JASMIN TERRACE AT BAKERSFIELD

Official classification

Type B

Official code

87224(a)

Regulation authority

CCR

What the official deficiency says

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) This requirement was not met as evidenced by:Licensee sent R1 to the hospital but did not allow R1 to return to the facility without following proper eviction processes which poses a potential health safety and or personal rights risk to residents in care.

Official plan of correction

Licensee agrees to submit in writing the understanding of this regulation and how it will be met by POC due date 01/23/26

Deadline recorded: Jan 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (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: (4) The licensee shall assist residents with self-administered medications as needed. This requrement was not met as evidenced by: Licensee did not administer R1's prescribed aspirin that was prescibed on 1/2/26 until 1/5/26, which poses an immediate health safety and or personal rights risk to residents in care.

Official plan of correction

Licensee agrees to conduct a medication training and will schedule the training by POC due date 01/15/26. Once training is complete Licensee will submit proof of training.

Deadline recorded: Jan 15, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met by: Licensee did not ensure R1 was free from abuse by R2 hitting R1 causing injury to R1's eye resulting in medical attention for R1 which poses an immediate health safety and or personal rights risk to residents in care.

Official plan of correction

Licensee agrees to submit a written plan to to ensure the safety of residents by POC due date 01/15/26

Deadline recorded: Jan 15, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f)Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by licensee did not provide R1 care and supervision during a doctor visit on 10/10/25, which possess an immediate, health, safety, and or personal rights risk to residents in care.

Official plan of correction

Licensee agrees to conduct care and supervision traning to ensure residents are provided care and supervision during appointments. Licensee agrees to submit date of training by POC due date of 12/03/2025 and will submit proof of training once training is completed.

Deadline recorded: Dec 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(7)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b) The following food service requirements shall apply:(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidenced by: Licensee is not providing sugar free options for desert to meet the requirements of R4's specialized diet, which poses a potential health safety and or personal right risk to residents in care.

Official plan of correction

Plan of Correction: Licensee agrees to meet this regulation by providing foods the meet the needs of the specialized diets. LPA will clear via visit. POC cleared during visit.

Deadline recorded: Jul 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:.(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. The following requirement has not been met as evidenced by: Resident 1 eloped from the facility on 06/13/2025, which poses an immediate, health, safety, or personal rights risk to residents in care.

Official plan of correction

Administrator will conduct in service training with facility staff on resident elopement and submit to LPA by POC date of 06/26/2025.

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

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 in having a large round dining room table blocking a fire exit, which poses an immediate health, safety or personal rights risk to persons in care. Civil Penalty was issued

Official plan of correction

POC Due Date: 06/25/2025 Plan of Correction Licensee agrees to remove the table from blocking the exit and agrees to not put any objects blocking any fire exit doors in the future. POC cleared during visit.

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) , the licensee did not comply with the section cited above in pre pouring medications for all residents in individual cups taped together in a tower with resident name scribbled (not readable) on each container, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/11/2025 Plan of Correction Licensee agrees to conduct a staff training on dispensing medications that will meet this regulation requirement and submit proof of training and sign in sheet by POC due date 7/11/25.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (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 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 was not met as evidenced by R1 continues to smoke in the facility, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agrees to submit a plan on how this regulation will be met by POC due date 02/07/25

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

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by Licensee did not ensure Administrator spoke to R1 appropriately and respectfully which poses an immediate health safety and or personal rights risk to residents in care.

Official plan of correction

Licensee agrees to conduct a staff training on personal rights by POC due date 09/15/24

Deadline recorded: Aug 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(3)(C)

Regulation authority

CCR

What the official deficiency says

(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. This requirement was not met as evidenced by: Licensee had towels with large holes in the linen closet which poses a potential health safety and or personal rights risk to residents in care.

Official plan of correction

Plan of Correction Licensee agrees to remove and replace all towels/linens with holes. Licensee agrees to conduct a staff training on appropriate linen supplies by POC due date 08/30/24.

Deadline recorded: Aug 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Licensee did not ensure R1 did not smoke inside of the facility which poses an immediate health, safety and or personal rights risk to residents in care.

Official plan of correction

POC Licensee agrees to submit a plan in writing on how this regulation will be met by POC due date.

Deadline recorded: Jun 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (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: Based on observation, interview, & record review the licensee failed to report 3 incidents to the Dept that occurred in the facility. R3 eloped from the facility and it was not reported to the Dept.

Official plan of correction

Procedure will be put into place to make sure all incidents are reported to the Dept within the proper time limit.

Deadline recorded: Jun 28, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care. (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: (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: Based on observation, interview, & record review the licensee failed to arrange or assist R4 with proper foot care.

