ALONDRA HOME

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465(h)(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, the licensee did not comply with the section cited above when LPA observed staff taking medication cup filled with medication tablets out of an unlock kitchen drawer, which poses an immediate health, safety or personal rights risk to person in care.

Official plan of correction

POC Due Date: 01/15/2026 Plan of Correction Staff immediately removed medication to lock medication cabinet. POC cleared during visit.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309(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 when LPA observed a knife inside the kitchen sink unlock and laundry detergent on the floor in the laundry room unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/15/2026 Plan of Correction Licensee removed laundry detergent into locked cabinet in the garage and locked the knife in the kitchen drawer. POC cleared during visit.

Official classification

Type A

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

87405(d)(2) Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, Fire Extinguisher has a service date of 01/06/25, which poses an immediate health and safety risk to the residents.

Official plan of correction

POC Due Date: 01/15/2026 Plan of Correction All fire extinguishers shall be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by POC due date 01/15/26.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Deficient Practice Statement Based on observation and records reviewed, 5 out of 15 of R5’s medications were checked by LPA and Administrator and observed not administered as directed by physician. Staff did not record medications administered for all 6 residents on 01/14/26 at 08:00AM, which poses/posed an immediate health and safety risk for the person in care.

Official plan of correction

POC Due Date: 01/15/2026 Plan of Correction Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation to Fresno CCL office by POC due date 01/15/26. All staff will be retrained on administering medications. Documentation of training topics and materials including date, training instructor, and staff attendance rooster to the Fresno CCL office by 01/27/26.

Official classification

Type B

Official code

87465(c)(3)

Regulation authority

CCR

What the official deficiency says

87465 (c)(3) A record of each dose is maintained in the resident's record. The record shall include the date and time …medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews and records reviewed, 8 out of 15 medications for R5 were not recorded in the resident’s MAR. Staff did not record medications administered for all 6 residents on 01/14/26 at 08:00AM, which poses a potential health and safety risk for the person in care.

Official plan of correction

POC Due Date: 01/16/2026 Plan of Correction Licensee recorded all R5’s medication into R5’s MARs during inspection. POC cleared during visit.

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 and includes: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview conducted, observation, and records reviewed, all of current R3,R4, R5 and R6’s medications were not recorded in Centrally Stored Medication (Lic 622) record, poses/posed a potential health and safety and personal rights risk to the resident in care.

Official plan of correction

POC Due Date: 01/23/2026 Plan of Correction Licensee recorded all medications into the residents’ Lic 622 for R3,R4, R5, and R6 during inspection. POC cleared during visit.

Official classification

Type B

Official code

87633(b)

Regulation authority

CCR

What the official deficiency says

87633(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident… 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 when LPA reviewed R1, R2, and R3 whose currently receiving hospice care with no current hospice care plan on file, which poses a potential health or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/27/2026 Plan of Correction Licensee will obtain R1, R2, and R3’s current hospice care plan and submit it to Fresno CCL by POC due date 01/27/26.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608 (a)(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 interview conducted, observation, and records reviewed, R5 uses half bed rail on hospital bed with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.

Official plan of correction

POC Due Date: 01/15/2026 Plan of Correction Licensee removed half bed rails during inspection. POC cleared during visit.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

87458(c)(1)(A) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A)Communicable tuberculosis. This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed, R4 do not have TB result on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/27/2026 Plan of Correction Licensee called during inspection and obtained from R4's placement agencys, R4's X-ray for TB. POC cleared during visit.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608 (a)(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: Based on observation and records reviewed, R1 and R2 uses half bed rail on hospital bed with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.

Official plan of correction

Licensee shall obtain doctor orders for R1 for full rail if physician indicates the need for full rail. Doctor orders for R4 and R5 indicate the need for half bed rail and if physician do not indicate the need for half bed rail, hail rail must be removed by POC due date 07/07/25.

Deadline recorded: Jul 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355(e)(2) 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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by: Deficient Practice Statement LPA observed S1 at the facility not fingerprinted cleared and not associated the facility which poses/posed an immediate risk to the health and safety of the residents.

