BURBANK HILLS COMFORT LIVING

Official classification

Type A

Official code

1569.311

Regulation authority

HSC

What the official deficiency says

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in not having carbon monoxide detector, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/12/2025 Plan of Correction Licensee immediately purchased the corbon monoxide detector and provided a receipt to LPA. Licensee will submit a picture of the carbon monoxide detector after installation.

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 having sharp objects accessable to residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/12/2025 Plan of Correction Staff immediately removed the sharp objects. Licensee will provide a statement of understanding of the regulation cited by POC due date of 02/12/2025 to ensure that all such items are kept locked.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in providing an updated facility sketch to CCLD with changes regarding room changes which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/28/2025 Plan of Correction Licensee will submit an updated facility sketch with current office/staff room, bedridden designated rooms and the ADU permit.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview with staff and record review, the licensee did not comply with the section cited above in regarding to death report of one resident, which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/18/2025 Plan of Correction Licensee will submit a Death Report to CCLD, along with copy of the death certificate.

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, the licensee did not comply with the section cited above in regards to a broken shed door, ceiling damages, air filter dust, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/11/2025 Plan of Correction Licensee will repair the damaged areas and will provide the pictures of the completed work by the POC due date. Licensee will ensure that the facility stays in good repair.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in having a torn window screen, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/11/2025 Plan of Correction Licensee will repair/replace the window screen and will provide the pictures of the completed work by the POC due date. Licensee will ensure that the facility stays in good repair.

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

Incidential Medical & Dental Care: For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all the following information This requirement is not met by evidence of: Based on record review, the licensee did not comply with the section cited above in 2 out of 3 residents did not have physicians’ orders in resident files, which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Administrator will ensure each resident has a copy of their completed physicians’ orders. Administrator understands that it is their responsibility to make sure each resident has physicians’ orders with their medications. Submit a copy of residents (R1-R3) physician orders by 3/18/22.

Deadline recorded: Mar 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 Crimanal Record Clearance(e) All individuals subject to a criminal record review pursant to Health and safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the department or This requirement is not met by evidence by: Based on record review on 3/8/2022, the licensee did not comply with the section cited above in 1 out of 1 Staff is not fingerprinted, associated or have background check clearance, which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

On 3/8/2022, staff (S3) immediately left the facility.Administrator acknowledged understanding that staff shall not return to work until criminal record clearance and association is complete. associated to the facility before S3 returns. Staff (S3) was cleared and associated to the facility on 3/10/22

Deadline recorded: Mar 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records: The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met by evidence by: Based on record review, the licensee did not comply with the section cited above in 1 out of 1 staff Administrator Certification expired 3/31/21.

Official plan of correction

Administrator will submit the required document to Sacramento and pay the necessary fees to renew certification. A copy of new administrator certification is due to licensing by POC date.

Deadline recorded: Mar 24, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment:Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met by evidence by: Based on record review, the licensee did not comply with the section cited above in 2 out of 3 residents physicians report was blank and not update, which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Administrator will ensure residents files will be updated with a completed physician’s report signed by the doctor. Submit a copy of residents (R1-R3) physicians report by POC date

Deadline recorded: Mar 30, 2022. 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

Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. The appraisal shall include, at a minimum, an evaluation of the 87457 Pre admission Appraisal- General: prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors. The licensee shall be permitted to use the form LIC 603 (Rev. 6/87), Preplacement Appraisal Information, to document the appraisal. This requirement is not met by evidence by: Based on record review, the licensee did not comply with the section cited above in 3 out of 3 residents did not have preplacement appraisal and functional capacities in resident files, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will ensure residents files will be updated with a completed pre appraisal and functional capabilities assessment in every residents file. Documents to be updated by 3/24/22. Submit a copy of residents (R1-R3) pre admission apprisal and functional capabilities assessment by POC date.

Deadline recorded: Mar 24, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

87208- Plan of Operation:Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met by evidence by: Administrator will ensure to submit a change of operation to CCLD and review regulation 87208(a) to ensure compliance in the future.

Official plan of correction

Based on observed, the licensee did not comply with the section cited above in Licensee did not inform CCLD and submitted a change of operation, which poses an immediate health, safety, or personal rights risk to persons in care. Administrator will update and submit a copy of facility sketch and change of operations by POC date.