Official plan of correction

Frequent body check on R4. Administrator will make arrangement with R4's doctor.

Deadline recorded: Jun 28, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). Health and Safety Code section 1569.2(c) provides: (c) " Care and supervision " means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. This requirement is not met as evidenced by: Based on observation, interview, and record review the licensee failed to follow physician orders by allowing the resident to elope from the facility unassisted. Facility did not know R3 left until R3's family arrived and was unable to locate R3 at the facility. This poses an immediate health, safety, or personal rights risk to residents in care.

Official plan of correction

R3 has been placed on special monitoring. Statement will be sent to LPA.

Deadline recorded: Jun 19, 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 in Licensee had cleaning supplies left unattended on R2's neighboring bed in room 51, which poses an immediate health, safety or personal rights risk to persons in care. Photos were taken.

Official plan of correction

POC Due Date: 06/19/2024 Plan of Correction Licensee agrees to conduct a staff training on locking up cleaning supplies by POC due date. Licensee agrees to submit copy of staff training with agenda and certificates.

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 and record review, the licensee did not comply with the section cited above in Licensee did not administer R7's medication by having one missed day, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/19/2024 Plan of Correction Licensee agrees to conduct a medication training. Licensee agrees to submit date of training and agenda for training by POC due date 6/19/24. Photos were taken. Civil Penalty issued.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to 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 in Licensee is allowing S3 to administrer R7's injections, which poses an immediate health, safety or personal rights risk to persons in care. R7's LIC 602 states R7 cannot administer own medications and S3 is not a licensed professional.

Official plan of correction

POC Due Date: 06/19/2024 Plan of Correction Licensee agrees to come up with a plan to move R7 to a higher level of care. Licensee will contact R7's conservator and submit plan by POC due date 06/19/24.

Official classification

Type A

Official code

87465(a)(5)(D)

Regulation authority

CCR

What the official deficiency says

(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (D) Assistance with self-administration does not include forcing a resident to take medications, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above in Licensee is crushing and administering R9's medications camoflauging them in R9's coffee, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/19/2024 Plan of Correction Licensee agrees to contact the doctor to get an order for crushing the medication and putting it in drink/food by POC due date 06/19/24. Licensee will submit a copy of the order and submit a written understanding of the regulation by POC due date 6/19/24.

Official classification

Type A

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in Licensee did not meet this regulation by administering CVS stomach relief, Kirkland acetaminophen and amazon allergy relief without a prescription to miscellaneous residents that request the medication, which poses an immediate health, safety or personal rights risk to persons in care. Photos of the non prescription medications were taken.

Official plan of correction

POC Due Date: 06/19/2024 Plan of Correction Licensee agrees to submit a written statement showing the understanding of the regulation by POC due date 6/19/24.

Official classification

Type A

Official code

87465(b)

Regulation authority

CCR

What the official deficiency says

(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. 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 in Licensee did not have a physician stating R8 and R11 could communicate the need for a prescription or non prescription medication, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/19/2024 Plan of Correction Licensee agrees to obtain a doctors note in writing stating whether or not residents are able to determine the need for a prescription or nonprescriotion medication by POC due date. Licensee agrees to submit the doctor note for R8 and R11.

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of 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 Licensee did not have a written physician order on a prescription blank for R8 and R11 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/19/2024 Plan of Correction Licensee agrees to obtain prescription blank with physician's orders for R8 and R11 by POC due date 6/19/24.

Official classification

Type A

Official code

1569.695(a)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: 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 have a disaster plan or a plan for dementia residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/19/2024 Plan of Correction Licensee agrees to submit a disaster plan to licensing on POC due date 06/19/24

Official classification

Type A

Official code

87608(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. 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 is in a geri chair all day without a doctors note to advise purpose or use of geri chair, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/19/2024 Plan of Correction Licensee agrees to get a physicians note identifying the use of the geri chair and identify when it is supposed to be used by POC due date 06/19/24. Licensee agrees to submit a copy of the the physicians note.

Official classification

Type A

Official code

87628(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview record review, the licensee did not comply with the section cited above in Licensee accepted R7 who's LIC 602 states R7 cannot administer R7's own injections or glucose testing, which poses an immediate health, safety or personal rights risk to persons in care. LPA's were unable to determine if R10 can administer own injections due to R10 not having a LIC602a.

Official plan of correction

POC Due Date: 06/19/2024 Plan of Correction Licensee agrees to make doctor appointments and submit apppointment dates for all diabetic residents recieving injecitons to obtain the correct form LIC602a by POC due date 06/19/24.

