HIGH DESERT HAVEN

Official classification

Type B

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

87202 Fire Clearance (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: Based on observation, interview, and record review the facility did not comply with the regulation listed abovedue to facility not notifying Licensing of changes made to fire clearance, which poses a potential health and safety risk to residents in care.

Official plan of correction

Administartor will provide proper documentation to Licensing by POC due date regarding changes in fire clearance.

Deadline recorded: Jul 31, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement is not met as evidenced by: Based on observation, interview, and record, the facility did not comply with the regulation listed above due to R1 having to go into R2's bedroom to access the bathroom, which poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator has moved R1 and R2 to indiviual rooms. This was verified during today's visit.

Deadline recorded: Jul 31, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(6)

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: (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observation, interview, and record, the facility did not comply with the regulation listed above due to R1's centerally stored medication log to not be completed correctly, which poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator will conduct new staff training on meds and ceneranllt stored log. Statement will be provided indicating when training will be completed.

Deadline recorded: Jul 31, 2026. 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) 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: Based on observation, the licensee did not comply with the section cited above in LPAs observed cleaning supplies, scissors, and lighter unlocked and accessible to facility residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will reach out to doctor regarding physican report for R1. Inservice will be conducted. A statement will be provided to the Dept by POC due date explaining action to be taken to correct deficiency.

Deadline recorded: Jul 21, 2026. A deadline is not proof that correction was completed.

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: Based on LPA observation, the licensee did not comply with the section cited above due to R1 having Ibuprofen 200 mg, and Diclofenac Sodium 1% in night stand unlocked and accessible, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will conduct in-service with staff. A statement will be provided to the Dept by POC due date explaining action to be taken to correct deficiency.

Deadline recorded: Jul 21, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2

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. This requirement is not met as evidenced by: Based on observation, interview, and record, the facility did not comply with the regulation listed above, which poses an Immediate health and safety risk to residents in care.

Official plan of correction

Facility will provide a statement regarding R2's needs being met and the possiblity of reassessing R2.

Deadline recorded: Jul 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (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: Based on observation, interview, and record, the facility did not comply with the regulation listed above, which poses an Immediate health and safety risk to residents in care.

Official plan of correction

During the visit facility posted a " No smoking- Oxygen in use " sign posted. POC cleared today.

Deadline recorded: Jul 20, 2026. 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) 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, the licensee did not comply with the section cited above in LPA's observed cleaning supplies unlocked and accesible to facility residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/13/2026 Plan of Correction Administrator will conduct staff training on ensuring toxins, cleaning supplies, and chemicals are locked an inaccesible to residents.

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 LPA observation, the licensee did not comply with the section cited above in Resident 5 has multiple over the couner medications in bathroom vanity unlocked and accesible, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/13/2026 Plan of Correction Administrator will conduct training with facility staff on ensuring medications are locked and inaccesible to facility residents and submit to LPA by POC date of 05/13/2026.

Official classification

Type B

Official code

87465(h)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: 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 in Resident 5's Centrally Stored Medication record is not accurate, including resident name not listed, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction Administrator will audit Centrally Stored medication records and ensure all are correct forms, and re train medication technicians on Centrally Stored record documentation and submit proof to LPA by POC date of 05/26/2026.

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 in Resident 1 and 2's admission agreement does not have resident name listed, Resident 4's admission agreement does not have accurate monthly rate is not accurate, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction Administrator will re train staff on admissions, and audit admission paperwork and submit proof to LPA by POC date of 05/26/2026.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. 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 in Resident 3's Needs and Services plan is not completed, updated annually as required, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction Administrator will audit resident needs and services, and re train staff on admissions, and submit proof to LPA by POC date of 05/26/2026.

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 was not met as evidenced by: During facility tour on 4/11/2026, LPAs observed the following in the assisted living building, 2 washers and 1 dryer that were inoperable, in the memory care building of the facility 1 washer and 1 dryer that were inoperable.

Official plan of correction

Facility purchased 3 washers and 2 dryers, invoices provided to LPA during complaint visit. DEFICIENCY CLEARED AT TIME OF VISIT

Deadline recorded: Apr 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental (a) A plan for incidental medical and dental care shall be developed by each facility…(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service… This requirement was not met as evidenced by: Based on interviews and records review, the Licensee did not comply with section 87465 when R1 and R2 missed scheduled appointments due to staff being unable to transport R1 and R2 to their appointments, which is a potential health and safety risk to residents in care.

