Facility condition and maintenanceType A
- Official classification
- Type A
- Official code
- 87303(e)(2)
- Regulation authority
- CCR
What the official deficiency says
(e) Water supplies and plumbing fixtures shall be maintained as follows: (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 [(observation) , the licensee did not comply with the section cited above in resident bathroom water measured at 135.4 F which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction Licensee agrees to correct water temperature to meet regulation measuring in between 105 F and 120 F and will submit of photo meeting the regulation by POC due date 08/14/25.
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 [(observation], the licensee did not comply with the section cited above in cleaning supplies (on kitchen counter and unlocked in laundry room) and round up pesticides (on outdoor table) were accessible to residents with dementia, which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction Licensee agrees to lock up chemicals making them inaccessible to residents by POC due date 8/14/25. Licensee locked laundry room during visit. POC cleared during visit.
Background checksType A
- 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) (record review)], the licensee did not comply with the section cited above in S1 was working at the facility when LPA arrived and S1 has not been associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care. Civil Penalty issued
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction Licensee agrees to submit transfer request by POC due date 08/14/25 and will not have S1 return to facility until transfer is complete.
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(a)(4)
- Regulation authority
- CCR
What the official deficiency says
(4) The licensee shall assist residents with self-administered medications as needed. 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 in R1's pills had no start date or MARS log to verify if R1 was receiving prescribed medications, which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction Licensee agrees to administer training to all staff administering medications. Licensee will submit certificates of all staff who are trained once training is complete. Licensee will submit a scheduled training date and who is administering the training by POC due date 08/14/25.
Medication handling and storageType A
- Official classification
- Type A
- Official code
- 87465(h)(2)
- Regulation authority
- CCR
What the official deficiency says
(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 to persons other than employees responsible for the supervision of the centrally stored medication. 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 in Resident medications were unlocked on dining room table, kitchen counter, medication cart located in dining area was unlocked and closet where additional medications were stored was unlocked, which poses an immediate health, safety or personal rights risk to persons in care
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction Licensee agrees lock all medications. Licensee locked all medications in the medication closet during visit. POC cleared during visit.
Licensing and administrationType B
- 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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above in S1 was the only employee at the facility upon LPA's arrival and S1 did not have a current CPR/First Aid certificate, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/15/2025 Plan of Correction Licensee agrees to submit a current CPR/First aid certificate for S1 by POC due date 08/15/25.
Staffing, personnel, and trainingType B
- 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) (interview) (record review)], the licensee did not comply with the section cited above in Administrator was the only staff on duty to assist residents and LPA, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/22/2025 Plan of Correction Licensee agrees to submit a plan to meet the requirements of this regulation by POC due date 08/22/25.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(e)
- Regulation authority
- CCR
What the official deficiency says
(e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked. 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 in not having personnel records on hours each staff work, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/29/2025 Plan of Correction Licensee agrees to create a staff schedule reflecting hours worked for each employee and submit by POC due date 08/29/25.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(d)
- Regulation authority
- CCR
What the official deficiency says
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: 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 in S1 did not have any training records, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/05/2025 Plan of Correction Licensee agrees to provide staff training for S1 that will be this requirement and will submit copies of training by POC due date 09/05/25.
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87613(a)(2)
- Regulation authority
- CCR
What the official deficiency says
(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs. 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 in there was no training for R1 oxygen administration and restricted health care condition, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/29/2025 Plan of Correction Licensee agrees to submit training for all staff for R1 by POC due date 08/29/25.
Medical and dental careType B
- Official classification
- Type B
- 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) (interview) (record review)], the licensee did not comply with the section cited above in not having a list of current medications for each resident, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/29/2025 Plan of Correction Licensee agrees to obtain a current list of medications from the residents physician for all residents in care and will submit copies of resident medication lists by POC due date 08/29/25.
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(d)(3)
- 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: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. 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 in not documenting PRN's for all residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/05/2025 Plan of Correction Licensee agrees to document all PRN's and submit in writing the understanding of this regulation by POC due date 09/05/25.
Records and plan of operationType B
- 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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above in 5 out of 5 resident files were missing documentation, R3 and R4 files were not at the facility to be reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/05/2025 Plan of Correction Licensee agrees to complete resident files by POC due date 09/05/25. LPA will return to facility to clear POC.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87458(a)
- Regulation authority
- CCR
What the official deficiency says
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. 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 in not having LIC 602 for R1 and R4, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/05/2025 Plan of Correction Licensee agrees to obtain current LIC 602 for R1 and R4 by POC due date 09/5/25. LPA will return to review POC.
Fire safety and emergency preparednessType B
- 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 in not conducting emergency drills and not having records of emergency drills, which poses/posed a potential health, safety or personnal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/22/2025 Plan of Correction Licensee agrees to conduct emergency drills and submit staff that completed the drill by POC due date 08/22/25.
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87633(b)(6)
- Regulation authority
- CCR
What the official deficiency says
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan. 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 in staff did not have training for the care R1, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/22/2025 Plan of Correction Licensee agrees to obtain training from hospice for the care of R1's. Licensee will submit staff training by POC due date 08/22/25.
Administrator qualificationsType A
- Official classification
- Type A
- 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 on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having the fire extinguisher serviced since 3/6/2024 which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction Licensee agrees to submit proof of having a fire extinguisher that meets this regulation by either purchasing a new fire extinguisher or servicing the fire extinguisher by POC due date 08/14/25.
Administrator qualificationsType B
- Official classification
- Type B
- Official code
- 87405(a)
- Regulation authority
- CCR
What the official deficiency says
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. 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 in not having suffiecient freedom from other responsibilities to permit adequate attention to the management and the administration of the facility leading to numerous citations during unannounced visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/29/2025 Plan of Correction Licensee agrees to submit in writing a plan on having sufficient freedom from other responsibilities to manage the facility and meet regulations by POC due date 08/29/25.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(f)
- Regulation authority
- CCR
What the official deficiency says
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by: 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 in 2 resident files and 1 staff file was in storage, plan of operation was not at facility for Licensing to review, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/05/2025 Plan of Correction Licensee agrees to submit in writing an understanding of how this regulation will be met by POC due date 08/22/25.
Incident reportingType B
- Official classification
- Type B
- Official code
- 87211(a)(1)
- Regulation authority
- CCR
What the official deficiency says
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. 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 in Licensee did not report R5 being admitted to the hospital on 8/3/25, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/05/2025 Plan of Correction Licensee agrees to submit a written understanding of this regulation and how it will be met by POC due date 09/5/25.