Official classification

Type A

Official code

87705(c)(4)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. 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 is locked in a geri chair in the dining area with no log of how often R1 is allowed out of the chair, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/19/2024 Plan of Correction Licensee agrees to submit a plan on how to care for R1 while he is not in the geri chair by POC due date 06/19/24.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) , the licensee did not comply with the section cited above in Licensee does not have alarms on the front door or the back doors that exit into the courtyard which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/19/2024 Plan of Correction Licensee agrees to have alarms on all exit doors and will submit service date of alarms to be put on doors by POC due date 6/19/24.

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 in Licensee did not clean community shower, Room 17 had a dirty depends on the floor, Room 33 had urine dried on the floor, Room 67 had an unknown dried substance on the floor, Room 50 had an unknown wet substance on the floor, inside the cabinet in the tv room had mold and dead insects, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2024 Plan of Correction Licensee agrees to clean the facility by POC due date 07/12/24. Civil Penalty issued.

Official classification

Type B

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) (interview), the licensee did not comply with the section cited above in Licensee did not have hot water turned on in R1's room and room 19 was 103.9 and room 6 104.9, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/28/2024 Plan of Correction Licensee agrees to submit photos of running hot water in Room 67. Maintenance came before the end of the day and turned the water back on. POC cleared during visit. Civil penalty issued.

Official classification

Type B

Official code

87303(e)(6)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. 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 Licensee did not have a working shower head in the TV bathroom, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/21/2024 Plan of Correction Licensee agrees to fix or replace shower head by POC due date 06/21/24 and submit photo.

Official classification

Type B

Official code

87307(a)(3)(C)

Regulation authority

CCR

What the official deficiency says

(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. 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 Licensee did not keep Room 49 bottom linen sheet clean, where a brown substance was observed and photographed (only bottom sheet was on the bed) which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/21/2024 Plan of Correction Licensee agrees to conduct a staff training on changing all bedding and not just the top portion of the bedding by POC due date 06/21/24.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. 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 Licensee did not maintain fence which is falling down and did not maintain fascia board around the facility is rotting (Photos taken), which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2024 Plan of Correction Licensee agrees to repair the fence and fix the facia board on the outside of the facility by POC due date 07/12/24

Official classification

Type B

Official code

87555(b)(7)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. 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 Licensee does not have a modified diet plan for R6, R7, R10 or R13, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/28/2024 Plan of Correction Licensee agrees to provide a plan on how this regulation will be met for pureed diets and diabetic diets by POC due date 06/28/24.

Official classification

Type B

Official code

87555(b)(17)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (17) In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service. If this person is not a nutritionist, a dietitian, or a home economist, provision shall be made for regular consultation from a person so qualified. The consultation services shall be provided at appropriate times, during at least one meal. A written record of the frequency, nature and duration of the consultant's visits shall be secured from the consultant and kept on file in the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not hire a full time qualified employee with formal training and does not have documentation of a nutritionist, dietician or a home economist visit consultations, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2024 Plan of Correction Licensee agrees to submit proof of meeting with qualified professional to meet this regulation by POC due date 07/12/24.

Official classification

Type B

Official code

87465(a)(8)

Regulation authority

CCR

What the official deficiency says

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview)], the licensee did not comply with the section cited above in Licensee did not have a first aid kit, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/21/2024 Plan of Correction Licensee agrees to submit photos and receipt of first aid kit by POC due date 06/21/24

Official classification

Type B

Official code

87465(c)(3)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can 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) 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 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 document R1's PRN doses, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2024 Plan of Correction Licensee agrees to provide training on documenting PRN's date time residents response and the dose of medication. Licensee agrees to submit training certificates that show training agenda, source of training and hours of trained by POC due date 07/12/24.

Official classification

Type B

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. 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 in Licensee did not have a diagnosis for R15 on R15's LIC602 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2024 Plan of Correction Licensee agrees to update R15's LIC602 to list a diagnosis by POC due date 07/12/24 and submit to LPA.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: 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 in Licensees LIC602 diagnosis for R6 did not match hospice diagnosis for R6 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2024 Plan of Correction Licensee agrees to update the LIC 602 to reflect R6's current diagnosis by POC due date 07/12/24.

Official classification

Type B

Official code

87606(b)

Regulation authority

CCR

What the official deficiency says

(b) A facility shall notify the local fire jurisdiction within 48 hours of accepting or retaining any bedridden person, as specified in Health and Safety Code Section 1569.72(f). This requirement is not met as evidenced by: Deficient Practice Statement Based on (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not notify fire of bedridden residents, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/21/2024 Plan of Correction Licensee agrees to provide proof of notifying fire of bedridden by POC due date 06/21/24.

