RIVERSTONE TERRACE SENIOR LIVING MEMORY CARE

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 (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: Deficient Practice Statement Based on observation, flooring in the laundry room was observed in disrepair, 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 Laundry room flooring will be in good repair by POC due date. Proof of repair will be submitted to the Fresno CCL by POC due date 06/29/26.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 (e)(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 degree C) and not more than 120 degree F (49 degree C). This requirement was not met as evidenced by: Deficient Practice Statement Based on observation, hot water temperature was tested and measured to be maintained at 96.2 degrees F in room D7, 91.9 degrees F in room D7, 91.9 degrees F in room A6, 93.7 degrees F in room B8, and 99.5 degrees F in room C6, which poses/ posed a potential health and safety risk for the person in care.

Official plan of correction

POC Due Date: 06/29/2026 Plan of Correction The facility shall maintain hot water temperatures between 105 degree F and 120 degree F. The facility will have a daily temperature log to ensure water temperature meets the regulation requirements. Daily temperature log with proof of hot water temperature is tested and maintained between 105 degree and 120 degree F shall be submitted to the Fresno CCL office by 06/29/26.

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

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(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…. This requirement is not met as evidenced by: Based on interviews and records review, staff did not provide care and supervision when R1 went AWOL on 11/14/25, and facility was not aware until the facility was notified by R1’s family which poses an immediate health and safety risks to persons in care.

Official plan of correction

Administrator agrees to have AWOL policy and procedures upated to ensure the requirements and procedures will be in place to ensure facility are aware of the reisdents whereabouts. POC will be submit to Fresno CCL by POC due date 11/26/25.

Deadline recorded: Nov 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

87465(d)(3) The date and time …medication was taken, the dosage taken, and the resident’s response shall be documented and maintained in the resident’s facility record. This requirement was not met as evidenced by: Based on observations, records reviewed, and interviews conducted, not all R1’s medication was record in R1’s Medication Administration Record (MAR), which poses/ posed a potential health and safety risk for the person in care.

Official plan of correction

All prescribed medications shall be recorded on resident MARs. Staff record all R1’s medication into R1's MAR during visit. POC cleared during visit.

Deadline recorded: Sep 9, 2025. 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 is not met as evidenced by: Based on interview conducted, observation, and records reviewed, all R1’s current medications were not record 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

All resident’s current medication shall be recorded on Lic 622. Staff record all R1’s medication onto Lic 622 during visit. POC cleared during visit.

Deadline recorded: Sep 9, 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) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by: LPA observed S1 not fingerprinted cleared and S2 who is fingerprinted cleared, not associated to facility were observed providing care for residents at the facility, which poses an immediate risk to the health and safety of the residents.

Official plan of correction

S1 and S2 was removed from the facility schedule immediately.S2 is not permitted back until fingerprint is cleared and associated. S2 is not permited back to the facility until assocaited. POC cleared during visit.

Deadline recorded: Aug 7, 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, S1 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’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

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 in room A5, room B6, and room C9 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

Proof of non-skid mat or strips in room A5, room B6, and C9 showers 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 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. Two out of four staff file 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 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, S2, and S3 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, S2, and S3’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(F)

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 and interview conducted with Administrator, 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, S2, and S3, which poses a potential health or personal rights risk to persons in care.

Official plan of correction

Proof of S1, S2, and S3’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

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: During course of a complaint investigation for complaint 24-AS-20240911151955, it was found that S1, S2, S3, S4, and S5 were not associated to the facility which poses an immediate risk to the health and safety of the residents.

Official plan of correction

S1 is no longer employed with the facility effective 11/01/24. S3 is immediately removed from the premise. S1, S2, S3, S4, and S5 is not permitted on the premise until associated. Proof of S2, S3, S4, and S5 associated to the facility shall be submitted to the department by 1/15/25.

Deadline recorded: Jan 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(d)(3)

Regulation authority

CCR

What the official deficiency says

87411(d)(3) Personnel Requirements - General Skill and knowledge required to provide necessary resident care and supervision… This requirement was not met as evidence by: Based on records review and interviews conducted, R1 sustained a fall and S1 found R1 next the resident’s bed. Staff failed to abide by the discharge instructions. Staff failed to contact emergency medical services until R1’s daughter instructions which poses an immediate health and safety risks to persons in care.

Official plan of correction

Facility shall review regulations 87411 and submit a written statement on steps facility will take to ensure regulations is met. Written statement is to be submitted to Fresno CCL by POC due date 01/15/25. All staff in-service training on providing resident care and supervision. Staff attendance rooster and topics of training material shall be submitted to the department by 02/03/25.

Deadline recorded: Jan 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

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 records review, and observation, R1’s MARs were reviewed, and medications were audit and shown that staff did not administer medications as directed by physician, which poses an immediate health and safety risk for the person in care.

Official plan of correction

POC Due Date: 07/10/2024 Plan of Correction Licensee shall submit document of steps the facility will take to ensure facility meets the regulation include ensure staff are administering medications as directed by physician to Fresno CCL office by POC due date 07/10/24.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above when LPA, Memory Care Director, and Maintenance staff observed kitchen door in disrepair and unlock. Residents were present in the dining area when knives and cleaning chemicals were unlocked in the kitchen accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Maintenance staff immediately repaired the kitchen door. POC cleared during visit.

Deadline recorded: Apr 26, 2024. A deadline is not proof that correction was completed.