CERRITOS VILLA 1

Official classification

Type B

Official code

87303(d)

Regulation authority

CCR

What the official deficiency says

(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above due to light in bathroom #2 not working when switch is pushed up and light fixture above the kitchen sink is missing and the bulbs are exposed, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2025 Plan of Correction Light in bathroom #2 will be fixed and a video of light working properly will be sent to LPA. Photo of covered light fixture will also be sent to LPA by POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) Maintenance and Operation (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 by having kitchen covered in grease stains and dust, and having tiles around kitchen sink which are cracked and held down with duct tape, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/14/2025 Plan of Correction Licensee will conduct a deep clean of the kitchen cabients inside and out and send LPA a photo. Licensee will send LPA a copy of the repair invoice and a photo of the replaced kitchen tiles by POC due date.

Official classification

Type B

Official code

87211(a)(1)(A)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including (...) (1) A written report (...) within seven days of the occurance of (...) (A) Death of any resident from any cause regardless of where the death occurred. This regulation is not met as evidenced by: Based on record review, LPAs determined that death the facility has not submitted three (3) death reports for three (3) residents who passed away since August of 2025, which poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator is to ensure that death reports are faxed to the department within seven days of occurance at all times. Administrator is to fax or email the death reports for the 3 residents to the LPA by the POC due date.

Deadline recorded: Oct 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(D)(5)

Regulation authority

CCR

What the official deficiency says

87405(d)(5) Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (5) Good character and a continuing reputation of personal integrity. This requirement has not been met as evidenced by: Verification of staff CPR training, staff course training and physicians report for R6 submitted to LPA by Administrator were verified to be falsified and altered.

Official plan of correction

Administrator will call board meeting to discuss this issue. Administrator states he takes full responsibility and will ensure all training and POC’s are cleared by him. Administrator will have head caregiver assist with training logs. Administrator will call board meeting to discuss this issue. Administrator states he takes full responsibility and will ensure all training and POC’s are cleared by him. Administrator will have head caregiver assist with training logs.

Deadline recorded: Nov 21, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87633(b)(4)

Regulation authority

CCR

What the official deficiency says

87633(b)(4) Hospice Care of Terminally Ill Residents (b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (4) A description of the area of licensee’s responsibility for implementing the plan including, but not limited to, facility staff duties; record keeping; and communication with the hospice agency, resident’s physician, and the resident’s responsible person(s), if any. This description shall include the type and frequency of the tasks to be performed by the facility. This requirement has not been met as evidenced by: Facility did not have a current care plane for R2 for prohibited health condition.

Official plan of correction

Administrator will submit a current care plan for R2 along with the responsibly of the facility of how to care for resident with a prohibit health condition,

Deadline recorded: Nov 21, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87633(f)(1)

Regulation authority

CCR

What the official deficiency says

87633(f)(1) Hospice Care of Terminally Ill Residents (f)The licensee shall maintain a record of all hospice-related training provided to the licensee or facility personnel for a period of three years. This record shall be available for review by the Department. (1) The record of each training session shall specify the names and credentials of the trainer, the persons in attendance, the subject matter covered, and the date and duration of the training session. This requirement has not been met as evidenced by: Based on record review all staff had no training for prohibited health conditions.

Official plan of correction

Administrator will send LPA training for staff by POC due date.

Deadline recorded: Nov 21, 2024. 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) 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 cleaning supplies were observed under kitchen sink and bathroom #1 unlocked which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/03/2024 Plan of Correction Caregiver locked cabinet in kitchen and removed comet cleaner at time of visit. Administrator will conduct training and send to LPA by email.

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 one (1) out of six (6) residents R3 medication were in refrigerator not in a locked box which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/03/2024 Plan of Correction Administrator agrees to purchase lock box for medication and send LPA pictures by email.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in one (1) out of six (6) residents R4 medication was not documented correctly and Administartor could not indicate when medication was started which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/03/2024 Plan of Correction Administrator will conduct inservice training on medication with staff and sent to LPA by POC due date.

Official classification

Type A

Official code

87606(c)

Regulation authority

CCR

What the official deficiency says

(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a). 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 facility has two (2) bedridden residents operating out of required scope fire clearance approved for one(1) which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/03/2024 Plan of Correction Administrator will certify what steps he will take to address to being over capacity.

Official classification

Type A

Official code

87633(a)(1)

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: (1) The licensee has received a hospice care waiver from the department. 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 two residents did not have hospice waiver facility has hospice clearance for one which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/03/2024 Plan of Correction Administartor will apply for hospice waiver increase and will certify what steps he will take to address being over capacity.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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 facility did not have liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/09/2024 Plan of Correction Administrator will renew insurance and send to LPA by email.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 front door auditory did not work which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/09/2024 Plan of Correction Administrator will replace batteries or device and send LPA video by text.

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 two (2) out of four (4) staff did not have CPR/First AID training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/09/2024 Plan of Correction Administartor will send S2 and S3 CPR/ First Aid training.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(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: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in two (2) out of two (2) residents R4 and R6 did not have current Physicians reports which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/09/2024 Plan of Correction Administartor will send LPA current Physicians reports by POC due date.

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 record review, the licensee did not comply with the section cited above in two (2) out of three (3) residents did not have a 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: 11/09/2024 Plan of Correction Administrator will send hospice care plan to LPA.

Official classification

Type B

Official code

87705(c)(3)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: 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 three (3) out of four (4) staff did not have training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/09/2024 Plan of Correction Administrator will send all training to LPA by POC due date.

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 2 out of 2 bathrooms water temperature tested between 121.8- 127.2 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2023 Plan of Correction The Licencee will adjust the water temperature and send photo proof of the log to LPA by POC due date.

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 which cleaning supplies and toxins was left unsecured in bathroom, kitchen and backyard, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2023 Plan of Correction The licencee will ensure all toxins, cleaning supplies and sharps are secured at all times. Please conduct staff in service and submit the documents to LPA by 12/11/2023. This citation was cleared during the visit.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on (observation), the licensee did not comply with the section cited above in which LPA observed medications for R1 was signed off as given before time and medications was missing, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2023 Plan of Correction The Licencee will conduct inservice on medication Administration with staff and send training to LPA by 12/11/2023.

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... shall prior to working... in a licensed facility: (2) Request a transfer of criminal record clearance. 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 staff S1 was not cleared or associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2023 Plan of Correction The licensee will associate the staff in question via Guardian and provide a copy of the facility association list via email by POC due date. The licensee will also understand employees has to be associated before working at the facility.

Official classification

Type B

Official code

87412(a)(13)(B)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement. 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 which LPA observed the administrator certificate expired on 8/31/2023, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/30/2023 Plan of Correction The licensee will submit hours of course taken to renew certifacte and submit the trainings to Sacramento by POC due date,

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements: (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: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 4 out of 5 staff files. S1, S2, S3, and S4 did not have a current CPR/First Aid training in their files, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/14/2021 Plan of Correction Administrator will ensure that all staff providing care have a current CPR/First Aid training and submit a copy of the certificate by 12/14/2021.