Official classification

Type B

Official code

87606(f)(3)

Regulation authority

CCR

What the official deficiency says

(f) To accept or retain a bedridden person, a facility shall ensure the following: (3) Staff records include documentation of staff training specific to Care of Bedridden Residents. 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 in Licensee did not have training for PM Staff on 0n 06/11/24 on how to care for bedridden residents, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2024 Plan of Correction Licensee agrees to conduct a staff training for all staff to be in compliance by POC due date 07/12/24.

Official classification

Type B

Official code

87609(b)(4)

Regulation authority

CCR

What the official deficiency says

(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s). 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 have an agreement in writing with home health regarding the responsibilities of R3's medical condtion, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/28/2024 Plan of Correction Licensee agrees to have a written agreement (plan of care) for R3 identifying the responsibilities of the facility and the responsibilities of the home health agency by POC due date 06/28/24.

Official classification

Type B

Official code

87633(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act (Health and Safety Code Section 1569 et seq.), all other requirements of Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver. 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 is not in substantial compliance by recieving repeated citations and not having proper documentation which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2024 Plan of Correction Licensee agrees to provide in writing a statement on how this regulation will be met and how the facility will become compliant by POC due date 07/12/24.

Official classification

Type B

Official code

87633(a)(4)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident's hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident's or prospective resident's Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s). 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 does not have care plans or current/complete plan of care for residents on hospice and R3's plan of care does not match R3's needs, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/28/2024 Plan of Correction LIcensee agrees to obtain a written hospice care plan for all residents on hospice and will submit plans of care by POC due date 06/28/24.

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 Licensee did not have staff training on how to use R5's hoyer lift, R1's oxygen equipment which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/28/2024 Plan of Correction Licensee agrees to have hospice train all staff on the use of equipment provided to all residents on hospice. Staff training provided to each individual hospice care plan that requires equipment by POC due date 06/28/24.

Official classification

Type B

Official code

87633(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client's care needs are being met at all times. 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 have current care plan for R6 which stated R6 was ambulatory but needed to be turned every two hours and the care plan was expired, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/28/2024 Plan of Correction Licensee agrees to have current care plans that are accurate to each resident. Licensee agrees to submit an updated, current care plan by POC due date 06/28/24.

Official classification

Type B

Official code

87705(c)(3)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training 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 Licensee does not have correct dementia training for all staff] which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/19/2024 Plan of Correction Licensee agrees to provide dementia training to meet all dementia training requirements by POC due date 07/19/24.

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by Licensee did not call 911 when R1 fell and hit head on floor, which poses an immediate health safety and personal rights risk to residents in care.

Official plan of correction

Plan of Correction Licensee agrees to conduct a staff training on when to contact emergency services by POC due date 5/3/24. LIcensee agrees to submit training agenda and certificates of trained staff.

Deadline recorded: May 3, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (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 was not met as evidenced by Licensee did not contact R1's authorized representative to inform R1's authorized representative R1 was hospitalized which poses a potential health, safety and or personal rights risk to residents in care.

Official plan of correction

Plan of Correction POC Licensee agrees to provide staff training on reporting procedures by POC due date 5/3/24. Licensee agrees to submit an agenda and certificates of trained staff by POC due date.

Deadline recorded: May 10, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(b)

Regulation authority

CCR

What the official deficiency says

87217 Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement was not met as evidenced by Licensee did not safegaurd R1's property which poses a potential health safety and personal rights risk to residents in care.

Official plan of correction

Plan of Correction POC Licensee agrees to train staff on safeguarding residents property and procedures for when staff are notified property is missing by POC due5/10/24. Licensee agrees to submit agenda of training and certificates of staff trained

Deadline recorded: May 10, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87633(4)

Regulation authority

CCR

What the official deficiency says

87633 Hospice Care of Terminally Ill Residents(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident’s hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident’s or prospective resident’s Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s). This requirement was not met as evidenced by R1 and R2 not having a Hospice Care Plan outling the responsibilities of the facility staff which poses an immediate health safety and or personal rights risk to residents in care.

Official plan of correction

Plan of Correction POC Licensee agrees to submit corrected Hospice care plans for R1 and R2. Licensee agrees to submit a written understanding of this regulation by POC due date 04/5/24.

Deadline recorded: Apr 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87633(A)

Regulation authority

CCR

What the official deficiency says

(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. (A) The training shall include but not be limited to typical needs of hospice patients, such as turning and incontinence care to prevent skin breakdown, hydration, and infection control. This requirement was not met as evidenced by. Licensee did not ensure staff was trained on turning R1, which poses a potential health safety and or personal rights risk to residents in care.

