MOUNTAIN VIEW CENTER

Official classification

Type B

Official code

87468.1(a)(12)(13)

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: (12) To wear their own clothes; to keep and use their own personal possessions, including their toilet articles; and to keep and be allowed to spend their own money. (13) To have access to individual storage space for private use. This requirement is not met as evidenced by: It was observed the facility maintains locks on resident closets prohibiting access.

Official plan of correction

The facility shall ensure residents’ rights to keep and use their own personal possessions and to always have individual access to storage space for private use. The Licensee/Administrator may request a facility wide waiver for locks for review.

Deadline recorded: Feb 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(6)

Regulation authority

CCR

What the official deficiency says

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility.

Official plan of correction

The facility shall ensure residents’ rights to make daily life choices, including access to personal belongings. The Administrator shall submit a written plan describing how resident personal rights will be protected. Effective immediately, resident closet locks shall no longer be used, and the Administrator shall submit written confirmation that the locks have been discontinued.

Deadline recorded: Jan 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 (a)(2) Personal Rights of Residents in All Facilities (a) Residents...shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: During inspection, LPA observed that (4) out of (6) resident bibs had food stains from the breakfast meal and according to staff, were going to be used again by residents for the lunch meal service.

Official plan of correction

Licensee, will send LPA, log indicating the washing of all resident bibs: staff name, date and time and number of bibs washed for 8 days. Licensee will also send LPA a copy of receipt of purchase of additional bibs by POC date.

Deadline recorded: Nov 11, 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, bathroom#8 water temp measured over 120 degree F, the licensee did not comply with the section cited above in 4 out of 4 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/27/2025 Plan of Correction Administrator will draft a plan on how the facility will comply with above regulation. Plan must be received by 8/27/25.

Official classification

Type B

Official code

87303(i)(1)(B)

Regulation authority

CCR

What the official deficiency says

(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, signal system was not turned on during inspection, the licensee did not comply with the section cited above in 37 out of 37 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/26/2025 Plan of Correction Administrator agreed to develop a daily log to document staff verifying on each shift that the signal box is operational. Proof of log was provided to LPA Ramirez during visit. No further action is required.

Official classification

Type B

Official code

87412(c)(2)(D)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (D) Number of training hours per subject. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, in-service training logs did not document training hours, the licensee did not comply with the section cited above in 37 out of 37 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2025 Plan of Correction Administrator will draft a plan on how the facility will comply with above regulation.

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, S3 and S4 did not have documentation of required annul training hours, the licensee did not comply with the section cited above in 37 out of 37 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2025 Plan of Correction Administrator will draft plan on how the facility will comply with above regulation.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(a) In addition to the rights listed in Section 87468.1,residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, and competency to meet their needs. This requirement was not met as evidenced by: staff failed to seek medical attention for 6 1/2 hours for R1 via ambualnce service for medical treatment. This poses immediate Health & Safety, or Persons Rights risk to persons in care.

Official plan of correction

Administrator will certify plan by 06/29/25 that indicates how the facility will comply with this regulation. Plan must be received by 06/29/25. Proof of staff re-training on this regulation must be received by 7/7/25 via email to LPA Ramirez.

Deadline recorded: Jun 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(4) Addtional Personal Rights of Residents in Privately Operated Facilities. (a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Staff did not asses R#3 for injury after fall and staff didnot follow R3's careplan

Official plan of correction

Administrator will give provide staff and direct staff personnel, training for understanding the care as listed in the residents’ careplans and residents’ personal rights by due date 11/08/24. Administrator will send a letter to licensing indicating Licensee has read and will comply section 87468 by 11/02/24.

Deadline recorded: Nov 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

87465(a)(1) Incidental Medical and Dental Care.(a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Resident not receiving timely medical assistance.

Official plan of correction

Administrator will give direct staff personnel, training for fall precautions, emergency procedures, reporting procedures by due date 11/08/24. Administrator will send a letter to licensing indicating Licensee has read and will comply section 87465 by 11/02/24.