Deadline recorded: Mar 24, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records:The licensee shall ensure that personnel records are maintained on the licensee, administrator, and each employee. Each personnel record shall contain the following information: This requirement is not met by evidence by: Based- on record review, the licensee did not comply with the section cited above in 2 out of 2 Staff employee rights was not in their files, which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Administrator will ensure each Staff record will have a copy of their employee rights by 3/24/22. Administartor will update staff file and submit a copy to Licensing by POC.

Deadline recorded: Mar 24, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87707(a)(2)(A)

Regulation authority

CCR

What the official deficiency says

87707 Training Requirments: Direct care staff shall complete at least eight hours of in-service training about serving residents with dementia within 12 months of working in the facility and in each succeeding 12-month period. Direct care staff hired as of July 3, 2004 shall complete the eight hours of in-service training within 12 months of that date and in each succeeding 12-month period. A minimum of two of the following training topics shall be covered annually, and all topics shall be covered within a three-year period… This requirement is not met by evidence by: During record review on 3/8/22 and todays visit LPAs observe no staff training.

Official plan of correction

Administrator will make sure to keep record of all staff training. Submit a copy of staff in service training by POC date.

Deadline recorded: Mar 24, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705

Regulation authority

CCR

What the official deficiency says

The following shall be stored inaccessible to residents with dementia: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 by evidence by: During LPAs tour facility staff had left cleaning supplies in hall closet.

Official plan of correction

Administrator will ensure disinfectants and cleaning supplies are locked at all times. Administrator removed disinfectants and cleaning supplies during the visit. Corrected during the visit

Deadline recorded: Mar 17, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87506(b)(10)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (10) Reports of the medical assessment specified in Section 87458 Medical Assessment, and of any special problems or precautions. This requirement is not met as evidenced by: Deficient Practice Statement

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type A

Official code

87465(a)(7)

Regulation authority

CCR

What the official deficiency says

(7) 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: Deficient Practice Statement

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 2 out of 3 residents physcians report was blank and not update, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/22/2022 Plan of Correction Administrator will make sure all residents physcians report and medical assistment is updated and placed in there files. A copy of each report will be sent to licensing.

Official classification

Type B

Official code

87465(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff. 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 [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: Plan of Correction

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (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: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by: when LPA arrived S3 was present at the facility and interacting with residents, S3 does not have criminal record clearance. Administrator told LPA that S3 has been volunteering in the facility for about a month and that she wanted to see how she did before she hired her. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator agrees to obtain criminal record clearance for S3 and ensure S3 is associated to the facility before S3 returns. Administrator understands that S3 is not allowed in the facility until this is completed. Furthermore, administrator understands that it is her responsibility to ensure that S3 has criminal record clearance and is associated before returning. **Immediate civil penalties assessed** Proof of correction due to CCL by plan of correction date of 12/15/18. Danyle.Wolter@dss.ca.gov

Deadline recorded: Dec 15, 2018. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: upon LPAs arrival, LPA observed S2 to be present at the facility. LPA reviewed S2's file and did not observe a LIC 9182 for criminal record clearance transfer request to the facility. Administrator was unable to provide proof of transfer request. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator agrees to complete LIC 9182 for S2 and turn it in to the Regional Office at Monterey Park. Administrator understands that S2 is not to be present in the facility until they are associated. Furthermore, administrator understands and agrees that it is their responsibility to ensure that the transfer request is complete before S2 returns to work. Proof of correction due to CCL by 12/15/18. **Immediate civil penalties assessed.** Danyle.Wolter@dss.ca.gov

Deadline recorded: Dec 15, 2018. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87755(a)

Regulation authority

CCR

What the official deficiency says

87755 Inspection Authority of the Licensing Agency (a) Any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter and inspect the entire premise of any place providing services at any time, with or without advance notice. This requirement is not met as evidenced by: during LPAs tour of facility with administrator, LPA could not inspect garage outside because it was locked and administrator did not have a key. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator agrees to review regulation 87755 and write a letter of understanding. Additionally, administrator agrees to ensure that a key is always at the facility to ensure garage is accessible. Proof of correction due to CCL by 12/15/18. Danyle.Wolter@dss.ca.gov **Immediate civil penalties assessed**