Official plan of correction

Plan of Correction POC Licensee agrees to complete staff training for all residents on Hospice by the Hospice agency by POC due date 4/25/24

Deadline recorded: Apr 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 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 was not met as evidenced by: Licensee did not keep common shower and toilets free from mold which poses a potential health safety and or personal rights risk to residents in care.

Official plan of correction

Licensee agrees to clean the entire facility having it free from dust, mold, any stains of bodily fluids by POC due date 04/1/24. LPA will return to facility to clear POC by visit. Civil Penalty was issued for repeat violation.

Deadline recorded: Apr 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(9)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met as evidenced by: Licensee did not provide warm meals to residents recieving food tray service to their rooms which poses a potential health safety and or personal rights risk to residents in care.

Official plan of correction

Plan of Correction: Licensee agrees to write a written statement on how this regulation will be met and will submit by POC due date of 1/19/24.

Deadline recorded: Jan 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Licensee did not ensure S1 treated R2 and R6 with dignity and respect, which poses an immediate health safety and or personal rights risk to residents in care.

Official plan of correction

Plan of Correction Licensee agrees to conduct a staff training on personal rights and will submit an agenda with sign in sheet by POC due date.

Deadline recorded: Dec 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (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: (4) The licensee shall assist residents with self-administered medications as needed.This requirement was not met as evidenced by: Licensee did not administer medications on 7/31/23 for R2, R3 and R4, which poses an immediate health safety and/or personal rights risk to residents in care.

Official plan of correction

Plan of Correction Licensee agrees to conduct a medication training and submit agenda and sign in sheet by POC due date 12/1/23.

Deadline recorded: Dec 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

..(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who... have a hospice care plan that specifies the need for full bed rails. This requirement was not met evident by: Based on observation and record review, the Licensee did not ensure the use of full bed rails was specified in R1's hospice care plan, which poses an immediate health and safety risk to persons in care.

Official plan of correction

Administrator agreed to contact R1's Hospice Agency and request the bed be changed to half rails or specify the reason for ful bed rails by POC due date of 9/30/2023.

Deadline recorded: Sep 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (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 was not met as evidenced by: Licensee did not respond to signal system for over an hour to assist C1, which poses an immediate health safety and or personal rights risk to clients in care.

Official plan of correction

Plan of Correction POC Licensee agrees to do staff training on meeting the clients needs and submit a plan for staffing to meet clients needs by POC due date

Deadline recorded: Sep 29, 2023. A deadline is not proof that correction was completed.

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 by residents rooms measuring above 125 F and under 85F which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2023 Plan of Correction Plan of Correction POC Licensee agrees to meet this regulation of water measuring between 105F to 120F. Licensee agrees to submit documentation of proof by POC due date.

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 and record review, the licensee did not comply with the section cited above by medicaitons were not administered/logged as being administered for several residents in care, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2023 Plan of Correction Plan of Correction POC Licensee agrees to submit copy of training for medication technicians by POC due date.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

(a) Each facility shall have and maintain a current, written definitive plan of operation. 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 records review and intervies, the licensee did not comply with the section cited above by not having a plan of operation 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: 09/22/2023 Plan of Correction Plan of Correction POC Licensee agrees to submit a photo of the facility's plan of operation to licensing by the POC due date.

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 by shared bathroom needing to be cleaned with toilet seat in bathroom shower and wash cloth on ground, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/25/2023 Plan of Correction Plan of Correction POC Licensee agrees to clean shared bathroom and submit a photo by POC due date.

Official classification

Type B

Official code

87506(b)(15)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. 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 by licensee not having admission agreements signed for residents, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/25/2023 Plan of Correction Plan of Correction POC Licensee agrees to provide a written understanding of this regulation and how it will be met by POC due date.

Official classification

Type B

Official code

87456(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and observation, the licensee did not comply with the section cited above by having residents in care that require a higher level of care, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/25/2023 Plan of Correction Plan of Correction POC Licensee agrees to submit a written understanding of this regulation and how it will be met by POC due date.

Official classification

Type B

Official code

87411(d)

Regulation authority

CCR

What the official deficiency says

Personnel Requirement 87411(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: Based on records review and interviews, the licensee did not comply with the section cited above by staff not having any current training, which poses/posed a potential health, safety or personal rights risk to persons in care. . Deficient Practice Statement Based on records review and interviews, the licensee did not comply with the section cited above by staff not having any current training, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/22/2023 Plan of Correction Plan of Correction POC Licensee agrees to complete a plan for training for all staff to meet all training regulations by POC due date 09/22/23. Licensee agrees to have all training completed for staff by 11/1/23.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on observation, LPA and LPM observed the ice and juice machines with mold, which poses a potential health and safety concerns to the residents in care.