Deadline recorded: Nov 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not being met as evidenced by: Based on record review, facility person(s) responsible for reviewing and implementing a residents Fall Care Plan, failed to give proper instructions to the residents’ caregiving staff. Resulting in the resident sustaining injuries. As indicated in SIR 09/01/23 and hospital report dated 09/04/23.

Official plan of correction

Administrator will give caregiving staff and direct staff personnel, training for understanding the care as listed in the residents’ IPP (Individual Program Plan) and residents’ personal rights by due date 10/25/24. On 10/11/24:Proof of correction was provided with Staff In-Service training for Falls,Resident Care, precautions and fall precautions, emergency procedures, hospice care.

Deadline recorded: Oct 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87458.2(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met evidenced by: Based on record review, the findings indicate that on 09/01/2023, Facility person(s) responsible for giving clear instructions and explanations of R3’s Fall Care Plan to the facility staff and to R3’s caregivers, resulting in R3’s injuries sustained.

Deadline recorded: Sep 12, 2024. 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, canopy covering was observed to be torn, the licensee did not comply with the section cited above in 37 out of 37 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/10/2024 Plan of Correction Licensee will replace canopy cover. Picture proof must be sent via email.

Official classification

Type A

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b) The following food service requirements shall apply:(26)Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidenced by: Based on LPA's observation, there was an insufficient amount of the required 2-day persihable foods for the amount of residents in care, which poses an immediate Health, Safety, or Personal Rights risks to persons in care.

Official plan of correction

Licensee will submit pictures of receipts and purchased foods to LPA, via email, by POC due date.

Deadline recorded: Dec 5, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (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... which shall include a reassessment of the resident’s dementia care needs. This rquirement was not met as evidenced by: Based on LPA's observation and interview, the licensee failed to obtain an annual medical assessment/Physician's Report for R2 as required, which poses a potential Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Licensee provided LPA a copy of updated Physician's Report dated 12/03/23. POC cleared.

Deadline recorded: Dec 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

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 facility administrator interview, the licensee did not comply with the section cited above, (38) out of (38) residents which poses an immediate health, safety or personal rights risk to persons in care. During today's visit, staff were unable to provide proof of liability insurance coverage

Official plan of correction

POC Due Date: 09/02/2023 Plan of Correction Facility administrator to submit proof of liability insuranced with the limits noted above to LPA Irra by POC due date.

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, (38) out of (38) residents which poses an immediate health, safety or personal rights risk to persons in care. LPAs observed debris on the side of the back building that are accessible to residents, visitors and staff. The following items were observed: (1) unsecured tall ladder, (2) large air conditioning units, (6) metal-like framing items, a shed inside the packaging, (1) roll of insulation, (1) plywood, (1) wooden pallet, (2) trays, (1) Geri Chair and (6) wheelchairs (of which 1 appears to be disassembled).

Official plan of correction

POC Due Date: 09/02/2023 Plan of Correction Facility Administrator to remove the debris and provide proof of correction (photos) to LPA Irra by POC due date.

Official classification

Type B

Official code

87555(b)(28)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements: (b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by: Based on LPA observation, food items were not properly covered which poses an potential health and safety risk to residents in care.

Official plan of correction

The licensee shall ensure all foods are protected against contamination. An in-service training shall be conducted with all staff and log shall be submitted to LPA by 5/23/23.

Deadline recorded: May 23, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(i)(1)(B)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (i) Facilities shall have signal systems... (1)All facilities licensed for 16 or more and all residential facilities having separate floors...shall have a signal system which shall: (B)Transmit a visual and/or auditory signal to a central staffed location... This requirement is not met as evidenced by: Based on observation and interview, the facility did not have a working signal system for residents to alert staff which poses a potential health and safety risk to residents in care.

