ENCINO TERRACE SENIOR LIVING

Official classification

Type A

Official code

87468.2(4)

Regulation authority

CCR

What the official deficiency says

Additional 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 interview and records review licensee did not comply with the section cited above. Facility failed to provide adequate supervision to prevent R1 from leaving the facility unsupervised. This poses an immediate health, safety or personal rights risk to persons in care

Official plan of correction

Licensee/Administrator to conducted in service training for all staff. Staff attendance sheet will be submitted to LPA by 06/08/26. In addition, Licensee/administrator will update R1's Appraisal Needs/services plan and send to LPA by POC due date: 06/08/26.

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

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care Services. [...]Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met base on information obtained during investigation: Staff #1 dispensed R1’s morning medications twice.This duplicate medication administration posed a potential health and safety risk to R1.

Official plan of correction

All Med Techs will receive refresher training on proper dispensing, verifying prior administration, documentation, and de escalation. POC:04/24/26

Deadline recorded: Apr 24, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)(3)

Regulation authority

CCR

What the official deficiency says

87468.1 (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, […](3)to be free from […] actions of a punitive nature […] This requirement has not been met based on resident did not give consent to touch/move belongings which poses a potential risk on residents in care.

Official plan of correction

All staff will receive immediate training on Personal Rights (87468) and Safeguarding Resident Property (87218), with emphasis on obtaining resident or responsible person consent before touching/moving belongings. POC Due Date: 05/01/26

Deadline recorded: Apr 24, 2026. 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 [...] Additional staff shall be employed as necessary to perform office work[...]The licensing agency may require any facility to provide additional staff whenever it determines [...]the needs of particular residents This requirement was not met based on licensing staff observation at time of visit which poses risk for residents in care.

Official plan of correction

Licensee/Administrator will provide hiring plan to LPA POC: 04/09/26

Deadline recorded: Apr 8, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87212(a)

Regulation authority

CCR

What the official deficiency says

87212 Emergency Disaster Plan. (a)Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available. (2) Plan for evacuation including: (A) Fire safety plan This requirement was not met based on licensing staff observation at time of visit which poses risk for residents in care.

Official plan of correction

Licensee/Administrator will provide Emergency disaster plan to LPA POC: 04/09/26

Deadline recorded: Apr 8, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (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 licensing agency staff This requirement was not met based on licensing staff observation at time of visit which poses a potential risk for residents in care.

Official plan of correction

Licensee/Administrator will submit plan on how to ensure resident records update and readily available for review POC: 04/17/26

Deadline recorded: Apr 17, 2026. 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

Eviction Notification (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5).[...]This is evidenced by: The Administrator failed to have R1 reassessed and failed to provide any warning notices or documentation that R1 is out of medical compliance, has any current behavior changes and/or is not following community rules.

Official plan of correction

Administrator will need to provide current reappraisal for R1, review Title 22 regarding Eviction process, provide plan on how to ensure residents that are not enrolled in facility managed care program remain compliant to include medically compliant. POC: 04/10/26

Deadline recorded: Apr 10, 2026. 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

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 has not been met based on Interviews and executive director admission hiring more staff which poses health and safety risk to the residents in care

Official plan of correction

Licensee will ensure additional staff is hired if required. The staff schedule and written information must be provided explaining the steps taken by the Administrator. POC:04/10/26

Deadline recorded: Apr 10, 2026. 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

Eviction Notification (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5).[...]This is evidenced by: The Administrator failed to have R1 reassessed and failed to provide any warning notices or documentation that R1 is out of medical compliance, has any current behavior changes and/or is not following community rules.

Official plan of correction

Administrator will need to provide current reappraisal for R1, review Title 22 regarding Eviction process, provide plan on how to ensure residents that are not enrolled in facility managed care program remain compliant to include medically compliant. POC: 04/10/26

Deadline recorded: Apr 10, 2026. 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

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 has not been met based on Interviews and executive director admission hiring more staff which poses health and safety risk to the residents in care

Official plan of correction

Licensee will ensure additional staff is hired if required. The staff schedule and written information must be provided explaining the steps taken by the Administrator. POC:04/10/26

Deadline recorded: Apr 10, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

80087(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement has not been met as evidenced by: Based on interviews and observation the floors in the facility (R1 room/3rd floor) are uneven which pose an immediate health and safety risk to residents in care.

Official plan of correction

The Licensee will obtain an inspection for the facility floors (carpeted) and provide a plan to repair/correct uneven floors within the facility POC: 02/09/26.

Deadline recorded: Feb 9, 2026. 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

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 has not been met based on: Interviews staff informed licensee need more staff/only two staff on Sunday Pm for resident assistance which poses health and safety risk to the residents in care.

Official plan of correction

Licensee will ensure additional staff is hiired if required. The staff schedule and written information must be provided explaining the steps taken by the Administrator. POC:02/20/26

Deadline recorded: Feb 17, 1984. 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

This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the section cited above due to 3rd floor carpet heavly stained, and paint on doors chipped which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/12/2025 Plan of Correction Administrator agreed to have carpet professionally cleaned and will provided corrective plan to address the room doors.

Official classification

Type B

Official code

87224(a)

Regulation authority

CCR

What the official deficiency says

Eviction Notification (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5).[...]This is evidenced by: The Administrator failed to have R1 reassessed and failed to provide any warning notices or documentation that R1 is out of medical compliance, has any current behavior changes and/or is not following community rules.

Official plan of correction

Administrator will need to provide current reappraisal for R1, review Title 22 regarding Eviction process, provide plan on how to ensure residents that are not enrolled in facility managed care program remain compliant to include medically compliant. POC: 10/01/25

Deadline recorded: Oct 1, 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

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met by: Based on the observations, the administrator/licensee did not comply with the section cited above in the areas of the elevator not working which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Administration/Licensee will need to keep the elevator in good repair at all times. POC Cleared at time of visit: 04/07/25

Deadline recorded: Apr 28, 2025. 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 acc...This requirement is not met by: Based on the observations, the administrator/licensee did not comply with the section cited above in the areas of construction/ passageways were not free of hazards, exposing of electrical wires/outlets which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Administration/Licensee will need to keep the passageways, electrical outlets covered, electrical wires not being exposed and send a picture to the LPA when the project/construction is completed. POC Due Date:04/21/25

Deadline recorded: Apr 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.695(g)

Regulation authority

HSC

What the official deficiency says

HSC1569.695- Emergency Plans(g) A facility shall make the plan available upon request to residents onsite, any responsible party for a resident, the local long-term care ombudsman, and local emergency responders...This requirement is not met by: Based on the observations, the administrator/licensee did not comply with the section cited above in the areas of the Emergency Plan not being available upon request which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Administration/Licensee will need to have the Emergency Plan available upon request: POC Due Date: 04/28/25

Deadline recorded: Apr 28, 2025. A deadline is not proof that correction was completed.