ACACIA GUEST HOME

Official classification

Type B

Official code

87413(a)(2)

Regulation authority

CCR

What the official deficiency says

87413 Personnel - Operations (a) In each facility: (2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. This requirement is not met as evidenced by: Based on interviews, the Administrator did not comply with the section cited above in which staff admitted to pinching R1’s cheek/face which poses a potential health, safety or personal rights risk to residents in care

Official plan of correction

Administrator agreed to submit a signed self-certification that they have read, reviewed and understood Title 22 Regs. 87413. Additionally, the administrator will conduct staff training about personal rights (Section 87468.1) and personnel requirements (Section 87413). Self-certification and in service training log signed/dated by staff shall be submitted by POC due date

Deadline recorded: Jun 26, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(c)(1)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) There is written direction from a physician, on a prescription blank....instructions regarding a time or circumstance (if any) when it should be discontinued,...(2) Once ordered by the physician the medication is given....(3) A record of each dose is maintained in the resident's record.... include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by: Based on observation, interviews and records review, the Administrator did not comply with the section cited above in which the medication administration records (MARs) for R1-R5 were outdated, incomplete, and medication administration were not recorded timely with several entries lacking the required staff initials verifying administration. which poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

Administrator agreed to re-train staff on the right procedure for recording MARs and proper medication administration to residents as prescribed by their Physicians. Administrator to submit in service training log along with topics discussed by POC due date.

Deadline recorded: Jun 26, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews and records review, the Administrator did not comply with the section cited above in which staff admitted and had been witnessed to use double diapers to (3) incontinent residents and there was no record or log for toileting assistance, repositioning or continence care plan which poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

Administrator agreed to submit a signed self-certification that they have read, reviewed and understood Title 22 Regs. 87468.1. Additionally, the administrator will develop and maintain a record or log for toileting assistance, repositioning and incontinence care plan for the residents. Both documents shall be submitted by POC due date.

Deadline recorded: Jun 26, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional 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: (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on observation, interviews, records review, the Administrator did not comply with the section cited above in which the residents were neglected as they were kept confined in their rooms, and were not provided a variety of planned activities which poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

Administrator to ensure that residents will not be confined in their rooms, staff provide activities, care and supervision necessary to meet their needs, and to review and understand the Title 22 regs. 87468.2. Administrator to develop daily planned activities for the residents which will be posted in the facility and will send a copy to CCL/LPA by POC due date.

Deadline recorded: Jun 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that there are toxins, garden materials in the backyard that were exposed and accessible to residents. Additionally, a gallon of bleach was out and used as door stopper in the kitchen which poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 03/07/2026 Plan of Correction Administrator will re-train staff about locking toxins, poisonous substances in a locked storage inaccessible to residents. In service training log shall be sent to CCL/LPA by POC due date.

Official classification

Type A

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

(g) All personnel records shall be maintained at the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above in that (3) out of (4) staff did not have a complete Personnel record on file which poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 03/09/2026 Plan of Correction Administrator to send completed personnel records of all (3) staff members to CCL/LPA by POC due date.

Official classification

Type A

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews and review of documentation, R1-R5's Medication Administration Record (MAR) for March 2026 is inaccurate. MAR for March 2026 shows that staff initialed the medication log for March 6, 2026 - March 7, 2026 even if the medications were not administered yet. Additionally, some of the residents morning medications were administered for March 6, 2026 but not properly initialed/documented on MAR which posed an immediate health and safety risk to residents in care.

Official plan of correction

POC Due Date: 03/09/2026 Plan of Correction Administrator shall ensure that the Medication Administration Records (MARs) are accurate for all residents. Administrator agreed to submit a plan of correction to avoid improper documentation of Medication Administration Record (MAR) and prevent medication errors.Additionally, all facility staff in charge of medication management shall be re-trained on Medication Management & proper documentation. A copy of the in-service training form along with topics discussed and signatures of staff present will be submitted to CCL/LPA by POC due date.

Official classification

Type B

Official code

87303(f)

Regulation authority

CCR

What the official deficiency says

(f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that the backyard was observed to be disorganized with miscellaneous junk and toxic materials around the area which poses/posed a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 03/20/2026 Plan of Correction Administrator clean up the backyard and store toxic materials in a locked cabinet. Administrator to send photos of the cleared backyard to CCL/LPA by POC due date.