Deadline recorded: Dec 15, 2018. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by: during LPAs medication review, LPA observed R4 to have PRNs and Vitamins which did not have physician orders. LPA reviewed R4s 602 and R4 is unable to administer own PRN medications. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator agrees to obtain physician orders for PRN medications or cease use. Additionally, administrator agrees to review regulation 87465 and write a letter of understanding. Proof of correction due to CCL by 12/15/18. Danyle.Wolter@dss.ca.gov

Deadline recorded: Dec 15, 2018. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (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: during LPAs medication review, LPA observed R3 and R4 to have medications which were prepoured for 7 days in a morning/afternoon/evening in a 7-day pill container. Administrator was unable to show LPA original containers as they were stored in the garage and the garage was locked and unable to be accessed. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator agrees to ensure that medication stays in its originally received container, administrator understands that medication cannot be prepoured. Administrator agrees to review regulation 87465 and send a letter of understanding to CCL by 12/15/18. Danyle.Wolter@dss.ca.gov **LPA provided administrator with link for medication guide. http://ccld.ca.gov/res/pdf/MedicationsGuide.pdf

Deadline recorded: Dec 15, 2018. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (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: during LPAs medication review, LPA observed R3 to have medications prepoured in a 7-day pill container but no other medications on hand. Administrator told LPA that R3 does not take medications but could not provide discontinue orders for the prescribed medications on R3's LIC 602. R3's medications are not being given per physician orders. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator agrees to obtain discontinue orders for R3s medication from physician. If physician states R3 still needs medications then administrator is to refill prescriptions. Proof of correction due to CCL by 12/15/18. Danyle.Wolter@dss.ca.gov

Deadline recorded: Dec 15, 2018. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General(c) All RCFE staff who assist residents with personal activities of daily living shall receive at least ten hours of initial training within the first four weeks of employment and at least four hours annually thereafter. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: during LPAs file review, LPA observed no staff to have current 1st Aid Training. This poses an immediate health and safety risk to residents in care

Official plan of correction

Administrator agrees to obtain First Aid Training for themself and ensure that staff have First Aid Training as well. Proof of scheduled first aid training due to CCL by 12/15/18. Danyle.Wolter@dss.ca.gov

Deadline recorded: Dec 15, 2018. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. [...] This requirement is not met as evidenced by: during LPAs inspection, LPA observed only administrator was able to assist all residents and prepare food for lunch. During file review, LPA observed the administrator is the only person associated to the facility and able to work. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator agrees to ensure that facility staff is adequate in numbers to ensure that residents needs are met 24-hours a day. Proof of correction due to CCL by 12/15/18. Danyle.Wolter@dss.ca.gov

Deadline recorded: Dec 15, 2018. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

87457 Pre-Admission Appraisal - General (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: during LPAs file review, LPA observed R1, R2, and R5 did not have Pre-Admission Appraisals completed before moving in. This poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator agrees to ensure that Pre-Admission appraisals are completed before residents move in. Furthermore, administrator agrees to complete appraisals on R1, R2, and R5. Proof of correction due to CCL by 1/11/19. Danyle.Wolter@dss.ca.gov

Deadline recorded: Jan 11, 2019. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: during LPAs file review, LPA observed R1 and R5 do not have medical assessments in their files. This poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator agrees to schedule appointments for R1 and R5 to have medical assessments completed. Proof of correction due to CCL by 1/11/19. Danyle.Wolter@dss.ca.gov

Deadline recorded: Jan 11, 2019. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by: during LPAs review of residents files, LPA observed R3 and R4 to have appraisals which have not been updated in the last 12 months as required. This poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator agrees to complete reappraisals for R3 and R4 by plan of corrections date of 1/11/19. Additionally, administrator agrees to create a calendar of when all residents reappraisals need to be completed.

Deadline recorded: Jan 11, 2019. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

§1569.625 Staff training; legislative findings; contents (b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision This requirement is not met as evidenced by: during LPAs file review LPA observed the only staff training completed in 2018 was dementia training, the other topics had not been covered. This poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator agrees to create a calendar for what training needs to be completed in 2019. Calendar will include what training will be done each month to ensure all training and topics are covered. Proof of correction due to CCL by 1/11/19. Danyle.Wolter@dss.ca.gov LPA printed out H & S Code 1569.625 in its entirety for administrator.

Deadline recorded: Jan 11, 2019. A deadline is not proof that correction was completed.