Official plan of correction

The licensee shall ensure the signal system is operable. The written plan shall indicate how the deficiency will be corrected and estimated date in which the signal system will be installed. This plan is due by 5/23/23. **A civil penalty is being assessed for a repeated violation.

Deadline recorded: May 23, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on complaints received on 11/24/20 (Control #28-AS-20201124163559) and on 12/15/20 (Control #28-AS-20201215092514) Residents were diagnosed with scabies within the timeframe of this complaint and interviews with staff revealed they were never trained on how to handle residents with scabies. Both complaint investigation findings were substantiated.

Official plan of correction

Cleared during visit. The department was provided a copy of Los Angeles County Public Health’s clearance letter dated 05/14/21, which indicate the facility was cleared of scabies outbreak.

Deadline recorded: Feb 7, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a)(1)(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: There are no records that indicate the facility notified R#1's authorized representative that R#1 had an un-witnessed fall on 09/08/20.

Official plan of correction

Licensee shall review section 87211 and provide a signed statement to the department by the POC date indicating the Licensee understands and will report to the department and Resident's authorized representatives of similar incidents which may occur in the future.

Deadline recorded: Feb 20, 2023. 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

87463 Reappraisals The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition... This requirement is not met as evidenced by: LPA observed that R1 did not have a reappraisal to update her declining mental/ health issues, which poses a potential Health, Safety or Personal Rights risk to the residents in care.

Official plan of correction

Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.

Deadline recorded: Feb 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

HSC

What the official deficiency says

87466 Observation of Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals un met needs. This requirement is not met as evidenced by: Based on interviews with staff which indicated that staff noticed a change in R1 after time of admission but did not conduct a reassessment due to R1 continous refusal, which poses a potential Health, Safety or Personal Rights risk to the residents in care.

Official plan of correction

Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.

Deadline recorded: Feb 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(a)

Regulation authority

CCR

What the official deficiency says

87224 Eviction Procedures(a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in... This requirement is not met as evidenced by: Based on LPA interviews and record review, the administrator refusal to accept R1 back to the facility upon discharge from hospital and not providing R1 with a 30 day eviction notice which poses a potential Health, Safety or Personal Rights risk to the residents in care.

Official plan of correction

Administrator to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Licensee to submit a faxed or mailed copy of POC by due date.

Deadline recorded: Feb 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on complaints received on 11/24/20 (Control #28-AS-20201124163559) and on 12/15/20 (Control #28-AS-20201215092514) Residents were diagnosed with scabies within the timeframe of this complaint and interviews with staff revealed they were never trained on how to handle residents with scabies. Both complaint investigation findings were substantiated.

Official plan of correction

Cleared during visit. The department was provided a copy of Los Angeles County Public Health’s clearance letter dated 05/14/21, which indicate the facility was cleared of scabies outbreak.

Deadline recorded: Jan 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of: Based on observation at approximately 10:04 AM resident (R1) eloped out of the facility after exiting the memory care unit through the unlocked front door exit without staff knowledge. Staff did not ensure the front door was closed properly. This posed an immediate safety risk to this resident in care.

Official plan of correction

Administrator agreed to submit a plan of correction including staff scheduling and supervision of residents. Update resident (R1’s) care plan. In addition, a staff in-service training regarding delayed egress exits, Dementia wandering behavior, methods of redirection, and resident care and supervision shall be conducted by POC due date.

Deadline recorded: Oct 7, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. In addition to ... Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on LPA observation resident (R1) eloped to the main street without staff knowledge. This poses an immediate Health and Safety risk to residents in care.

Official plan of correction

Administrator agrees to submit a written plan stating how this was corrected, and what was done. Submit proof of staff training and attach training topics.