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, the licensee did not comply with the section cited above in that there are no working auditory devices in the exit points which poses/posed a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 03/20/2026 Plan of Correction Administrator to install buzzers/auditory devices on all exit doors/points and send photos as proof to CCL/LPA by POC due date.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in that (3) out of (4) staff working in the facility do not have cardiopulmonary resuscitation (CPR) training and first aid training which poses/posed a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 03/20/2026 Plan of Correction Administrator will send proof of enrollment for first aid/CPR training for (1) day shift staff and (1) night shift staff to LPA by POC due date.

Official classification

Type B

Official code

87412(a)

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: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 2 out of 3 staff which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/25/2025 Plan of Correction The licensee shall ensure each staff has a personnel record/job application on file. The personnel record for Staff #2 and #3 shall be submitted to LPA by 3/25/25.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive 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 1 out of 3 staff which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 03/25/2025 Plan of Correction The licensee shall ensure all staff providing care receive first aid training. The POC for Staff #3 shall be submitted to LPA by 3/25/25.

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. 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 3 staff which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 03/25/2025 Plan of Correction The licensee shall ensure staff #3 receives a TB test and provide the results to LPA by 3/25/25.

Official classification

Type B

Official code

87307(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (a) Living accommodations and grounds...(2) Resident bedrooms shall be provided...(B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This requirement is not met as evidenced by: Based on observation, Resident #1 was moved to a dining room area per the facility sketch which poses a potential personal rights risk to residents in care.

Official plan of correction

The licensee will appropriately place Resident #1 in a resident room as indicated on the facility sketch. The licensee will also provide photos of all resident #1's belongings removed from the room. This POC is due by 8/15/24. **A civil penalty has been issued due to a repeated violation.

Deadline recorded: Aug 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (a) Living accommodations and grounds...(2) Resident bedrooms shall be provided...(B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This requirement is not met as evidenced by: Based on observation, Resident #1 was moved to a dining room area per the facility sketch which poses a potential personal rights risk to residents in care.

Official plan of correction

The licensee shall appropriately place Resident #1 in a resident room as indicated on the facility sketch. The licensee shall submit a statement acknowledging this regulation has been read. The licensee will also provide photos of the resident #1's belongings removed from the common area and into an assigned room. This POC is due by 5/2/24.

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

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports... 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 which 3 out of 6 residents' medications were not properly administered as prescribed nor properly documented which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/10/2024 Plan of Correction The licensee shall conduct a staff training on medication distribution and documentation. The log shall be submitted to LPA by 4/10/24.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in which 3 out of the 3 staff files reviewed did not have current CPR/first aid certification which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/07/2023 Plan of Correction Licensee shall arrange CPR/First Aid course for all employees who have expired certificates and submit proof of certification by 4/7/23.

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 in 3 out of 3 staff files did not have the number of training hours required annually which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2023 Plan of Correction The licensee shall review all staff (including Administrator) files to ensure the required training hours are maintained. The POC is due 3/31/23.

Official classification

Type B

Official code

87456(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 1 out of the 5 resident files reviewed did not have the current physician's report which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2023 Plan of Correction The licensee shall obtain a current medical assessment for resident #5 by POC due date 3/31/23.

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 in which the complaint poster was not posted at the facility which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2023 Plan of Correction The licensee shall submit proof that the RCFE Complaint Poster is posted by the main entryway of the facility by 3/31/23.

Official classification

Type B

Official code

87506(b)(10)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (10) Reports of the medical assessment specified in Section 87458 Medical Assessment, and of any special problems or precautions. This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed, the licensee did not comply with the section cited above in 2 out of 5 resident records which poses a potential health, safety or personal rights risk to persons in care. Resident #1 (R1) was admitted on 6/6/21 and did not have a physician's report on file. Resident #2 (R2) was admitted on 9/1/21 and did not have a physician's report on file.

Official plan of correction

POC Due Date: 04/08/2022 Plan of Correction Facility will provide proof of recent physician's report for both residents. Proof is due by 4/8/22.