MEADOWBROOK AT AGOURA HILLS

Official classification

Type B

Official code

1569.312(a)

Regulation authority

HSC

What the official deficiency says

1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as R1 eloped from the facility while under the care of staff and was found by law enforcement away from the facility approximately 49 minutes later which poses a potential safety risk to clients in care.

Official plan of correction

Following the incident, R1’s primary care provider and responsible party were notified, R1 was reassessed and their Service Plan was updated, and staff received an in-service training on elopement prevention protocols and procedures for managing delayed egress door malfunctions. POC is cleared.

Deadline recorded: Aug 12, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

87625 Managed Incontinence (b)…Requirements for Allowable Health Conditions, the licensee shall be responsible...:(3) Ensuring that incontinent residents are kept clean and dry and that the facility... This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above, as facility staff failed to ensure that R1 was kept clesn and dry, which posed an immediate health and safety risk to residents in care.

Official plan of correction

ED conducted a in-service training with caregivers regarding R1's needs, refusals and incontinent frequently checks.

Deadline recorded: Oct 30, 2025. 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: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in three residents rooms that were observed with prescribed medications or over the counter medications and residents could not store their own medications per their LIC602 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/08/2025 Plan of Correction The Licensee will properly secure the medications from all three rooms and conduct training for staff regarding the requirements for centrally stored medications and send CCLD proof by POC due date.

Official classification

Type B

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 two cleaning carts that were left unattended with chemicals accessible to the residents in care which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/18/2025 Plan of Correction Both carts were locked upon observation. ED will conduct training for all staff regarding regulation 87309 in its entirety and submit proof no later than POC due date.

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 record review, the licensee did not comply with the section cited above in one resident who's last LIC602 is dated 11/08/2022 which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/18/2025 Plan of Correction Administrator will ensure each resident is offered an annual medical visit, either in person or via video, every twelve months. Administrator will review the above listed regulation and submit a statement of understanding to CCLD by POC due date,

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities: 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 evidence by Based on self-reported incident reports the licensee did not comply with the section cited above when a resident was given dog food they were not treated with dignity, which posed a pontential personal rights risk to residents in care.

Official plan of correction

S1 is no longer working at the facility. Administrator agrees to develop a plan on how they will ensure residents are treated with dignity.

Deadline recorded: Apr 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(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 is not met as evidence by: Based on interview and record review, the licensee failed to comply with the section cited above, as R1 sustained a back fracture due to S1 taking R1 on an outing without their assistive device which is an immediate health risk to R1 in care.

Official plan of correction

Plan of correction cleared: S1 received a corrective action and safety training regarding the use of assistive device and scheduled programs. An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1569.49(c)(1).

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

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(4)residents…shall have all of the following personal rights: 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 evidence by: Based on interviews, andrecords review, the licensee did not comply with the section cited above as Staff did not respond to residents calls for assistance in a timely manner, which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee will submit a plan on how they will ensure residents pendant calls are answered in a timely manner. Licensee will provide plan to LPA via email by COB 2/28/2025. If training will be held, licensee will submit proof of training.

Deadline recorded: Feb 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Staff did not dispense prescribed medication to three residents during an evacuation which posed an potential health and safety risk to residents in care.

Official plan of correction

Licensee will schedule medication training for all med-techs that includes medication distribution during an evacuation and submit proof to CCLD no later than POC due date.

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

Official classification

Type A

Official code

87355(e)(1-2)

Regulation authority

CCR

What the official deficiency says

87355(e) All individuals subject to a criminal record review ... shall prior to working, residing ... in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or (2)Request a transfer of a criminal record clearance This requirement is not met as evidence by: Based on interviews and record review, the licensee did not comply with the section cited above. The Operations Specialist/Interim Administrator is not finger printed cleared and associated to the facility, which posed an immediate health and safety risk to residents in care.