Official plan of correction

Plan of Correction POC Licensee agrees to clean the ice and juice machine by POC due date 09/1/23.

Deadline recorded: Sep 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(1) Personal Rights of Residents in All Facilities- Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on observation, LPAs observed R1 left outside calling for help, which poses a potential health and safety concern.

Official plan of correction

Plan of Correction POC Licensee agrees to conduct training on personal rights by POC due date 09/01/23

Deadline recorded: Sep 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(b)(3)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. (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: Licensee did not log in MARS dates and times for PRN narcotic medications were being administered to R1 which poses an immediate health safety or personal rights risks to residents in care.

Official plan of correction

Plan of Correction POC Licensee agrees to conduct a PRN training for all medication technicians by the pharmacy by POC due date 09/15/23.

Deadline recorded: Aug 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)(14)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff (14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by Licensee was logging R1's Buspirone medication as being given, yet medication had been discontinued since 2019 which poses a potential health safety and personal rights risk to residents in care.

Official plan of correction

Plan of Correction Poc Licensee agrees to submit a written plan to licensing on how this regulation will be met by POC due date 09/15/23.

Deadline recorded: Sep 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Licensee retrained a resident (R1) with a prohibited health condition (unstagable wound), which poses an immediate health, safety, and/or personal rights risk to residents in care.

Official plan of correction

Plan of Correction POC Licensee agrees to find appropriate care for R1 by POC due date 06/13/23.

Deadline recorded: Jun 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87616(a)(b)(1)(2)

Regulation authority

CCR

What the official deficiency says

87616 Exceptions for Health Conditions (a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means. (b) Written requests shall include, but are not limited to the following: (1) Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition. (2) The licensee's plan for ensuring that the resident's health related needs can be met by the facility. This requirement was not met as evidenced by Licensee did not have or submit a restricted/prohibited health care plan to licensing for approval for R1's prohibited health condition which poses a potential Health, Safety or personal rights risk to the residents in care.

Official plan of correction

Plan of Correction POC Licensee agrees to submit in writing clear of this regulation and how it will be met in the future by POC due date. Repeat violation Civil Penalties issued.

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

Official classification

Type A

Official code

87629(b)(1)

Regulation authority

CCR

What the official deficiency says

87629 Injections (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensees who admit or retain residents who require injections shall be responsible for the following: (1) Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement was not met as evidenced by: Licensee's staff which are not skilled professionals were administering injections for R1's restricted health condition which poses an immediate health, safety and/or personal rights risk to residents in care.

Official plan of correction

Plan of Correction. Licensee agrees to submit in writing the understanding of this regulation.

Deadline recorded: Jun 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (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 was not met as evidence by: Administrator has recieved several citations under Title 22, with repeat violations which poses a potential health safety and/or personal rights risk to residents in care.

Official plan of correction

Plan of Correction POC Administrator agrees to review Title 22 regulations regarding all restrictive/prohibited health conditions and when to obtain an exception and will submit in writing the understanding of these regulations and the improtance of understanding Title 22 by POC due date 06/16/23

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

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (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 was not met as evidenced by Licensee did not submit incident reports for R1's hospitalization on 2/24/23, 3/18/23 and 4/18/23 which poses a potential Health, Safety or personal rights risk to the residents in care.

Official plan of correction

Plan of Correction POC LIcensee agrees to submit in writing the understanding of this regulation and how the regulation will be met by POC due date 05/08/23.

Deadline recorded: May 8, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87613(a)(2)(A)(B)

Regulation authority

CCR

What the official deficiency says

87613 General Requirements for Restricted Health Conditions (a) Prior to admission of a resident with a restricted health condition, the licensee shall: (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. (A) Training shall include hands-on instruction in both general procedures and resident-specific procedures (B)Training shall be completed prior to the staff providing services to the resident.This requirement was not met as evidenced by: Licensee did not have staff trained by a licensed professional to care for R1's restricted health condition which poses a potential Health, Safety or personal rights risk to the residents in care.

Official plan of correction

Plan of Correction POC Licensee agrees to have staff trained for the care of R1's restricted health condition by a licensed professional. Licensee agrees to submit documentation of training by the licensed professional, a roster of staff trained, and the responsibilities of staff for R1's retricted health condition by POC due date 5/12/23

Deadline recorded: May 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87616(a)(b)(1)(2)

Regulation authority

CCR

What the official deficiency says

87616 Exceptions for Health Conditions (a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means. (b) Written requests shall include, but are not limited to, the following: (1) Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition. (2) The licensee's plan for ensuring that the resident's health related needs can be met by the facility. This requirement was not met as evidenced by Licensee did not have or submit a restricted health care plan to licensing for approval for R1's restricted health condition which poses a potential Health, Safety or personal rights risk to the residents in care.