Deadline recorded: Oct 7, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(16)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b) The following food service requirements shall apply: (16) In facilities licensed for sixteen (16) to forty-nine (49) residents, one person shall be designated who has primary responsibility for food planning, preparation and service. This person shall be provided with appropriate training. This requirement is not met as evidence by: S-5’s Food Handling Training Certificate expired 11/24/2021. Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in S-5/Cook did not have a current Food Handling Training Certificate which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2022 Plan of Correction Facility Administrator to submit proof of Food Handling Training enrollment for S-5 and submit to LPA Irra by POC due date of 10/13/22.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements - General (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: S-4- First Aid/CPR Certificate issued 09/28/2020 (2 year certification). Expired: 09/28/2022. Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above as S-4 First Aid/CPR Certificate expired which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2022 Plan of Correction Facility Administrator to submit proof of enrollment for first aid certification for S-4 to LPA Irra by POC due date of 10/13/2022.

Official classification

Type A

Official code

87303(i)(1)(B)

Regulation authority

CCR

What the official deficiency says

(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section above in that the signal system is non-operational throughout the facility. Per Administrator, the signal system has been out of service for approximately (2) months. Per Administrator, Residents that are able to request for assistance were given a hand held bell to use; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/07/2022 Plan of Correction Administrator shall submit a written plan stating how the facility will address the deficiency and repair plans.

Official classification

Type B

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. 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 R-1 (room#8), R-5 (room #6), R-9 has oxygen concentrators inside their bedroom but did not have oxygen in use signage; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2022 Plan of Correction Administrator shall place an oxygen sign on the resident's doors. Submit picture proof by POC due date.

Official classification

Type A

Official code

87303(e)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observatio, the licensee failed to comply with the section above in that restroom in Wing #2 water temperature measured at 123*. Restroom between room #2 and room #3 water temperature measured at 124.5*. Restroom between room #6 and room #7 water temperature measured at 122.3*. Restroom between room #8 and room #9 water temperature measured at 124*. Restroom between room #18 and room #19 water temperature measured at 103.2*. Restroom between room #14 and room #15 water measured at 100.4*; which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 10/07/2022 Plan of Correction Administrator shall adjust water temperature and submit a water temperature log by the end of business day tomorrow. Include a written statement that states the facility's protocols in ensuring the hot water temperatures will be maintained according to Title 22 regulations.

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

Personal Rights Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public...(A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20 " x 26 " in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee failed to comply in the section above in that LPA observed the CCL " Let us no " complaint poster posted. However, the poster measured 8 " x10 " as opposed to the required measurement of 20 " x 26 " as per Title 22; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2022 Plan of Correction Administrator shall submit proof that a 20 x 26 complaint poster has been posted.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency. (D) Any incident which threatens the welfare, safety or health of any resident. This deficiency was evidenced by the following: The facility had (3) residents diagnosed with scabies and did not report it to CCL. A case was open with the County of Los Angeles public health, CCL was not notified.

Official plan of correction

Administrator was called and agreed to send a written statement that facility will report all communicable/contagious diseases to CCL in a timely manner.

Deadline recorded: Aug 26, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(3)(A)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services. (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:

Official plan of correction

Facility Administrator to ensure each bed is equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. LPA Irra conducted tours of this facility on 04/14/22, 04/28/22, 05/11/22, 05/26/22 and 06/08/22 and did not observe any beds to be placed on the floor. DEFICIENCY CORRECTED.

Deadline recorded: Jul 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(3)(A)

Regulation authority

CCR

What the official deficiency says

THIS IS A CONTINUATION OF ABOVE. (A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for matresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary. This standard is not met as evidence by: LPA Almaraz observed R-2’s bed to be on the floor during the virtual tour conducted on 11/30/2020. Staff interviews revealed R-2’s bed was on the floor due to R-2 being a fall risk.

Official plan of correction

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Deadline recorded: Jul 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.38(b)(1)

Regulation authority

HSC

What the official deficiency says

Posting of licensing reports; disclosure to new residents. (b) A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following events: (1)The department commences proceedings to suspend or revoke the license of the facility pursuant to Section 1569.50. This deficiency was evidenced by the following: Accusation is dated 4/8/22 and Administrator confirmed responsible parties and Ombudsman have not been notified in writing.