Official plan of correction

The licensee will submit a plan describing how they will ensure staff are fingerprint cleared and associated to the facility prior to working. Submit proof to CCL by 12/13/2024 Immediate $500 civil penalty assessed.

Deadline recorded: Dec 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(4)residents…shall have all of the following personal rights: 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 evidence by: Based on interviews,records review, and observation the licensee did not comply with the section cited above as Staff did not respond to residents calls for assistance in a timely manner, which poses a potential health and safety risk to residents in care.

Official plan of correction

Business Office Manager agreed to have an in service with all staff regarding how to respond resident calls in a timely manner and will also develop a plan to ensure that pendant calls are answered in a timely manner. Will submit proof of inservice and plan to CCL by 12/26/2024.

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

Official classification

Type A

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. 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 the kitchen sink of assisted living which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2024 Plan of Correction ED agrees to place a warning sign by 09/11/2024 and submit proof to CCL.

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 four (4) resident rooms and one unlocked storage room which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2024 Plan of Correction Storage room was locked during the visit. ED agrees to conduct an audit and remove all items that could pose a danger to the resident in the four rooms observed and submit a letter of understanding of regulation 87309 and submit to CCL by 09/11/2024.

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 three resident rooms observed with medications, and per their physicians room they cannot store and administer their medication which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2024 Plan of Correction ED agrees to conduct an audit and remove all items that could pose a danger to the resident in the three rooms observed with medications and submit a plan on how they will ensure the community is following regulation 87465 and submit to CCL by 09/11/2024.

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 seven (7) resident rooms where the hot water measured above 120 degrees which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2024 Plan of Correction ED agrees to adjust the water temperature in all of the rooms observed with the water temperature above 120 degrees and ensure the water measures between 105-a20 degress and submit proof to CCL by 09/11/2024.

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 two (2) resident rooms where the LPA observed smoke detector not operable or a missing smoke detector which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2024 Plan of Correction ED agrees to place operable smoke detectors in both rooms and submit proof to CCL by 09/11/2024.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

87608(a)(5)(A) (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. (5)Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above as R1’s half bed rails were removed, which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed bedrails will beput back on as of 08/14/2024 and provide a 30 day notice abou the bedrail policy to residents responsible parties and submit documentation to CCL by POC due date.

Deadline recorded: Aug 19, 2024. 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

(a) Each licensee shall furnish to the licensing agency such reports as the Department...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:

Official plan of correction

The Licensee has agreed to review regulation 87211 and submit a statement of understanding to CCL no later than 12/29/2023. Based on interview and record review, the licensee failed to comply with the section above as the licensee failed to submit a written report to the appropriate agencies regarding the alleged abuse between S3 and R1 which is a potential health and safety risk to residents in care.

Deadline recorded: Dec 29, 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

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as interviews revealed there are times when only two caregivers are on duty in the memory care with 28 residents which poses a potential health and safety risk for residents in care.

Official plan of correction

The Licensee has agreed to review regulation 87411 and submit a statement of understanding to CCL no later than 12/29/2023.

Deadline recorded: Dec 22, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(g)

Regulation authority

CCR

What the official deficiency says

(g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation and record review, the licensee did not comply with the section cited above as personal hygiene items were found unlocked and accessible to resident in care inside the memory care unit,which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/25/2023 Plan of Correction The Executive Director has agreed to do the following: 1.) Items were locked immediately at the time of the visit. 2.) Review Regulation 87705 and submit Statement of Understanding to CCL by 08/29/2023.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental,...such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interview and record review, the licensee failed to comply with the section cited above as R1's responsible party was not notified of a change of condition timely which poses a potential health and safety risk to R1 in care.

Official plan of correction

The Administrator shall submit a plan of correction on how they will ensure the deficiency does not occur again. Plan of correction to be submitted to CCL by 07/21/2023.

