction Licensee stated they will submit the LIC 200 and LIC 9054 to CCL to get additional bedridden approval from fire department. Forms will be submitted to CCL by POC date as proof of correction.

Official classification

Type A

Official code

1569.69(e)(3)

Regulation authority

HSC

What the official deficiency says

(e) Each person who provides employee training under this section shall meet the following education and experience requirements: (3) The licensed residential care facility for the elderly shall maintain the following documentation on each person who provides employee training under this section: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review of staff records. The licensee did not comply with the section cited above in that 3 of 4 staff files reviewed did not have the required documentation. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/22/2025 Plan of Correction Licensee stated a plan of correction in writting will be submitted to CCL by POC date. Plan to include updating personnel files, type of training, time completed, person providing the training, title, signatures and dates. Licensee stated once completed updates will be provided to CCL.

Official classification

Type B

Official code

87309(c)

Regulation authority

CCR

What the official deficiency says

(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation. The licensee did not comply with the section cited above in that over-the-counter medication observed in refrigerator and in kitchen cabinet unlocked and accessible. Tools observed in backyard unlocked and accessible. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/31/2025 Plan of Correction Licensee stated tools will be removed and placed in the locked pool area. Medications will be removed and placed into a locked cabinet/closet. Pictures will be provided as proof of correction.

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 LPA observations. The licensee did not comply with the section cited above in living room couch observed with tears and in need of replacement. Hallway vent/air filter observed dirty and in need of cleaning/replacement. Patio fan drooping and in need of replacement. Backyard fence observed leaning and with broken boards in need of repair. Dog feces observed on walkway and in yard in need of cleaning. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/31/2025 Plan of Correction Licensee stated corrections will be completed and pictures will be submitted to CCL as proof of correction by POC date.

Official classification

Type B

Official code

87307(d)

Regulation authority

CCR

What the official deficiency says

(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations. The licensee did not comply with the section cited above in of front entrance observed with stairs and ramp without hand railing. Back door steps observed without hand railing. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/31/2025 Plan of Correction Licensee stated hand railing will be installed. Pictures will be supplied to CCL by POC date as proof of correction.

Official classification

Type B

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. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation of non-perishable food source. The licensee did not comply with the section cited above in non-perishable food source observed was not sufficient for 6 residents in care. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/24/2025 Plan of Correction Licensee stated they will purchase additional groceries and supply the recipt as proof of correction.

Official classification

Type B

Official code

87468.1(a)(6)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation. The licensee did not comply with the section cited above in that the facility was observed with a locking pin and a hole at the bottom of the front door. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/31/2025 Plan of Correction Licensee stated they will throw away the pin. Hole at the bottom of the door will be filled. Picture will be provided to CCL by POC date as proof of correction.

Official classification

Type B

Official code

1569.683

Regulation authority

HSC

What the official deficiency says

1569.683 Eviction notices; reasons for eviction contents; service (a)...reasons relied upon for the eviction, with specific facts...(2) Resources available to assist in identifying alternative housing and care options...(3) Information about the resident's right to file a complaint...(4)...statement: " In order to evict a resident... " (b)...serving a 30-day notice...shall notify, or mail a copy of the notice to quit to, the resident's responsible person. This requirement was not met as evidence by " LPA observation of the eviction notice submitted to R1 and responsible party. Eviction notice was not completed correctly. Licensee failed to include required verbiage and submit to CCL for approval. This poses a potential health, safety and or personal rights risk to resident in care.

Official plan of correction

Licensee will amend Notice of Eviction to R1 including all required information. The amended notice shall include the date of notice and amended eviction date to allow 30 days from date of amended notice. Health and Safety Code and required language was printed and provided.

Deadline recorded: Aug 18, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87615(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Persons ...a health condition including...shall not be admitted or retained in a residential care facility for the elderly:(2) Gastrostomy tubes. This requirement was not met as evidence by: LPA observation of R1 medical records, need and assessment and hopice care plan. R1 requires a higher level of care and no re-appraisal was completed. This poses a potential health, safety and or personal rights risk to resident in care.

Official plan of correction

Licensee to reassess R1 and provided updated documentation to CCL. All staff to complete training on regulations for prohibited health conditions, restricted health conditions and acceptance and retention. Licensee to provide training material and in-service sign in sheet to CCL by POC date.

Deadline recorded: Aug 18, 2023. A deadline is not proof that correction was completed.