Official plan of correction

Facility will provide proof to the department that all residents' responsible parties and the Ombudsman have been notified in writing of the Accusation.

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

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...... This requirement was not met as evidence by: The investigation revealed information from staff #24 and resident's family who personally witnessed many of the actions and behaviors of resident #7. Former staff members reported seeing resident #7 touch, fondle and rub female residents on their breasts and vaginal area. Resident #7 was found in another resident's room while resident #7 pants were down and resident #7 was also found in the bed of a female resident and was caught taking a female dementia resident to the back area of the facility. Resident #7 also attempted to sexually assault a female resident while under the influence of a substance. Despite, staff #24 being aware of resident #7 inappropriate sexual actions and behaviors with facility residents, no substantive action was taken by staff #24 to stop resident #7 behaviors and facility residents continued to be victimized by resident #7.

Official plan of correction

Administrator to provide a letter from licensee indicating licensee has read and will comply with section 87468.1 (a) (3). Administrator will create a plan outlining the steps taken when they are notified by staff or persons about possible abuse by POC due date.

Deadline recorded: Apr 20, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Interviews with staff stated that Resident #9 had scabies first and later gave it to Resident #3. Per staff #24, hospice agency said it was not scabies and later determined that it was. The facility did not report scabies to Community Care Licensing. former administrator stated the Licensee, staff and families were notified of the outbreak. During the 04/13/21 site visit, LPA Almaraz received documents indicating that the Los Angeles County Public Health was being notified and a case was being opened.

Official plan of correction

Cleared during visit. Administrator provided a copy of Los Angeles County Public Health’s clearance letter dated 05/14/21, which indicate the facility was cleared of scabies outbreak.

Deadline recorded: May 3, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.38(b)(1)

Regulation authority

HSC

What the official deficiency says

Posting of licensing reports; disclosure to new residents. (b) A licensed residential care facility for the elderly shall provide written notice to a resident, the resident’s responsible party, if any, and the local long-term care ombudsman, within 10 days from the occurrence of either of the following events: (1)The department commences proceedings to suspend or revoke the license of the facility pursuant to Section 1569.50. This standard is not met as evidence by: LPA toured facility grounds with Laura Hernandez and did not observe the Accusation to be posted. Ms. Hernandez also confirmed that the Accusation had not been posted.

Official plan of correction

Assistant Administrator posted the Accusation in a conspicuous location in the facility prior to LPA's departure today. PENDING: Licensee shall provide written notification of Accusation to residents, resident's responsible parties, and the Long Term Care Ombudsman by due date of 04/18/22 and provide proof of given notification to LPA Irra by 04/18/22.

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

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...... This requirement was not met as evidence by: The Administrator was notified and aware about the sexual abuse Resident #9 was doing to other residents and did not take action to mitigate the abuse.

Official plan of correction

Administrator will ensure all residents are free from any type of abuse from staff or other residents. Administrator will create a plan outlining the steps taken when they are notified by staff or persons about possible abuse. Plan will be submitted to LPA via fax only by POC due date.

Deadline recorded: Nov 4, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency.....(D) Any incident which threatens the welfare, safety or health of any resident..... . This requirement was not met as by evidence: The facility had (3) residents diagnoses with scabies and did not report it to CCL. A case was open with the County of Los Angeles public health and CCL was not notified.

Official plan of correction

Administrator will ensure to report any cases of contagious diseases/infections to CCL immediatelty and provide all cross reporting information made to other agencies. Administrator will submit a plan stating what actions/steps will be taken when there is a case in the facility via fax by POC due date.

Deadline recorded: Nov 10, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...... This requirement was not met as evidence by: The Administrator was notified and aware about the sexual abuse Resident #9 was doing to other residents and did not take action to mitigate the abuse.

