RIVERSTONE TERRACE SENIOR LIVING

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309(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 and records reviewed, the Licensee did not comply with the section cited above when LPA and A1 observed an Ant spray bottle in under kitchen sink in R1’s bedroom unlocked and accessible to the residents in care, this poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2026 Plan of Correction Administrator immediately removed and locked chemical bottle. POC cleared during visit.

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... not accessible to persons other than employees... This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and records reviewed, the licensee did not comply with the section cited above when LPA and A1 observed multiple medications stored in R2’s bathroom shelf unlocked and accessible to the resident, which poses an immediate health, safety or personal rights risk to person in care.

Official plan of correction

POC Due Date: 06/24/2026 Plan of Correction Administrator immediately removed medication into locked medications. 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, expired perishable and rotten fruits were observed in the refrigerator and rotten fruits observed in the walk in pantry, poses/posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2026 Plan of Correction Staff immediately disregarded expired and molded food and fruits. 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: Deficient Practice Statement Based on observation and records reviewed, R3 bed was observed with a 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: 06/29/2026 Plan of Correction Facility will obtain doctor’s order for half rail bed and submitted to the Fresno CCL by POC due date 06/29/26.

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

87608(a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents wh o are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and records reviewed, R1 who’s not receiving hospice care was observed with a hospital bed with full rail, which poses/posed a potential health and safety and personal rights risk to the resident in care.

Official plan of correction

POC Due Date: 06/26/2026 Plan of Correction Full rail bed are prohibited for resident not receiving hospice care with physician order and shall be removed by POC due date 06/26/26

Official classification

Type B

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

87412(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement was not met as evidenced by: Deficient Practice Statement Based on record review and interview, the licensee did not comply with the section cited above when requested by the department to review staff files was informed by Administrator that all staff files are not maintained at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/25/2026 Plan of Correction Licensee will submit a written statement detailing the steps the facility will take to ensure the requirements for section 87412 are going to be met and ensure that all staff files are kept at the facility by POC due date 07/13/26. Written statement will be submitted to the Fresno CCL office by POC due date 06/25/26.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355(e)(1)Criminal Record Clearance (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: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by: S1 is not fingerprinted clear and not associated with the facility, which poses an immediate risk to the health and safety of the residents.

Official plan of correction

S1 is to be removed from the facility schedule immediately and not permitted back until fingerprinted cleared and associated. POC cleared during visit.

Deadline recorded: Aug 7, 2025. 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

87309(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: Based on observation, the licensee did not comply with the section cited above when LPA and A1 observed on 07/24/25, a Hydrogen Peroxide bottle in R1’s bathroom counter, unlocked accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator immediately removed the chemical bottle. POC cleared during visit.

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

Official classification

Type B

Official code

87303(e)(5)(A)

Regulation authority

CCR

What the official deficiency says

87303(e)(5)(A) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above when LPA and A1 observed on 07/24/25, in room 102, room 202, and room 407 with no nonskid mat or nonskid strip in bathroom showers, this poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility immediately placed slip-resistant strips in bathrooms showers. POC cleared during visit.

Deadline recorded: Aug 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(c)

Regulation authority

CCR

What the official deficiency says

87412(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Based on records reviewed and interviews, administrator informed LPA that all staff have no trainings record on file, records reviewed staff do not the required trainings on file, which poses a potential health and safety risk for the person in care.

Official plan of correction

Facility shall review regulation section 87412 and ensure that all staff have the required training. Statement of how the facility will met the regulations and include date all staff trainings will be completed and training records will be on file. Statement shall be submitted to the Fresno CCL by POC due date 08/12/25.

Deadline recorded: Aug 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 (c)(1) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on records reviewed and interview conducted with Administrator, S1 and S2 do not have First Aid, this poses an immediate health and safety risk for the residents in care.

Official plan of correction

Licensee shall ensure that staff have current First Aid training. Proof of S1 and S2’s First Aid training is to be submitted to the Fresno CCL by 08/07/25.

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

Official classification

Type B

Official code

1796.45

Regulation authority

HSC

What the official deficiency says

HSC 1796.45 Affiliated home care aides hired on or after January 1, 2016, shall submit to an examination 90 days prior to employment, or within seven days after employment, to determine that the individual is free of active tuberculosis disease. This requirement is not met as evidenced by: Based on records review and interview conducted with Administrator, S1 do not have a TB result on file which poses a potential risk to the health and safety of the residents.

