FIL-AM HOME FOR SENIORS II

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

All personnel, including the licensee and administrator, shall be in good health, and physically capable of performing assigned tasks .... shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician This requiment is not met as evidenced by: Based on record review, the licensee did not comply with the cited section. Three (3) of four (4) staff files lacked TB test results and/or physical examinations, posing a potential health and safety risk to persons in care.

Official plan of correction

The licensee agrees to ensure all staff obtain TB tests and physical examinations. Proof of completed TB tests and physical exams for all staff will be submitted by the POC date.

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

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... This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requiment is not met as evidenced by: Based on record review, the licensee did not comply with the cited section, as three (3) of four (4) staff files lacked required ongoing training documentation, posing a potential health and safety risk to persons in care

Official plan of correction

Licensee is to ensure annual training requirements are met annually. Licensee will update training requirements and send of proof of training by POC date.

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

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training... (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: Based on record review, the licensee did not comply with the cited section, as one (1) of four (4) staff lacked proof of first aid certification, posing a potential health and safety risk to persons in care.

Official plan of correction

Licensee to ensure staff receive first aid training as per regulation. Licensee to submit proof of first aid training for staff by POC date.

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

Official classification

Type B

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 residents file, and a label on the medication... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the cited section, as two (2) of four (4) residents had over-the-counter medications without physician orders, posing a potential health risk to persons in care.

Official plan of correction

Licensee to obtain a physician’s order for Imodium and Claritin (allergy medication) or discontinue medications and submit by POC due date. Licensee to continue to review PRN policy with residents’ families.

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

Official classification

Type B

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... who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services... (1) The licensee has received a hospice care waiver from the department. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the cited section, facility exceeded its hospice waiver capacity (2 approved; 4 on hospice), posing a potential health and safety risk to persons in care.

Official plan of correction

Licensee to ensure they are following their approved hospice waiver. Licensee to submit a request for a hospice waiver increase.

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

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition.. keep the appraisal accurate. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above in six (6) out of six (6) residents did not have updated re-appraisals which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to ensure they are updating appraisals as frequently as necessary or once every twelve months. Licensee to submit updated re-appraisals by POC date.

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

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results.. (A) Communicable tuberculosis. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above in six (6) out of six (6) residents did not have TB test on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee is to ensure compliance on Communicable Tuberculosis examinations prior to acceptance of a resident. Licensee is to submit proof of TB test by POC date.

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

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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. Four (3) out of four (4) staff files did not contain TB test results or physical examinations, which poses/posed a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/23/2025 Plan of Correction The licensee agrees to ensure all staff obtain TB tests and physical examinations. Proof of completed TB tests and physical exams for all staff will be submitted by the POC date.

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 record review, the licensee did not comply with the section cited above as three (3) out of four (4) staff files did not contain documentation of required ongoing/continuing training which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/23/2025 Plan of Correction Licensee is to ensure annual training requirements are met annually. Licensee will update training requirements and send proof by POC date.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(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: Deficient Practice Statement Based on record review the licensee did not comply with the section cited above in one (1) out of six (6) residents file did not contain a current physician’s order authorizing the use of bed rails which poses/posed a potential health, safety or personal rights risk to

Official plan of correction

POC Due Date: 12/23/2025 Plan of Correction Licensee to obtain a physicians order for bed rails.

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 by kitchen cabinet door lock being broken which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/03/2025 Plan of Correction Licensee shall ensure that disinfectants, cleaning solutions be locked at all times. Licensee to fix lock on cabinet door. ***POC cleared at the time of visit.***

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (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 one (1) out of four (4) staff/caregivers did not have proof of first aid certification which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/23/2025 Plan of Correction Licensee to ensure staff receive first aid training as per regulation. Licensee to submit proof of first aid training for staff by POC date.

Official classification

Type B

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 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: Deficient Practice Statement Based on observation the licensee did not comply with the section cited above in two (2) out four (4) residents, medication review revealed there were over the counter medications not prescribed by physician which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/23/2025 Plan of Correction Licensee to obtain a physician’s order for Imodium and Claritin (allergy medication) or discontinue medications and submit by POC due date. Licensee to continue to review PRN policy with residents’ families.