Official plan of correction

Administrator will ensure all residents are free from any type of abuse from staff or other residents. Administrator will create a plan outlining the steps taken when they are notified by staff or persons about possible abuse. Plan will be submitted to LPA via fax only by POC due date.

Deadline recorded: Nov 4, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...... This requirement was not met as evidence by: The facility allowed staff members to tie residents with bedsheets onto the back of their wheel chairs were it was not reachable for residents to un tie themselves.

Official plan of correction

Administrator will ensure no residents are tied with bedsheets and will conduct personal rights training with all staff. Administrator will provide proof of personal rights training conducted by POC due date. Administrator will submit proof via fax only to LPA.

Deadline recorded: Nov 5, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency.....(D) Any incident which threatens the welfare, safety or health of any resident..... . This requirement was not met as by evidence: The facility had (3) residents diagnosed with scabies and did not report it to CCL. A case was open with the County of Los Angeles public health and CCL was not notified.

Official plan of correction

Administrator will ensure to report any cases of contagious diseases/infections to CCL immediatelty and provide all cross reporting information made to other agencies. Administrator will submit a plan stating what actions/steps will be taken when there is a case in the facility via fax by POC due date.

Deadline recorded: Nov 10, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (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 ...... The licensing agency shall be authorized to require other additional documentation..... This requirement was not met as evidence by: The Administrator was allowing staff to put residents in Gerry chairs without a physcians order in place and tying residents with bedsheets without any orders.

Official plan of correction

Administrator shall ensure that all residents using a Gerry chair have an order prior to using the chair and will keep a copy of the order on their file. The facility will also request and submit a plan if they plan on using the chair for residents who do not have an order in place. Administrator shall read section 87608 of the CCR and submit a written, signed statement stating they have read and understood the section and will abide by it. Administrator will fax documents by POC due date.

Deadline recorded: Nov 10, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of..... The licensing agency may require any facility to provide additional staff whenever it determines..... . This requirement was not met as evidence by: The Administrator did not provide sufficient staff to assist all residents in care which resulted in residents not being assisted with their ADL's at times.

Official plan of correction

Administrator will reasses all current residents needs and assess new one's to determine the needs of residents and put a plan of action in place to ensure the facility has the appropriate staffing. Administrator will submit a staff schedule and a LIC 500 by POC due date via fax to LPA. Staffing agencies???

Deadline recorded: Nov 10, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468 Personal Rights (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 was not met as evidence by: The facility had dirty matresses, ripped box springs and broken closet room doors. Images also provided showed a resident sleeping on a matress on the floor without a bed frame

Official plan of correction

Administrator will ensure all resident have a bed frame and will replace or sanitize any dirty or ripped mattresses and/or box springs. Administrator will ensure extra bed frames and mattress are available on the premesis by POC due date and will submit proof via fax to LPA.

Deadline recorded: Nov 10, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(3)(D)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accomadations and Services (a) Living accommodations and grounds shall be related to the facility's function..... The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident.... (D) Hygiene items of general use such as soap and toilet paper. This requirement was not met as evidence by: Based on in interviews conducted the facility would run out of hygiene supply and when there was some it was inaccesible to staff, specially during the night shift. Residents had to share deodorant, shampoo, soap and hair brush's.

Official plan of correction

Administrator will purchase extra hygiene and ensure each resident has their own personal hygiene and ensure staff have access to the supply when needed. Administrator will submit picture of supply available to LPA via fax only by POC due date.

Deadline recorded: Nov 10, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87415(a)(2)

Regulation authority

CCR

What the official deficiency says

87415 Night Supervision (a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures,.... and shall be available as indicated below to assist in caring for residents in the event of an emergency. (2) In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake. Another employee shall be on call, and capable of responding within ten minutes. This requirement was not met as evidence by: Only one caregiver was on shift at night, several times and was not able to assist all residents with their ADL's

Official plan of correction

Administrator will ensure at least 2 staff are on shift when there is more than 14 residents at the facility or they determine they need 2 caregivers based on the residents needs. Administrator will send a signed statement stating their plan of action by fax by POC due date.

