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, the licensee did not comply with the section cited above due to R3 have multiple extension cords plugged into each other with additional devices plugged into the extension cords which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/04/2026 Plan of Correction Administrator will remove the extesion cords. Administator will provided a picture to the Dept to by POC due date.
Facility condition and maintenanceType A
- Official classification
- Type A
- Official code
- 87307(a)(3)(D)
- Regulation authority
- CCR
What the official deficiency says
(D) Hygiene items of general use such as soap and toilet paper. 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 due to physician reports for R3 & R4 stating they are at risk with personal hygiene products. LPAs observed hygiene products accessible throughout the facility, which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/04/2026 Plan of Correction Administrator will remove hygiene products. Verification will be sent to the Dept by POC due date.
Facility condition and maintenanceType A
- Official classification
- Type A
- Official code
- 87307(e)(1)
- Regulation authority
- CCR
What the official deficiency says
(e) The licensee shall supervise residents as needed and as determined by the resident's appraisal pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to or when there is use of the following items: (1) Ranges, ovens, heaters, fireplaces, wood stoves, inserts, and other heating devices. 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 due to physician reports for R3 & R4 stating they are at risk when in proximity or ranges. LPA observed stove knobs to be on the stove throughout the inspection, which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/04/2026 Plan of Correction Administrator removed stove knobs during visit.
Hazardous items and storageType A
- Official classification
- Type A
- Official code
- 87309(a)
- Regulation authority
- CCR
What the official deficiency says
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & record review, the licensee did not comply with the section cited above due to LPAs observing knives unlocked in kitchen drawer and unlocked outside shed storing pest spray and cans of paint, which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/04/2026 Plan of Correction Knives were removing during today's visit. Administrator will remove the bug spray and cans of paint from the shed. Verification will be sent to the Dept by POC due date.
Background checksType A
- Official classification
- Type A
- Official code
- 87355(e)(3)
- Regulation authority
- CCR
What the official deficiency says
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 due to S1 not being associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/04/2026 Plan of Correction Administrator will submit LIC9182 for S1 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 due to R2's medications being stored in a different container to be given at a later time, which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/04/2026 Plan of Correction Administrator spoke with staff, and will provide a statement to the Dept by POC due date.
Health conditions and treatmentsType A
- Official classification
- Type A
- Official code
- 87608(a)(5)(B)
- Regulation authority
- CCR
What the official deficiency says
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation & record review, the licensee did not comply with the section cited above due to R4 not being on hospice and no doctor's order for full bed rail, which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/04/2026 Plan of Correction Administrator will get a doctor's note for full bed rails, and provide verification 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 due to not notifying the Fire Dept in writing regarding R3 having oxygen, which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/04/2026 Plan of Correction Administrator will provided a copy of written letter sent to the Fire Dept. Verification will be sent to POC.
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, & record review, the licensee did not comply with the section cited above due to the following being observed: pest debris in dishwasher, pantry door unkept/unsanitary, kitchen floor to be unkept/unsanitary, broken shower door handle with a sharp edge in common bathroom, urine smell in R2’s room, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/10/2026 Plan of Correction Administrator will have items cleaned and verification will be provided to the Dept by POC due date.
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87618(b)(3)(B)
- Regulation authority
- CCR
What the official deficiency says
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. 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 due to not having " non-smoking- Oxygen in use " signs posted at the facility, which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/10/2026 Plan of Correction Administator will post signs and provide verification to the Dept by POC due date.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.69(b)
- Regulation authority
- HSC
What the official deficiency says
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), 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 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 due to not having the required amout of medication training for staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/10/2026 Plan of Correction Administrator will conduct training and provide verification of training to the Dept by POC due date.
Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(c)(2)
- 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: (2) Once ordered by the physician the medication is given according to the physician's directions. 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 due to R2's medication not being given properly and was filled August 5, 2025, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/10/2026 Plan of Correction Administrator will follow-up with R2's doctor regarding medication they are no longer taking. Verification of follow-up will be provided to the Dept by POC due date.
Medication handling and storageType B
- 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 due to R2's PRN medications not being logged, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/10/2026 Plan of Correction Administrator will be in-service and follow-up with doctor regarding to PRN. Verification of in-service will be provided to the Dept by POC due date.
Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87506(a)
- Regulation authority
- CCR
What the official deficiency says
(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. 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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/10/2026 Plan of Correction
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(h)
- Regulation authority
- CCR
What the official deficiency says
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. 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 due to R1 & R5 not having current physician reports on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/10/2026 Plan of Correction Aministrator will have physician reports update and verification will be provided to the Dept by POC due date.
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87618(b)(5)
- Regulation authority
- CCR
What the official deficiency says
(5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment. 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 due to not having staff training for R3's oxygen, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/10/2026 Plan of Correction Administrator will have hospice come out and provide training verification. Verification will be provided to the Dept by POC due date.
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87633(b)(4)
- 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: (4) A description of the licensee's area of responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident's physician, and the resident's responsible person(s), if any. This description shall include the type and frequency of the tasks to be performed by 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 due to facility not having current description for R3's care plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/10/2026 Plan of Correction Administrator will provided needed documentation from hospice and provide verification to the Dept by POC due date.