Official plan of correction

All staff have a TB result on file prior or within 7 days after employment. S1’s TB result shall be submitted to the Fresno CCL office by POC due date 08/19/25.

Deadline recorded: Aug 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411

Regulation authority

CCR

What the official deficiency says

87411(F) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when LPA reviewed staff files and observed no health screening were on file for S1 and S2, which poses a potential health or personal rights risk to persons in care.

Official plan of correction

Proof of S1 and S2’s health screening to CCL by POC due date 08/19/25.

Deadline recorded: Aug 19, 2025. 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

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 when LPA and A1 observed janitor cart with cleaning chemicals unlock set aside in hall between the receptionist desks and facility bathroom. LPA and A1 observed two tool sets with box cutter stored in room 106 unlock. LPA and A1 observed a knife and sharp from blinder stored in room 107’s kitchen unlocked 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: 07/10/2024 Plan of Correction Staff immediately removed janitor’s cart. Administrator immediately removed sharps, and tool sets to a lock room. POC cleared during visit.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

Centrally stored medicines shall be kept in a safe and locked place... not accessible to persons other than employees... 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 and A1 observed a medication on top of resident’s nightstand in room 107 unlocked 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: 07/10/2024 Plan of Correction Administrator immediately removed and locked the medication bottle in the medication room. POC cleared during visit.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 observation, the licensee did not comply with the section cited above when LPA observed mold inside facility’s ice machine which poses a potential health, safety or personal rights risk to person in care.

Official plan of correction

POC Due Date: 07/15/2024 Plan of Correction Ice machine was cleaned immediately. POC cleared during visit.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation 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: Based on records reviewed, interview conducted and tour, the licensee did not comply with the section cited above. LPA and Assistant Executive Director observed lives and dead ants in residents’ room and records shown ants was inspected in residents' room which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee shall submit written plan to CCL of what preserved measure will be taken to ensure ants are prevented from reoccurring by 1/16/23. In the meantime, a thorough check in all rooms is to be completed with a follow up on weekly basis check.

Deadline recorded: Jan 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(f)

Regulation authority

CCR

What the official deficiency says

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by LPAs observation of records review and interviews. facility should have issued the refund within 15 days of R1's removal of personal belongings from the facility.

Official plan of correction

Facility refunded the Estate of Resident R1 on 12/29/21. Facility has provided a copy of the move out form ensure reimbursements are made will submit a plan to ensure residents that move out of the facility, will be taken off automatic payments at the time of move out. POC cleared

Deadline recorded: May 13, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(4)(B)

Regulation authority

CCR

What the official deficiency says

The conditions under which a licensee may increase or change rates shall be specified in the admission agreement, pursuant to Health and Safety Code sections 1569.655 and 1569.657. This requirement was not met when facility raised R1’s monthly rate on 2/1/18 and 2/1/19 without obtaining the signature of R1 and/or R1’s responsible party. This is a potential risk to residents in care.

Official plan of correction

POC should include facility’s plan to issue the refund for the total amount owed within 30 days.

Deadline recorded: Feb 28, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(g)(B)(3)

Regulation authority

CCR

What the official deficiency says

A statement acknowledging any additional items and/or services that the resident refused to purchase at the time the admission agreement was signed, which shall be signed and dated by the resident or the resident’s representative, if any, and attached to the admission agreement. This requirement was not met when facility charged R1 for tray service for a period of 8 months without any written acknowledgement. This is a potential risk to residents in care.

Official plan of correction

POC should include facility’s plan to issue a refund for the total amount owed within 30 days.

Deadline recorded: Feb 28, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (11) To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidenced by interviews conducted with reporting party and executive director, stating visitation hours are being restricted to hours not available to family members.

Official plan of correction

Executive Director will review CCLD current PINS and CDPH current guidelines to clarify the different guidelines given. LPA is providing PIN 21-40-ASC and regulation cited for review. ED will accommodate the families specific to resident's needs regarding visitation and personal rights.

Deadline recorded: Jan 21, 2022. A deadline is not proof that correction was completed.