Deadline recorded: Nov 10, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (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 ...... The licensing agency shall be authorized to require other additional documentation..... This requirement was not met as evidence by: Staff at the facility were putting resident #1 in a Gerry chair and using the table tray without prior approval or physcians order.

Official plan of correction

Administrator shall ensure that all residents using a Gerry chair have an order prior to using the chair and will keep a copy of the order on their file. The facility will also request and submit a plan if they plan on using the chair for residents who do not have an order in place. Administrator shall read section 87608 of the CCR and submit a written, signed statement stating they have read and understoof the section and will abide by it. POC due by 11/01/2021.

Deadline recorded: Nov 1, 2021. A deadline is not proof that correction was completed.

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 and record review, the licensee did not comply with the section cited above by having the exterior gate locked with a chain and pad lock, and having the side gate door locked with on both sides with with a key. Based on interviews the gate door is locked at all time along with the gate and all caregivers have a key for the gate door. No fire clearance is on file with approval and licensing did not receive a request for the intent to lock all exterior gates and doors, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/01/2021 Plan of Correction Administrator will unlock exterior gate and door immediately. Will obtain approval from the Fire Department if they intent to lock the exterior gates and doors and will send their request to CCL prior to locking the gates and door.

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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. Resident #4 and #9 had half bed rails and both had orders on file for full bed rails, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/07/2021 Plan of Correction Administrator will obtain full bed rails for (R4) and (R7) and will send proof of correction to LPA by POC due date.

Official classification

Type B

Official code

87618(b)(5)

Regulation authority

CCR

What the official deficiency says

(5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment. 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 by not having previous training records on file for staff in regards to Oxygen administration and handling. (R4) and (R7) records indicate they have been receiving Oxygen since 2020. The facility only had a sign-in sheet with the topic of Oxygen for the year of 2021 which poses potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/07/2021 Plan of Correction Administrator shalll have all staff trained on Administration of Oxygen and will maintain records of training on file. Administrator will provide training to LPA by POC due date.

Official classification

Type B

Official code

87705(c)(6)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. 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. Resident #7 and #9 had missing reapprasails for previous years. (R7) had missing reappraisals for the year of 2018 and 2020. (R9) had missing reapprasails for the years of 2017 and 2018 which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/07/2021 Plan of Correction Administrator will send a written plan of as to how they will comply with this regulation and will ensure all reapprasails are completed and filed in the residents file.

Official classification

Type B

Official code

1569.695(a)(4)(B)

Regulation authority

HSC

What the official deficiency says

This requirement is not met as evidenced by: Upon reviewing the Emergency Disaster Plan for Residential Care For Residential Care Facilities for the Elderly (LIC 610E) it was incomplete with missing components and had an incorrect number for CCLD. Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2021 Plan of Correction Administrator will review the LIC 610E and ensure all emergency numbers are correct and missing components are completed along with verifying responsible members are current employees of the facility. Administrator will send updated LIC 610E to LPA by POC due date.

Official classification

Type B

Official code

15969.695(a)(7)(F)

Regulation authority

HSC

What the official deficiency says

This requirement is not met as evidenced by: Upon reviewing Emergency and Disaster Plan for Rseidential Care Facilities for the Elderly (LIC 610E) the facility did not have a plan in place for residents on oxygen in the event of disaster/emergency. LPA's verified Oxygen tanks which did not require electricity with the Med-Tech and Administrator. The facility only had (7) full tanks. Per Med-Tech and Administrator the tanks last anywhere from 6-8hrs. The facility has a total of (4) residents on Oxygen which would not be sufficient for 72 hours. Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2021 Plan of Correction The Administrator shall come up with a plan to ensure all residents who are on Oxygen, have available the adequate amount of oxygen for each resident for a period of 72hrs in the event of an emergency and will send the plan to LPA by the POC due date.

