DOWNEY RETIREMENT CENTER

Official classification

Type A

Official code

87465(h)(3)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (3) Each container shall carry all of the information specified in (6)(A) through (E) below plus expiration date and number of refills. This requirememt was not met as evidence by: Facility failed to have a separate container with the required information on the label for residents #1 and #2.

Official plan of correction

Facility to conduct a training for all staff that assist with medication and email a copy of the training log to LPA by POC due date. (on 9/12/25 LPA received a copy of the medication training log, training was conducted on 9/9/25).During todays visit LPA reviewed PRN medications for R1-R3, all PRN's were accounted for with proper lables and listed on the eMAR. POC is cleared no further action is needed.

Deadline recorded: Feb 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 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: (4) The licensee shall assist residents with self-administered medications as needed. This requirememt was not met as evidence by: Facility failed to obtain a Discontinue Order and centrally store R1 and R3’s PRN medications.

Official plan of correction

Facility to conduct a training for all staff that assist with medication and email a copy of the training log to LPA by POC due date (on 9/12/25 LPA received a copy of the medication training log, training was conducted on 9/9/25).During todays visit LPA reviewed PRN medications for R1-R3, all PRN's were accounted for with proper lables and listed on the eMAR. POC is cleared no further action is needed.

Deadline recorded: Feb 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)(A-E)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication. This requirememt was not met as evidence by: Facility failed to list R1 and R2’s medication on the eMAR

Official plan of correction

Facility to conduct a training for all staff that assist with medication and email a copy of the training log to LPA by POC due date (on 9/12/25 LPA received a copy of the medication training log, training was conducted on 9/9/25). During todays visit LPA reviewed PRN medications for R1-R3, all PRN's were accounted for with proper lables and listed on the eMAR. POC is cleared no further action is needed.

Deadline recorded: Feb 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by: Deficient Practice Statement Based on medication review, the licensee did not comply with the section cited above as LPA found that there were missing medications for 3 out of 10 residents during medication review. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2025 Plan of Correction Administrator/Licensee to provide proof that medication is on order for the residents missing medications via email by POC due date (LPA emailed a list of resident names and missing medications to Administrator and created an 812 with information). To clear POC LPA is asking that there be an staff training on medication (for staff that assist with medication) and email a copy of the training log participant list with signatures to LPA by 9/12/25.

Official classification

Type B

Official code

87463(i)

Regulation authority

CCR

What the official deficiency says

(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above as during record review LPA observed 4 resident files that were missing their yearly reappraisal, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/12/2025 Plan of Correction Administrator/Licensee to email a copy of the updated reappraisal/needs and service plan to LPA by POC due date. (LPA provided a list of names to Administrator via email for residents that are missing their reappraisals)

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 was not met as evidenced by: documentation of staff training records did not reflect number of training hours per subject. This poses a potiential health, safety, or Personal Rights risk to persons in care.

Official plan of correction

*NO FURTHER ACTION REQUIRED. POC CLEARED on 8/12/25* Administrator Mendibles emailed plan that outlines steps the facility will take to ensure staff training hours are documented according to regulations noted in Title 22. Email was received 7/3/25.

Deadline recorded: Aug 12, 2025. 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

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: rooms 202,210,211,223 234 and 124 are not kept sanitary due to onging insect infestation. This poses a potiential health, safety, or Personal Rights risk to persons in care.

Official plan of correction

*NO FURTHER ACTION REQUIRED. POC CLEARED* Staff agreed to send a plan to address how the facility plans to keep these rooms sanitary and free of insects. Proof must be sent via email to LPA Ramirez.

Deadline recorded: Aug 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidenced by: based on records reviewed caregivers did not receive annual training as specified in H & S 1569.625 and 1569.69. This poses a potiential health, safety, or Personal Rights risk to persons in care.

Official plan of correction

*NO FURTHER ACTION REQUIRED. POC CLEARED*Administrator will certify plan on how caregivers will receive initial and annual training according to this regulation. Plan must be received by 7/7/25.

Deadline recorded: Aug 12, 2025. 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

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: rooms 202,210,211,223 234 and 124 are not kept sanitary due to onging insect infestation. This poses a potiential health, safety, or Personal Rights risk to persons in care.

Official plan of correction

*NO FURTHER ACTION REQUIRED. POC CLEARED* Staff agreed to send a plan to address how the facility plans to keep these rooms sanitary and free of insects. Proof must be sent via email to LPA Ramirez.

Deadline recorded: Jul 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidenced by: based on records reviewed caregivers did not receive annual training as specified in H & S 1569.625 and 1569.69. This poses a potiential health, safety, or Personal Rights risk to persons in care.

Official plan of correction

*NO FURTHER ACTION REQUIRED. POC CLEARED*Administrator will certify plan on how caregivers will receive initial and annual training according to this regulation. Plan must be received by 7/7/25.

Deadline recorded: Jul 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(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 was not met as evidenced by: documentation of staff training did not reflect number of training hours per subject. This poses a potiential health, safety, or Personal Rights risk to persons in care.

Official plan of correction

*NO FURTHER ACTION REQUIRED. POC CLEARED*Administrator will certify plan on how the facility will document training hours for staff. Plan must be received by 7/7/25.

Deadline recorded: Jul 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

(b)The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement was not met as evidenced by: on 5/28/25, massive roach infestation was observed in the facility kitchen area. This poses a immediate risk to the health, safety, or personal rights of persons in care.

Official plan of correction

Staff agreed to send a plan to address how the facility plans to keep the kitchen area free from insects by 6/29/25. Proof from pest control services that the facility kitchen area is free from insects, is due by July 7, 2025. Proof must be sent via email to LPA Ramirez.