Official plan of correction

Plan of Correction POC Licensee agrees to submit a plan of care for R1's restricted health condition by POC due date.

Deadline recorded: May 8, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(2)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (a) Based on the individual's.... the facility shall provide assistance and care for the resident in those activities of daily living...postural supports may be used under the following conditions.(2) Postural supports shall be fastened or tied in a manner that permits quick release by the resident. This requirement was not met as evidenced by: Licensee did not ensure that R1's postural support lap belt permits quick release by the resident. R1's lap belt fastenes in the back of R1's wheelchair, R1 cannot reach it. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

AD has agreed to provide R1 with a self releasing lap belt and obtain a revised physician's order. AD will provide proof of the new belt and physician's order to CCLD via pictures and video via email by the due date.

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

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (a) …the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include….limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care……. This requirement was not met as evidenced by: Licensee did not ensure that full bed rails were only used for residents receiving hospice. R1 has an order for half side rails. R1 was observed in bed will full bedrails in raised position. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

AD has agreed to have the full rails removed and half rails placed. AD will obtain a revised physician's order for the half rails. Proof of correction will be provided with pictures to be emailed to CCLD by the due date.

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

Official classification

Type B

Official code

87468.1(11)

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 evidence by LPA observation of a sign at the front entrance stating “visitors limited due to renovations” (renovations started 11/14/22). This poses a potential personal rights, health and/or safety risk to residents in care.

Official plan of correction

Administrator to provide in-service for all staff. Meet with resident counsel for visitation. Administrator to provide a copy of training material and sign in sheet for training provided. Administrator to submit to CCL by POC date.

Deadline recorded: Feb 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(g)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met as evidence by LPA observation of food in kitchen improperly stored in freezer (food observed with freezer burn and in incorrect freezer bags. This poses a potential personal rights, health and/or safety risk to residents in care.

Official plan of correction

Administrator to provide in-service for all staff. Administrator to provide a copy of training material and sign in sheet for training provided. Administrator to submit to CCL by POC date.

Deadline recorded: Feb 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidence by LPA observation of laundry room unlock with chemicals accessible to residents with dementia. This poses a potential personal rights, health and/or safety risk to residents in care.

Official plan of correction

Administrator to provide in-service for all staff. Administrator to provide a copy of training material and sign in sheet for training provided. Administrator to submit to CCL by POC date.

Deadline recorded: Feb 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.69(b)

Regulation authority

HSC

What the official deficiency says

§1569.69 Employees assisting residents with self-administration of medication; training requirements. (b) Each employee who received training...and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication related issues in each succeeding 12-month period. This requirement was not met as evidenced by LPAs interview with Administrator and records review of staff training show last medication training's for current staff were in 2019. If not corrected, this poses a potential risk to residents in care.

Official plan of correction

Administrator will provide and complete the required annual medication training for all staff assisting in medications by 02/20/2023. Administrator will send proof of training to LPA via email.

Deadline recorded: Feb 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 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 was not met as evidence by LPA's observations in being that 3 of 6 rooms observed with shower not funtioning or not functioning properly. This is a potential personal rights, health or safety risk to residents in care.

Official plan of correction

Maintence to fix any and all showers not functioning and/or not functioning properly. Administrator to provide in-service for all staff. Administrator to provide a copy of training material and sign in sheet for training provided and a maintence log for corrections made. Administrator to submit to CCL by POC date.

Deadline recorded: Jan 27, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation 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 LPAs observation of facility doors stained with dirt, fly traps hanging over dining room tables and light fixtures surrounded with cobwebs and bugs.

Official plan of correction

Administrator will clean walls, light fixtures and doors. Administrator will paint hallways and doors to remove stains and submit proof of correction by way of pictures by POC date.

Deadline recorded: Oct 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87470(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

Infection Control Requirements 87470 (a) A licensee shall ensure that infection control practices are maintained as follows:(2)Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows:(B) Walls and window coverings... shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary or when they are visibly contaminated or soiled. Walls and window coverings in resident care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary or when they are visibly contaminated or soiled. This requirement is not met as evidenced by LPAs observation of facility hallway walls that were stained with feces and bodily fluids.

Official plan of correction

Administrator will complete cleaning facility hallway and ceiling lights from cobwebs and bugs. Once done Administrator will notify CCLD when job is completed by 10/05/2022

Deadline recorded: Oct 5, 2022. A deadline is not proof that correction was completed.