Official plan of correction

Licensee agrees to submit a written statement on how this regulation will be met by the facility by POC due date 02/13/26

Deadline recorded: Feb 13, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87219(f)

Regulation authority

CCR

What the official deficiency says

87219 Planned Activities(f) In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities… This requirement was not met as evidenced by: Based on interviews and records review, the Licensee did not comply with section 87219 when the Activities Director was not given staff assistance to ensure activities were provided as scheduled, when the Activities Director was not available, which is a potential health and safety risk to residents in care.

Official plan of correction

Licensee agrees to submit a written statement on how the facility will meet this regulation by POC due date 02/13/26.

Deadline recorded: Feb 13, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(20)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (20)To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents for reasons other than those permitted by state law or regulations and shall comply with all eviction and relocation protections for residents… This requirement was not met as evidenced by: Based on interviews and record review, the Licensee did not comply with section 87468.2 when facility staff transferred R1 to a hospital and refused to accept R1 back once R1 was discharged, which is a potential health and safety risk to residents in care.

Official plan of correction

Licensee agrees to conduct a staff training on resident's personal rights by POC due date 02/13/26.

Deadline recorded: Mar 13, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87457(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

87457 Pre-Admission Appraisal (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall document, at a minimum: (A) An evaluation of the prospective resident's functional capabilities, mental condition, and social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factor. This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not properly conduct a pre-admission appraisal which poses a potential Health and Safety or Personal Rights risk to persons in care. R1 was taken to the hospital due to behaviors and staff not being able to meet R1's needs. R1 does not have a completed pre-admission appraisal and did not have a re-appraisal completed when R1 returned to the facility.

Official plan of correction

Licensee will conduct staff training to cover pre-apprasials and reapprasials. Verification of training and topics coveed will be provided to LPA by POC date 12/22/2025

Deadline recorded: Dec 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(d)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not provide the records being requested in a timely manner which poses a potential Health and Safety or Personal Rights risk to persons in care. On 11/18/2025 LPA verbally requested a printout of resident's call button log and via email on 11/25/2025. Verification was not provided until 12/10/2025.

Official plan of correction

Licensee is able to use flash drive to download documents and print when needed.

Deadline recorded: Dec 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space and Access (a) Except as specified in subsection, 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: Based on observation and interview, the licensee did not comply with the regulation listed above, which poses an immediate Health and Safety or Personal Rights risk to persons in care. LPA observed an unoccupied housekeeping cart with chemicals and cleaning supplies being accessible to residents in care.

Official plan of correction

Licensee will talk with housekeeping and metal lock boxes will be bought to store chemicals and cleaning supplies on cart.

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

Official classification

Type B

Official code

1569.655

Regulation authority

HSC

What the official deficiency says

§1569.655 Increase in fee rates for elderly residents; 90 days’ written notice standing amount of reasons for increase; application of section (a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 90 days’ prior written notice to the residents or the residents’ representatives setting forth the amount of the increase and the reason or reasons for the increase, including a description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident. This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the regulation listed above, which poses a potential Health and Safety, Personal Rights risk to persons in care. LPA observed a letter informing residents on a rent increase which did not have a date, providing 90-day notice.

Official plan of correction

Facility will give residents letters that the inital increase notice is not valid. Proper notice will be provided and given to resdients with correct dates. Facility will provide LPA copies of the letters.

Deadline recorded: Nov 25, 2025. 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. 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 as evidenced by Licensee did not ensure R1 was free from abuse due to R1 being hit by R2 causing R1 to be hospitalized, 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 a plan to ensure how this regulation will be met by POC due date 10/16/25.

Deadline recorded: Oct 16, 2025. 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 timely. For example Licensee submitted incident reports that occurred on 09/6/25 and 09/7/25 on 09/19/25 which poses a potential health safety and or personal rights risk to residents in care.

Official plan of correction

POC LIcensee agrees submit a plan in writing on how this regulation will be met by POC due date 10/16/25.