Deadline recorded: Jul 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

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. This requirement is not met as evidenced by: Based on interviews and record review, the licensee failed to comply with the section cited above as insufficient staffing resulted in residents getting their medications late which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator shall submit a plan of correction on how they will ensure the deficiency does not occur again. Plan of correction to be submitted to CCL by 07/21/2023.

Deadline recorded: Jul 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(f)(1)

Regulation authority

CCR

What the official deficiency says

87464(f)(1) 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 is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. R1 was not provided the proper supervision to ensure resident's safety. R1 left the facility unassisted, which led to a fall resulting in injuries and hospitalization, which posed an immediate health and safety risk..

Official plan of correction

Licensee will submit a written action plan regarding proper resident care and supervision to CCL by POC due date 05/19/2023. An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1569.49(c).

Deadline recorded: May 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(d)(1)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified... (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above.The Administrator (former) was unaware of R1’s physician report that indicated R1 was not allowed to leave the facility unattended, posing an immediate health and safety risk to R1.

Official plan of correction

Administrator (former) Troy Byington no longer works at facility. No plan of correction at this time.

Deadline recorded: May 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87456(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…. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above. R1 was not provided timely medical treatment on 02/13/2020 which led to R1’s death, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee will have staff complete training on timely medical treatment and emergency procedures. Submit proof of correction to CCL by 05/19/2023. An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1569.49(c).

Deadline recorded: May 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87628(a)

Regulation authority

CCR

What the official deficiency says

87628(a) Diabetes (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…and is able to administer his/her own medication…, or has it administered by an appropriately skilled professional. Based on record review, the licensee did not comply with the section cited above. R1 needed assistance with glucose testing and medication administration, which was performed by a med tech and not an appropriately skilled professional, which posed an immediate health risk...

Official plan of correction

Licensee will submit plan on how you will ensure glucose testing and insulin injections are performed by an appropriately skilled professional. Submit to CCL by 05/19/2023.

Deadline recorded: May 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705(c)(5) Care of Persons with Dementia (c) Licensees who accept... residents with dementia shall.... ensuring the following: (5)Each resident with dementia shall have medical assessment,.. at least annually…This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. R1’s condition changed on 7/27/2019 when R1 was moved from AL to the MC Unit. Licensee failed to update R1’s medical assessment, which posed a potential health and safety risk.

Official plan of correction

Licensee will submit memo of understanding regarding updating medical assessments due to change of condition. Submit to CCL by 05/19/2023

Deadline recorded: May 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(6)

Regulation authority

CCR

What the official deficiency says

87705(c)(6) Care of Persons with Dementia (c)Licensees who... retain residents with dementia...responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. Based on record review, the licensee did not comply with the section cited above. This requirement is not met as evidence by: The licensee failed to develop a care plan to meet R1’s needs and update the care plan when conditions changed, which posed a potential health and safety risk to residents in care.

Official plan of correction

Licensee will submit memo of understanding regarding updating care plans and appraisals due to change of condition. Submit to CCL by 05/19/2023.

Deadline recorded: May 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(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 is not met as evidence by: Based on interview and record review, the licensee failed to comply with the section cited above, as R1 sustained injury due to S1 using hot water when bathing R1 which is an immediate health risk to R1 in care.

Official plan of correction

The Administrator terminated S1, relocated R1 to a new room, and conducted an in-service training with all staff on 02/20/2023. Plan of correction is cleared.

Deadline recorded: Feb 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

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).....(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on interviews and record review, two former Administrators had knowledge of suspected abuse and failed to comply with applicable laws, and regulations which poses an immediate health and safety risk to residents in care.

Official plan of correction

Both Administrators are no longer employed by the licensee. No plan of correction due to this time.

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

Official classification

Type A

Official code

87211(c)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (c) Any suspected physical abuse that does not result in serious bodily injury...shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within 24 hours as required by W & I Code Section 15630(b)(1). This requirement is not met as evidenced by: Based on interviews and record review, former Administrators Vanessa Jewel and Matan Bursytn had knowledge of suspected abuse pertaining to S1 and residents in care and failed to report to local ombudsman, CCLD and law enforcement which poses an immediate health and safety risk to residents in care.

