LAS CASITAS ASSISTED LIVING

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Food in expired containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in maintianing several containers of expired tomato sauce/salsa in the pantry, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Staff immediately removed and destroyed the expired containers. Licensee will ensure there are no expired food items anywhere in the facilty and will keep a record of the purchase dates. POC cleared on today's visit.

Deadline recorded: Nov 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) 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: Based on observation, the licensee did not comply with the section cited above, medications were stored in weekly pills boxes, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Staff immediately removed the medications from the pill boxes. Licensee will ensure medications are always kept in original containers and only removed during medication administration. POC cleared on today's visit.

Deadline recorded: Nov 24, 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 6 out 7 resident bathrooms water temperature was tested between 125.2-143.8 which is not within the required 105-120 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/27/2024 Plan of Correction Administrator will adjust the water heater and will certify in writing that will ensure water temperature is within the required 105-120 degrees F., to the department by POC due date 10/27/24.

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 cleaning supplies were observed unlocked at the time of the visit in the kitchen accessible to the residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/27/2024 Plan of Correction Administrator will provide in-service training to staff regarding dementia regulations and will provide a copy to the department by POC due date 10/27/24.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. 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 3 out of 5 resident files reviewed residents have a dementia diagnosis which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/27/2024 Plan of Correction Administrator will provide auditory devices in each exit door and will provide a picture to the department by POC due date 10/27/24.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 4 out of 4 staff files reviewed staff las CPR training was conducted in 2019 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/01/2024 Plan of Correction Administrator will ensure staff takes CPR/First Aid training and submit a copy to the department by POC due date 11/1/24.

Official classification

Type B

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

(d) 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 as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in current administrator certificate or training were not available for review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/01/2024 Plan of Correction Administrator will provide a copy of current administrator certificate or eopies of certification submitted to the department for renewal, or enrollement to renew certificate to the department by POC due date 11/1/24.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 4 staff did not have records of training within the last 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/01/2024 Plan of Correction Administrator will provide staff with 20 hours of training including the topics above and will submit a copy to the department by POC due date 11/1/24.

Official classification

Type B

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. 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 1 out of 5 residents, resident #3 did not have a copy of TB test clearance which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/01/2024 Plan of Correction Administrator will obtain TB test clearance for R3 and submit a copy to the department by POC due date 11/1/24.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 last fire drill was conducted on 10/19/19 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/01/2024 Plan of Correction Adminsitrator will provide an emergency dril and will submit a copy to the deparment by POC due date 11/1/24.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(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: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. 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 8 out of 9 residents have half bed rails in their beds which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/01/2024 Plan of Correction Administrator will submit a bed rail request order from the physician to the department by POC due date 11/1/24.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. 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 3 out of 5 residents, R3 last physician's report was conducted on 6/12/19 and no appraisal was done, R4 last physician's report was 11/9/21 and no appraisal was done, and R5 physician's report was 2/22/21 and appraisal done 2/15/21 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/02/2024 Plan of Correction Administrator will request a physician report for R3-R5 and will conduct an appraisal for R3-R5 and will submit a copy for each to the department by POC due date 11/2/24.

Official classification

Type B

Official code

87412(b)(2)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (b) Personnel records shall be maintained for all volunteers and shall contain the following: (2) Health screening documents as specified in Section 87411(f). 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 4 staff, S3-S4 did not have a health screening/TB test on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/01/2024 Plan of Correction Administrator will ensure staff obtain a health screening TB test and submit a copy to the department by POC due date 11/1/24.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

(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 evidenced by: Deficient Practice Statement Based on observaton, the licensee did not comply with the section cited above in that LPA was not screened upon entry, which poses an immediate health, safety or personal rights risk to persons in care. COVID-19 screening protocols i.e. visitor sign-in binder, thermometer, and screening questions were not observed to be in place. Home health staff were also present during today's visit, and were not screened.

Official plan of correction

POC Due Date: 03/17/2022 Plan of Correction Administrator shall put in place COVID-19 infection control visitor screening practices. Submit in writing how this was corrected, and include a picture of the screening area.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 that during the physical plant tour of resident rooms, dementia residents (R1-R2's) room had a Febreze deodorizer and Clorox cleaning supplies inside room 1641, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/17/2022 Plan of Correction Administrator shall conduct staff training regarding regulation 87705, check all resident rooms for potential hazards, and submit proof of correction by POC due date.

Official classification

Type A

Official code

87705(l)(2)

Regulation authority

CCR

What the official deficiency says

(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. 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 that the main entrance gate is locked, and had a metal wire on the top of the gate preventing anyone inside the premises from exiting. In addition, the rear gate had a lock that prevents the right side door from opening. Locking mechanisms that require a key and/or inaccessible to residents for exit are against fire safety code which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/17/2022 Plan of Correction Administrator shall remove all locks that require key on exit doors, and wire placed by staff in the front entrance door. Submit picture proof, staff training log, and a written statement of what was done to correct it.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

(a) 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 as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in that LPA requested to see the Plan of Operation to check meal/dining services, but staff was not able to find the Plan of Operation, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/21/2022 Plan of Correction Administrator shall submit a copy of the plan of operation, and ensure it is in the facility at all times.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 that staff was not able to find record of the last facility emergency drill, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/21/2022 Plan of Correction Administrator shall conduct quarterly emergency drills. Submit proof of emergency drill by POC due date.