Official classification

Type B

Official code

15969.695(b)

Regulation authority

HSC

What the official deficiency says

This requirement is not met as evidenced by: Per Administrator and staff member only new hires are provided training and they do not provide the training annually. Administrator could not provide training material. Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2021 Plan of Correction The Administrator shall ensure all staff receive training annually. Administrator will provide training curriculume to the LPA by POC due date and proof of training conducted with all staff.

Official classification

Type B

Official code

15969.695(f)(2)(B)

Regulation authority

HSC

What the official deficiency says

This requirement is not met as evidenced by: The facility did not have keys available or a designated location for the keys of an emergency vehicle used to transport residents in the event of an evacuation. Deficient Practice Statement Based on observation, interviews and record review, the licensee did not comply with the section cited above which poses posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2021 Plan of Correction The Administrator shall have designate a vehicle and implement a location for the keys at the facility. Administrator will incorporate the information onto the plan and send the updated LIC610E to LPA by POC due date

Official classification

Type B

Official code

15969.695(a)(3)

Regulation authority

HSC

What the official deficiency says

This requirement is not met as evidenced by: The facility did not have an emerhency route listed on their LIC 610E. Per Administrator, the previous Administrator was working on the form and resigned without completing it. Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2021 Plan of Correction Administrator will create an emergency route and update their LIC 610E. Administrator will send the updated LIC 610E to the 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 5 bathrooms not being withing the required range per Title 22 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/02/2021 Plan of Correction Licensee shall adjust water temperatures for the whole facility to be within regulation limits of 105-120 degree F immediately. Licensee will monitor for 7 days straight and will document the readings. Licensee will send proof of correction by submitting the log to LPA upon completeing the 7 day log.

Official classification

Type A

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. 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 2 out of 10 residents did not have their medication labeled with their name which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/02/2021 Plan of Correction Licensee will label residents #4 and #6's medication and will ensure all medication is labeled with the appropiate residents name/information. Licensee will send picture of correction by POC due date

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 in 1 out of 4 staff records reviewed did not have a health screening form which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/10/2021 Plan of Correction Licensee will send LPA a copy of Staff #4's health screening form and will ensure all staff files have a copy of the form in their file.

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. Both linen closets on the left wing had what appeared to be rat droppings and bathroom in room #18 on the right side wing has a peeling boarder on the wall of the bathroom floor near the toilet which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/10/2021 Plan of Correction Licensee willl contact a exterminator to come and service the facility and will have the bathroom border/wall repaired. Licensee will send LPA a picture of the bathroom border/wall and a copy of the exterminator report.

Official classification

Type B

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Bathroom in room #4 was missing a non-skid mat which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/03/2021 Plan of Correction Licensee will ensure all bathrooms maintain a non-skid mat/skid. Licensee will send a picture of correction to LPA by POC due date.

Official classification

Type B

Official code

87303(i)(1)(A)

Regulation authority

CCR

What the official deficiency says

(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. 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 not having an operable call system that alerts staff which room needs assistance which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/15/2021 Plan of Correction Licensee will have the call system service and ensure all call systems in each room are working. Licensee shall send receipt of service by POC due date.

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Personal Rights and Community Care Licensing (CCL) " Let us no " (PUB 475) complaint poster was not present at the facility which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/02/2021 Plan of Correction Licensee shall post both, Personal Rights and CCL complaint poster. Licensee shall send pictures as proof of correction by POC due date. During the visit, staff posted complaint poster.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) A plan for incidental medical and dental care shall be developed by wach facility. The plan shall eencourage routine medical and dental care and provide for assistance in obtaining such care, by complaince with the following: (1) The licensee shall arranging, for medical and dental care appropriate to the conditions and needs of residents 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 2 out of 10 residents medications were not present at the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/02/2021 Plan of Correction Licensee shall obtain missing medication for both residents, Resident #6 and #9, and will send a picture of medication by POC due date to LPA.