Deadline recorded: Jun 29, 2025. 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

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: rooms 202,210,211,223 234 and 124 are not kept sanitary due to roaches infestation not being kept under control. LPA Ramirez observation of live roach in trap. Staff not adhereing to pest control recommendations to rid theses rooms of insects.

Official plan of correction

Staff agreed to send a plan to address how the facility plans to keep these rooms sanitary. Proof must be sent via email to LPA Ramirez.

Deadline recorded: Jul 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met as evidenced by: based on records reviewed caregivers did not receive annual training as specified in H & S 1569.625 and 1569.69.

Official plan of correction

Administrator will certify plan on how caregivers will receive initial and annual training according to this regulation. Plan must be received by 7/7/25.

Deadline recorded: Jul 7, 2025. A deadline is not proof that correction was completed.

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 was not met as evidenced by: documentation of staff training did not reflect number of training hours per subject.

Official plan of correction

Administrator will certify plan on how the facility will document training hours for staff. Plan must be received by 7/7/25.

Deadline recorded: Jul 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

Oxygen Administration - Gas and Liquid. (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: Based on observation, resident room 109 has an oxygen tank in the room, and a " No Smoking-Oxygen in Use " sign was not posted outside resident room door and not at appropriate areas, which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Administrator shall ensure that a No Smoking-Oxygen in Use sign is posted on resident door or appropriate areas when oxygen tanks are used inside the room. Submit picture proof that the signs are posted.

Deadline recorded: Jan 28, 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 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: (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 was not met as evidence by: The Department received a Special Incident Report on 5/21/24 stating that on 5/18/24 R1 sustained injuries and was sent to the hospital after being experiencing a unwitnessed fall when S1 left R1 unattended during a shower for approximately 5 minutes. Interviews with Administrator and S1 confirmed this story as well as record review of both S1 and R1.

Official plan of correction

Licensee/Administrator to retrain all staff in assisting Residents with Activities of Daily Living (ADL's) and training on proper procedures to take when a back up caregiver assistance is needed. Copy ot the training materials along with the date trainings will be conducted, must be emailed to LPA by 6/1/21. tena.herrera@dss.ca.gov

Deadline recorded: Jun 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

Observation of the 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 unmet needs.....the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement has not been met as evidenced by: Based on medical record review and interviews, staff failed to provide provide adequate care and supervision, which resulted in injuries to R1 that required hospitalization. This is an immediate health and safety risk to the residents in care.

Official plan of correction

Administrator agress to: 1. Conduct staff training on regulation 87466 and staff communication protocols regarding changes in residents conditions. 2. Submit a written plan by tomorrow how the deficiency will be corrected. 3. Submit proof that staff were trained by 9/14/2023.

Deadline recorded: Sep 8, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87101(c)(3)(A)

Regulation authority

CCR

What the official deficiency says

Definitions. " Care and Supervision " means those activities which if provided shall require the facility to be licensed... " Care and Supervision " shall include, but not be limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents: (A) Assistance in dressing, grooming, bathing and other personal hygiene; This requirement was not met evidenced by: Per record review & photographs, caregiver staff failed to provide assistance services as indicated on Resident Appraisal dated 3/30/2021; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agreed to submit a care plan that addresses care responsibilities/protocols for residents with declining/change in health conditions. Submit POC by tomorrow.

Deadline recorded: Sep 8, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements: (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents... This requirement is not met as evidence by: Based on observation Licensee did not ensure staff properly stored and disposed of expired/best by food items wich poses a potential personal right, health, or safey risk to the persons in care.

Official plan of correction

Administrator will provide in-service training to kitchen staff regarding quality of food, storing, disposing, shelf life of food items, and will submit a copy of in-service training with topic, duration of training, and sign-in log by POC due date 7/14/23.

Deadline recorded: Jul 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental, Medical, and Dental: (h) The following requirements shall apply: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision. This requirement is not met as evidence by: Based on document review staff did not properly stored medication which poses an immediate risk to the safety, health, or personal rights to the persons in care.

Official plan of correction

Administrator will scheduel in-service by 7/8/23, will provide in-service training to Medication technicians and will submit a copy of in-service training with topic, duration of training, and sign-in log to the department by 7/14/23.

Deadline recorded: Jul 8, 2023. 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 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: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: 2 out of 10 Residents interviewed indicate Staff has handled them in a rough manner.

Official plan of correction

Licensee shall provide additional training to Staff in regards to the handling of Residents. LIcensee shall provide proof of training to the department by the POC date.

Deadline recorded: May 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(g)(2)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This deficiency was evidenced by the following: Records reviewed S1 was hired on 10/4/19. Facility did not request fingerprint transfer until 6/18/20. S1's fingerprints were never associated to this facility. Staff also confirmed S1 was a staff member at the facility.

Official plan of correction

Facility will certify all staff will have a fingerprint clearance and will be associated to the facility prior to employment or initial presence in the facility. It should be noted, S1 no longer works for the facility as of July 2020. Civil penalties were issued in the amount of $500.

Deadline recorded: Apr 6, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

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:(5) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Resident #1 did not receive their medication from Dec. 01, 2021 to Dec. 06, 2021 because facility was not able to obtain refill authorization from doctor.

Official plan of correction

Licensee shall provide additional training to all Staff responsible for medication assistance and provide proof to the department by the POC date.

Deadline recorded: Dec 14, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by: Resident #1's prescription medications were not refilled in a timely manner causing Resident #1's prescription medications not being administered from Dec. 01, 2021 to Dec. 06, 2021.

Official plan of correction

Licensee shall revise Medication Plan of Operation to ensure that future medication refills are requested and obtained in a timely manner.

Deadline recorded: Dec 14, 2021. A deadline is not proof that correction was completed.