WESTCHESTER HOME ON SPRUCE, THE

Official classification

Type A

Official code

87202(a)

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: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above due to facility having wrought iron gate that was not in place, when facility received fire clearance. Facility has a chain link lock at the top of one door leading to the backyard and a sliding lock on the top of the side door, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2026 Plan of Correction Facility remove the additional locks on the doors and will have the iron gate removed. Verification will be sent to the Dept by POC due date.

Official classification

Type A

Official code

87307(e)(1)

Regulation authority

CCR

What the official deficiency says

(e) The licensee shall supervise residents as needed and as determined by the resident's appraisal pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to or when there is use of the following items: (1) Ranges, ovens, heaters, fireplaces, wood stoves, inserts, and other heating devices. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & record review, the licensee did not comply with the section cited above due to having knobs on the stovetop with no written verification if resident are at risk, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2026 Plan of Correction Staff removed the stove knobs from the stove while LPA was at the facility.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above due to not having current liability insurance, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2026 Plan of Correction

Official classification

Type B

Official code

87303(a)(1)

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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above due to cracked uneven tile in front of the toilet in a common bathroom, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2026 Plan of Correction

Official classification

Type B

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

(5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above due to a common bathroom not having a non-slip mat, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2026 Plan of Correction Facility will provide statement and timeline of when items will be corrected. Verification will be sent to the Dpet by POC due date.

Official classification

Type B

Official code

87407(k)

Regulation authority

CCR

What the official deficiency says

(k) Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days, to: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above idue to not providing a wriitten notice within 30 days, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2026 Plan of Correction Facility will provide proper paperwork to make updates. Verification will be provided to the Dept by POC due 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, interview, & record review, the licensee did not comply with the section cited above due to conducting last drill in January 2026, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2026 Plan of Correction Facility will conduct drills and provide verification to the Dept by POC due date.

Official classification

Type A

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above due to not maintaining a record of centrally stored medications, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2026 Plan of Correction Facility will provide current centrally stored log to the Dept by POC due date.

Official classification

Type A

Official code

87202(a)

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: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above kitchen observed to have a locked wrought iron gate making kitchen inaccessible to residents. The wrought iron gate was not in place, when facility received fire clearance. Designated fire exit from backyard observed to be locked at time of inspection, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/09/2025 Plan of Correction Facility to submit written statement to include plan to unlock gate and removal of wrought iron gate.

Official classification

Type A

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. 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 3 out of 5 residents Medication reviewed and observed that 3 out of 5 residents did not receive medications due to medication not being refilled, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/09/2025 Plan of Correction Facility to submit written statement to include training plan for medication.

Official classification

Type B

Official code

1569.618(b)

Regulation authority

HSC

What the official deficiency says

(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above. During last facility visit on 3/28/25, Administrator on record was not present and LPA was informed that she had been absent from facility and had moved out of state to attend school. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2025 Plan of Correction Packet for Administrator submitted to Department on 4/07/25 and is currently under review. DEFICIENCY CLEARED AT TIME OF INSPECTION.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: 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 facility is not following plan of operation, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2025 Plan of Correction Facility to submit written plan to Department to meet regulation requirements

Official classification

Type B

Official code

1569.618(c)

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: 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 care plans on file for all residents state residents should have 1:1 staffing, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2025 Plan of Correction Care plans for all residents will be updated and submitted to department.

Official classification

Type B

Official code

1569.625(c)

Regulation authority

HSC

What the official deficiency says

(c) The training shall include, but not be limited to, all of the following: 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 all staff files reviewed did not contained training regulations as mandated, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2025 Plan of Correction Facility to submit written plan to department to meet regulation requirements

Official classification

Type B

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above R1 should be receiving Physical therapy and has not attended scheduled appointments since initial examination, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2025 Plan of Correction Facility to scheudle phsyical therapy appointments and submit list of scheudled appointments to department.

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 record review, the licensee did not comply with the section cited above in 5 out of 5 resident files are missing doucments which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2025 Plan of Correction Facility to submit a written plan of when records will be completed.

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

87465(h)(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by: Based on observation, LPA checked R1’s medication with Administrator present. LPA observed in R1’s Furosemide 20 mg medication bottle, 5 capsule that were different size stored in with the Furosemide tablets which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The five small capsule was immediately removed by Administrator. Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation which will include ensuring that all medications are stored in original container with no other medications. Statement will submit to Fresno CCL office by POC due date 12/12/24.

Deadline recorded: Dec 12, 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)(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. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, there are no Centrally Stored Medication Record (Lic 622) on file for all four residents, which poses/ posed a potential health, safety, or personal rights risk for the person in care.

Official plan of correction

Licensee shall ensure that all residents have Lic 622 on file and up to date. Copy of Lic 622 for all 4 residents will be submitted to Fresno CCL by POC due date 12/17/24.

Deadline recorded: Dec 17, 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. LPA observed med (Medication) cart was unlocked and accessible; and a bottle of toilet cleaner was observed accessible and stored in cabinet under bathroom sink in first hall bathroom, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/21/2023 Plan of Correction Licensee will submit in-service training to all staff on the topic of cited regulation CCR 87309(a), to CCL by POC due 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. LPA observed two paint cans accessible in the unlocked first hall bathroom cabinet, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/28/2023 Plan of Correction Licensee immediately removed the two paint cans to the locked garage unit. POC cleared during inspection.

Official classification

Type A

Official code

87355(e)(3)

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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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. S3 has been working in the facility since 4/22/22, was present in the facility during inspection, and does not have a completed request for transfer of criminal record clearance, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/28/2023 Plan of Correction Licensee completed the LIC9182 form and LPA was able to complete the transfer of criminal record clearance of S3 on the Guardian website. POC cleared during the inspection.

Official classification

Type A

Official code

87355(e)(4)

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: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at 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. S1 has been working in the facility since 3/27/23, was present during the inspection, and does not have a completed request for transfer of criminal record exemption, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/28/2023 Plan of Correction S1 left the facility during the inspection. Licensee provided a written statement that Licensee will ensure completion of a request for transfer of criminal record exemption for S1 by verifying with CPMB, the Fresno Regional Office, or LPA and stating that S1 will not be working until verification is made. POC cleared during inspection.