Official plan of correction

POC Due Date: 02/14/2025 Plan of Correction S1 is not permitted back until associated and fingerprinted cleared. S1 is to be removed from the facility immediately.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465(h)(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, the licensee did not comply with the section cited above when LPA observed at 10:44AM, the residents’ medications in pharmacy bag on the table in the activity room and the medical closet unlock which poses an immediate health, safety or personal rights risk to person in care.

Official plan of correction

POC Due Date: 02/14/2025 Plan of Correction Licensee removed the residents’ medication to medication closet and locked medication closet. Licensee shall ensure to have resident’s medication are locked and inaccessible to residents at all times. POC cleared during visit.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309(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 when LPA observed knives stored in kitchen drawer unlock. Cleaning chemicals stored under kitchen sink unlock. LPA observed multiple chemicals in the garage unlock. Garage chemical cabinet in the garage was observed unlock and the outside shed was observed unlock accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/14/2025 Plan of Correction Licensee locked kitchen drawer and garage chemical cabinet. Chemicals were removed and placed in garage chemical cabinet. Keys were removed from the lock on the kitchen drawer and garage chemical cabinet. Licensee locked outside shed and removed keys from pad lock. POC cleared during visit.

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

87555(b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state, and local authorities. Good in damaged containers shall not be accepted, used, or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, multiple perishable foods were observed with expired date which poses/posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/14/2025 Plan of Correction Licensee disregarded expired food. POC cleared during visit.

Official classification

Type A

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 and includes: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, licensee did not comply with the section cited above when R1’s medication Valacyclovir Hcl 1 gram, Pepcid Famotidine 20 mg, and Chewable Ginger 50 mg was not logged in centrally stored list which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/14/2025 Plan of Correction Licensee shall ensure that all resident’s medications that are centrally stored are record in the facility. Licensee to submit copies of Centrally Stored Medication Record (Lic 622) for R1 to CCL by POC due date 02/14/25.

Official classification

Type B

Official code

87465(c)(3)

Regulation authority

CCR

What the official deficiency says

87465(c)(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement was not met as evidenced by: Deficient Practice Statement Based on interview conducted and records reviewed, all residents’ medications were administered on 02/11/25, 02/12/25 and on 02/13/25 at 08:00am. Staff did not recorded into the residents’ Medication Administration Record (MAR) which poses/posed a potential health and safety risk to the resident in care.

Official plan of correction

POC Due Date: 02/21/2025 Plan of Correction All staff shall be retrained on in-service training on medications. Medication training shall also include administering medications, reviewing medications, and documentation. Documentation of training topics with staff attendance rooster shall be submitted to the Fresno CCL office by 02/21/25

Official classification

Type B

Official code

1569.695

Regulation authority

HSC

What the official deficiency says

HSC 1569.695 Emergency Plans (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 was not met as evidenced by: Deficient Practice Statement Based on interview conducted and records reviewed, last emergency drill conducted was on 07/03/24, which poses/posed a potential health and safety risk to the resident in care.

Official plan of correction

POC Due Date: 02/21/2025 Plan of Correction Licensee shall ensure emergency drill are conducted quarterly. Licensee shall be submitted emergency drill conducted to the Fresno CCL office POC due date 02/21/25.

Official classification

Type B

Official code

87412(c)(2)

Regulation authority

CCR

What the official deficiency says

87412(c)(2) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training… This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed and interviews, S3 training material do not include dates, trainer’s name and number of hours completed which poses/posed a potential health and safety risk for the person in care.

Official plan of correction

POC Due Date: 02/21/2025 Plan of Correction Licensee shall review regulation and ensure that all staff have the required training and orientation. Proof of trainings is to be submitted to the Fresno CCL office by the POC due date 02/21/25. Proof of training shall include the following: Trainer’s full name; Subject(s) covered in the training; Date(s) of attendance; and Number of training hours per subject.