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 was not met as evidenced by LPAs observation of holes in interior facility doors that lead to the outside and floor in the entrance of the facility was in disrepair.

Official plan of correction

Administrator will replace the 3 broken doors and provide pictures / receipts evidencing the new doors by POC date.

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

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities:(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by LPAs interviews with residents and LPAs observation of the auditory alarm system that is continuously beeping loudly throughout the facility. Interviews with residents state this is causing mental distress.

Official plan of correction

Administrator will submit a plan of action on how to address the loud beeping sounds of the call lights by POC date.

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

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation 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 LPAs observation of facility doors stained with dirt, fly traps hanging over dining room tables and light fixtures surrounded with cobwebs and bugs.

Official plan of correction

Administrator will clean walls, light fixtures and doors. Administrator will paint hallways and doors to remove stains and submit proof of correction by way of pictures by POC date.

Deadline recorded: Oct 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87470(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

Infection Control Requirements 87470 (a) A licensee shall ensure that infection control practices are maintained as follows:(2)Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows:(B) Walls and window coverings... shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary or when they are visibly contaminated or soiled. Walls and window coverings in resident care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary or when they are visibly contaminated or soiled. This requirement is not met as evidenced by LPAs observation of facility hallway walls that were stained with feces and bodily fluids.

Official plan of correction

Administrator will complete cleaning facility hallway and ceiling lights from cobwebs and bugs. Once done Administrator will notify CCLD when job is completed by 10/05/2022

Deadline recorded: Oct 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465(a)(4)A plan for incidental medical and dental care shall be developed by each facility. .....provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: A sample of the medication was conducted, and files reviewed. R1 and R2 medication's were reviewed and was found that medication was missed and or not properly handled.

Official plan of correction

A reconcile is completed for all the medications given on a daily basis. On a weekly basis administrator is reviewing/ reconciling all MARs/medication.

Deadline recorded: Aug 16, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(6)

Regulation authority

CCR

What the official deficiency says

87303(e)(6) (e)Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. This requirement was not met as evidenced by: Based on observation R1’s shower was not latching and staying closed.

Official plan of correction

Shower door latch was repaired during visit

Deadline recorded: Sep 2, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

87465(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, the licensee did not comply with the section cited above when staffs applied Calmoseptine ointment to blisters on R1's bottom which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee stated that all staff will be retrained on regulations to ensure every prescription and nonprescription PRN medication shall have a written order from a physician. Evident of staff in-service training will be submitted to department by due date. Licensee will continue to conduct an in-service training for staff quarterly and have the training documents.

Deadline recorded: Feb 11, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care-The licensee shall assist residents with self administered medications as needed. MARS observed not maintained ensuring that residents are receiving assistance with rx as needed

Official plan of correction

Admin to submit plan to be submitted by due date that outline a plan with dates on how issue will be corrected, including staff training. Repeat Violation < 8/4/21 > Immediate Civil Penalty of $250 assessed.

Deadline recorded: Nov 23, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation-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. Cockroaches present in facility in resident rooms. Current Pest Control contract is insufficient to meet the facility need to control cockroaches.

Official plan of correction

Admin to review current Pest Control contract & to reassess current need of facility to control cockroaches. Copy of updated Pest Control contract to be submitted by due date. Repeat Violation < 8/26/21 > Immediate Civil Penalty of $250 assessed.

Deadline recorded: Dec 19, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care-The licensee shall assist residents with self-administered medications as needed. MARS observed not maintained ensuring that residents are receiving assistance with rx as needed.

Official plan of correction

Admin to submit plan by due date that outlined a plan with dates on how issue will be corrected, including staff training.

Deadline recorded: Nov 23, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87645(h)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care-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. Variety of unidentified medications & vitamins observed in R1's room - not centrally stored or maintained in a locked location

Official plan of correction

Admin to remove all items that should be centrally stored from R1's room. Admin to submit plan by due date that outlined a plan with dates on how issue will be corrected, including staff training.

Deadline recorded: Nov 23, 2021. 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

Storage Space - Disinfectants, cleaning solutions, poisons,...shall be... inaccessible to clients. Cleaning cart containing miscellaneous cleansers & bug spray observed in hallway outside of room while staff was cleaning in resident room.

Official plan of correction

Administrator agrees to submit plan of how cleansers, & other items used by housekeeping that pose a risk will be made inaccessible while in use. Plan to include all staff training. Plan to be submitted by due date. Copy of completed training to be submitted after training completed.

Deadline recorded: Aug 27, 2021. A deadline is not proof that correction was completed.