Official classification

Type B

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 as the facility has a hospice waiver for only two (2) but currently has four (4) residents on hospice which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/23/2025 Plan of Correction Licensee to ensure they they are following their approved hospice waiver. Licensee to submit a request for a hospice waiver increase.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review the licensee did not comply with the section cited above in six (6) out of six (6) residents did not have updated re-appraisals which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/23/2025 Plan of Correction Licensee to ensure they are updating appraisals as frequently as necessary or once every twelve months. Licensee to submit updated re-appraisals by POC date.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. 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 six (6) out of six (6) residents did not have 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: 12/23/2025 Plan of Correction Licensee is to ensure compliance on Communicable Tuberculosis examinations prior to acceptance of a resident. Licensee is to submit proof of TB text by POC date.

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, medications were observed in 2 different trays on top of R2's nightstand, the licensee did not comply with the section cited above in 1 out of 5 residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/01/2023 Plan of Correction Licensee will remove medications from R2's room and centrally store. Licensee will re-train staff on medication safe keeping and send proof of re-training by 12/14/23. Proof must be submitted via email.

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, licensee did not provide proof of liability insurance, the licensee did not comply with the section cited above in 5 out of 5 residents, and/or staff, visitor sand which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/14/2023 Plan of Correction Licensee will maintain liability insurance as required. Must send proof via email by 12/14/23.

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, licensee could not provide documented proof of quarterly drills, the licensee did not comply with the section cited above in 5 out of 5 residents, and/or staff, visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/14/2023 Plan of Correction Licensee will conduct quarterly drills and maintain log according to Title 22. Proof of documented drill must be emailed by 12/14/23.

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, R3 did not have annual medical assessment, the licensee did not comply with the section cited above in 1 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/14/2023 Plan of Correction Licensee will submit proof of recent medical assessment and ensure it is done annually for residents with dementia or if change of condition is observed.

Official classification

Type A

Official code

87470(c)(1)(F)

Regulation authority

CCR

What the official deficiency says

Infection Control Requirements (c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (F)Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned as evidenced by safe and effective job performance. This standard is not met as evidence by: LPA observed Staff #2 (S-2) not wearing a mask. LPA observed S-2 obtain an N-95 mask shortly after LPA's arrival, however, S-2, was not wearing the N-95 mask correctly as (1) mask strap was hanging under S-2's chin.

Official plan of correction

Administrator will ensure that facility is following California Dept of Public Health and CCLD requirements. Administrator will provide a written statement stating that staff will be retrained, and will comply with CDSS requirements and regulations, and will maintain a safe and healthful environment for residents and staff.

Deadline recorded: Feb 3, 2023. A deadline is not proof that correction was completed.

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,backyard contained animal feces throughout the backyard area, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/05/2022 Plan of Correction Administrator/Licensee will clean up animal feces and remind staff to clean up feces daily. Administrator will send photo proof of correction. Staff began to clean up feces while LPA was conducting tour.

Official classification

Type B

Official code

87303(a)(1)

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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, resident bathroom floor had hair, stains and dirt throughout shower floor, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/05/2022 Plan of Correction Administrator/Licensee will clean and sanitize bathroom floor and shower. Photo proof will be submitted. Administrator/licensee will remind staff to clean and sanitize bathroom on a regular basis. Staff began to clean toilet while LPA was typing report.

Official classification

Type B

Official code

87303(e)(6)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, sink #1 in resident bathroom was leaking water from hot faucet knob when turned on, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/10/2022 Plan of Correction Administrator/Licensee will provide photo proof and receipt of faucet repair. Administrator posted " OUT OF ORDER " sign on faucet and advised residents and staff to use sink #2 located inside same bathroom.

Official classification

Type B

Official code

87412(a)(11)

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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed, the licensee did not comply with the section cited above in 2 out of 4 files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care. S1 and S2 did not have a health screening with proof of a TB clearance on file.

Official plan of correction

POC Due Date: 02/04/2022 Plan of Correction Facility will submit a copy of the health screening with TB clearances for both staff members by POC due date.