Fire safety and emergency preparednessType A
- 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, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed the emergency exit through the garage to not be obstruction free.
Official plan of correction
POC Due Date: 03/03/2026 Plan of Correction Licensee will clear pathway for emergency exit. Picture verificaiton will be sent to the Dept by POC due date.
Hazardous items and storageType A
- Official classification
- Type A
- Official code
- 87309(b)
- Regulation authority
- CCR
What the official deficiency says
(b) Residents may have access to items specified in subsection (a) for personal use unless there is documentation, as specified in Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, that indicates the resident's or other residents’ safety would be at risk if allowed access. 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 which poses an immediate health, safety or personal rights risk to persons in care. 2 (R3 & R4) of the 6 residents are listed as being at risk if hygiene products are accessible to residents.
Official plan of correction
POC Due Date: 03/03/2026 Plan of Correction Administrator will follow-up with hospice and provide new information to the Dept. Verification will be sent to the Dept by POC due date.
Medication handling and storageType A
- Official classification
- Type A
- 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, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed medication being placed in containers to be given at a later time. S1 stated it is to make it easier when giving medications.
Official plan of correction
POC Due Date: 03/03/2026 Plan of Correction Licensee will not longer transfer medications to other containers. Verification will be sent to the Dept by POC due date.
Medication handling and storageType A
- Official classification
- Type A
- Official code
- 87465(h)(2)
- Regulation authority
- CCR
What the official deficiency says
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed medication in unlocked cabinet behind the kitchen table.
Official plan of correction
POC Due Date: 03/03/2026 Plan of Correction Licensee will place lock on cabinet door. Verification will be provided to the Dept by POC due date.
Health conditions and treatmentsType A
- Official classification
- Type A
- Official code
- 87618(b)(3)(A)
- Regulation authority
- CCR
What the official deficiency says
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA spoke with Administrator Michelle who stated there was no written report made to the local fire department regarding the oxygen equipment being used at the house.
Official plan of correction
POC Due Date: 03/03/2026 Plan of Correction Licensee will report to the local fire dept and provide a copy to licensing. Verification will be sent to the Dept by POC due date.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 1569.625(b)(2)
- Regulation authority
- HSC
What the official deficiency says
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 which poses/posed a potential health, safety or personal rights risk to persons in care. LPA reviewed files and only found current training to equal a total of 9 hours for S2 & S3.
Official plan of correction
POC Due Date: 03/20/2026 Plan of Correction Licensee will will completed training with staff and provide verification of training. Verification will be sent to the Dept by POC due date.
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(a)
- Regulation authority
- CCR
What the official deficiency says
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & interview, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed torn screens on the side of the house, torn screen door from the Master Bedroom, water damage under the kitchen sink, debris inside of the kitchen oven.
Official plan of correction
POC Due Date: 03/13/2026 Plan of Correction Licensee will fix the items listed above and verificaiton will be sent to the Dept. Verification will be provided to the Dept by POC due date.
Health conditions and treatmentsType B
- 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 which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 03/13/2026 Plan of Correction Licensee will provide current hospice care plan by POC due date.