Official plan of correction

The current administrator shall ensure all staff receive training pertaining to W & I Code Section 15630 and mandated reporting and submit proof to CCL by 10/04/2022.

Deadline recorded: Oct 4, 2022. 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 is not met as evidenced by: Based on record review and interviews, the licensee failed to comply with the section cited above, as S1 had multiple reported inappropriate interactions with R1, R2, R3, R4, R5, R6, and R7 which poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

S1 was terminated from employment. The current administrator shall ensure all staff receive training pertaining to W & I Code Section 15630 and mandated reporting and submit proof to CCL by 10/04/2022. The Administrator also stated moving forward, any male caregivers will have a witness with them when providing ADL care for female residents. The Administrator will put this in writing and submit to CCL by 10/04/2022.

Deadline recorded: Oct 4, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

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 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 as at least two resident out of 29 in the memory care have Dementia and over the counter medications were being stored in an unlocked memory care unit resident room which poses an immediate health and safety risk to other memory care residents in care.

Official plan of correction

POC Due Date: 09/19/2022 Plan of Correction The medications were secured in the medication room during the inspection. The Administrator agrees to get the resident a lock box for their medications and conduct an in-service training with staff regarding regulation 87705 and ensuring the resident keeps their medications inaccessible to other residents in care at all time. The plan of correction will be submitted by 09/19/2022.

Official classification

Type A

Official code

87465(a)

Regulation authority

CCR

What the official deficiency says

87465(a)(5) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above, as residents did not receive the evening dosage of medication on 11/28/2021, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. The staff in question was let go, and no longer works at the community. 2. An in-service was held with medication technicians. Sign-in sheet and appropriate documents to be submitted 12/07/2021

Deadline recorded: Dec 7, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(A-D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) (1) (A-D) 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 requirement is not met as evidenced by: Based on record review and interview, the licensee failed to comply with the section cited above as the facility failed to submit written reports as required, which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator shall review Regulation 87211 and submit a written memo of understanding of the regulation to CCL by 12/07/2021

Deadline recorded: Dec 7, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)

Regulation authority

CCR

What the official deficiency says

87465(a)(5) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above, as residents were not receiving medication timely and recently the residents did not receive evening medications on 11/28/2021, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. The staff in question was let go, and no longer works at the community. 2. An in-service was held with medication technicians. Sign-in sheet and appropriate documents to be submitted 12/07/2021

Deadline recorded: Dec 7, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(A-D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) (1) (A-D) 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 requirement is not met as evidenced by: Based on record review and interview, the licensee failed to comply with the section cited above as a written report was not received within 7 days of the 10/21/2021 occurrence which poses a potential health, safety, or personal rights risk to residents in care.

Official plan of correction

The Administrator shall review Regulation 87211 and submit a written memo of understanding of the regulation to CCL by 11/12/2021.

Deadline recorded: Nov 12, 2021. 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(a) Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interview and records review, the licensee did not comply with the section cited above, as the facility is experiencing staffing challenges, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee has agreed to do the following: 1. Submit a staffing plan, demonstrating how staff numbers will be sufficient to meet the needs of all residents. Plan should also detail how the facility will appropriately assist with residents whom require two staff assistance. Submit Plan by 10/06/2021, end of day

Deadline recorded: Oct 6, 2021. 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(a) Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interview and records review, the licensee did not comply with the section cited above, as the facility is experiencing staffing challenges, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee has agreed to do the following: 1. Submit a staffing plan, demonstrating how staff numbers will be sufficient to meet the needs of all residents. Plan should also detail how the facility will appropriately assist with residents whom require two staff assistance. Submit Plan by 10/06/2021, end of day

Deadline recorded: Oct 6, 2021. A deadline is not proof that correction was completed.