Deadline recorded: Oct 16, 2025. 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

(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 is not met as evidenced by: staff left medication accessible during medication administration and R1 then injesting R2's medications resulting in R1 needing medical attention; which poses an immediate risk to the health, safety, or personal rights risk to the residents in care.

Official plan of correction

Facility completed staff training on Medication Administration on 08/21/25. Proof of training was submitted to LPA Doucette on 9/3/25. POC cleared during visit.

Deadline recorded: Sep 4, 2025. 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 by R1 and R4 not receiving several medications in the month of June 2025, which poses and immediate health safety and personal rights risk to residents in care.

Official plan of correction

Plan of Correction: Licensee agrees to submit a plan indicating the date and source of medication training and submit by POC due date 08/07/25

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

Official classification

Type A

Official code

87609(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). THie requirement was not met as evidenced by Licensee did not have a Home Health Care Plan or staff training for R2's restricted health condition and straff are cleaning the insertion area of the restricted health condition and R8 does not have a restricted Health Care Plan for R8's restricted health condition, which poses an immediate health safety and or personal rights risk to residents in care.

Official plan of correction

The Licensee agrees to submit a of a home health care plan for R8 due to R2 no longer residing at the facility by 08/7/25

Deadline recorded: Aug 7, 2025. 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 ection 1569.2(c). This requirement was not met as evidenced by: Licensee did not meet R1's inontinence needs and staff not responding to call lights within in a timely manner on several days in the month of June 2025 ranging from 15 minute to 1 hour 45 minutes which poses an immediate health safety and personal rights to residents in care.

Official plan of correction

Licensee agrees to submit a written plan on how care and supervision needs will be met by POC due date 08/07/25

Deadline recorded: Aug 6, 2025. 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

(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 R7 not having a Hospice Care Plan indicating care needed which poses a potential health safety and personal rights risk to residents in care.

Official plan of correction

Plan Of Correction Licensee agrees to obtain a complete hospice care plan for R7 by POC due date 08/12/25.

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

Official classification

Type B

Official code

87211(a)

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 report R1 and R4's missed medications 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 a plan on how this regulation will be met by POC due date 08/12/25

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

Official classification

Type A

Official code

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 LPA's observed water in Resident 3's bedroom measured to be 130 degrees, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/17/2025 Plan of Correction Administrator will ensure water temperature in Resident 4's bedroom and send proof to LPA by POC date of 07/17/2025.

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, the licensee did not comply with the section cited above in medications unlocked and accessible to Resident 2 despite Physicians report documenting they are not to administer own medications, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/17/2025 Plan of Correction Administrator will provide medication administration training to facility staff by POC date of 07/17/2025.

Official classification

Type B

Official code

87633(b)

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: 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 Resident 4 does not have required hospice care plan, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/30/2025 Plan of Correction Administrator will provide hospice care plan to LPA's by POC date of 07/30/2025.

Official classification

Type A

Official code

87465(a)

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. The following requirement has not been met as evidenced by: Resident 1 was not given several doses of medication on 06/13/2024, which poses an immediate, health, safety, or personal rights risk to residents in care.

Official plan of correction

Administrator will conduct training with staff on resident medications upon admission and submit to LPA by POC date 06/25/2025.

Deadline recorded: Jun 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(a)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (a) The services provided by the facility shall be conducted so as to continue and promote, to the extent possible, independence and self-direction for all persons accepted for care. Such persons shall be encouraged to participate as fully as their conditions permit in daily living activities both in the facility and in the community. The following requirement has not been met as evidenced by: Resident 1 was not showered after which poses a potential, health, safety, or personal rights risk to residents in care.

Official plan of correction

Administrator will conduct training with staff on Basic services of residents including bathing and submit to LPA by POC date of 07/09/2025.

Deadline recorded: Jul 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87265(a)

Regulation authority

CCR

What the official deficiency says

87625 Managed Incontinence(a) The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition under the following circumstances: The following requirement has not been met as evidenced by: Resident 1 was not assisted timely with incontinent care, which poses a potential, health, safety, or personal rights risk to residents in care.

Official plan of correction

Administrator will conduct training with staff on Incontinent care of residents including bathing and submit to LPA by POC date of 07/09/2025.

Deadline recorded: Jul 2, 2025. A deadline is not proof that correction was completed.