Hazardous items and storageType A
- 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 LPA observation, the licensee did not comply with the section cited above in 1 out of 11 persons which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/02/2026 Plan of Correction The Licensee shall conduct an in house training pertinent to chemical/cleaning substances, and posions storage by POC date and provide LPA with training verification via email.
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(e)(2)
- Regulation authority
- CCR
What the official deficiency says
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 11 out of 11 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/02/2026 Plan of Correction The Licensee is to have maintenance adjust or identify faucets with warning label of Hot water exceeding 120 degrees F by POC date and provide proof to LPA via email.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(c)
- Regulation authority
- CCR
What the official deficiency says
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. 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 11 out of 11 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/02/2026 Plan of Correction Licensee is to provide LPA proof via email of staff Onboarding training and orientation by POC date.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- 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 observation and record review, the licensee did not comply with the section cited above in 5 out of 5 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/02/2026 Plan of Correction The Licensee provide LPA with training verification proof via email by POC date.
Food serviceType B
- 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 an 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, the licensee did not comply with the section cited above in 11 out of 11 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/02/2026 Plan of Correction The Licensee is to provide an in house training to facility staff on food handeling services, best practice to label foods with expiration dates, Licensee is to provide LPA proof of staff training by POC date. .
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87456(a)(3)
- Regulation authority
- CCR
What the official deficiency says
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation and record review, the licensee did not comply with the section cited above in 2 out of 11 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/19/2026 Plan of Correction The Licensee is to schedule a medical evaluation/assessment to the residents who were accepted from Sunset Villa and provide proof to LPA by POC date.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(b)
- Regulation authority
- CCR
What the official deficiency says
(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation and record review, the licensee did not comply with the section cited above in 5 out of 11 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/02/2026 Plan of Correction The Licensee is to secure documentation of the residents reappraisals and provide proof to LPA by POC date.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(h)(1)
- Regulation authority
- CCR
What the official deficiency says
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, interview, and record review, the licensee did not comply with the section cited above in 5 out of 11 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/02/2026 Plan of Correction The Licensee is to schedule all residents who are pending annual routine medical visits and provide LPA with documentation via email before POC date.
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87608(a)(3)
- Regulation authority
- CCR
What the official deficiency says
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. 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 6 out of 11 residents who have full bed rails, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/02/2026 Plan of Correction The Licensee is to provide proof of hospice care plan for the use and need of full length bed rails on or before the POC date.