Hazardous items and storageType A
- 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 the observation, the licensee did not comply with the section cited above in one out of one cabinet of knives were not locked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 04/28/2026 Plan of Correction The administrator/Licensee will make sure that the cabinets that have knives are kept locked and inaccessible to all residents and visitors.
Staffing, personnel, and trainingType A
- Official classification
- Type A
- Official code
- 87412(a)(13)
- 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: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: This requirement is not met as evidenced by: Deficient Practice Statement Based on the record review the licensee did not comply with the section cited above in two (2) out of three (3) staff did not have their fingerprint/Criminal Clearance at the facility which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 04/28/2026 Plan of Correction The administrator/Licensee will make sure that all staff working at the facility are fingerprinted have criminal clearance.
Health conditions and treatmentsType A
- Official classification
- Type A
- Official code
- 87615(a)
- Regulation authority
- CCR
What the official deficiency says
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: This requirement is not met as evidenced by: Deficient Practice Statement Based on the observation the licensee did not comply with the section cited above in one (1) out of five (5) residents had a feeding tube which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 04/28/2026 Plan of Correction The administrator/Licensee will make sure that the resident that has the feeding tube is returned to a hospital or/and the feeding tube is removed per doctor's orders.
Licensing and administrationType B
- Official classification
- Type B
- Official code
- 1569.605
- Regulation authority
- HSC
What the official deficiency says
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Deficient Practice Statement Based on the record review the licensee did not comply with the section cited above in there was no liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/11/2026 Plan of Correction The administrator/Licensee will make sure that the liability insurance is sent to the Woodland Hills Regional Office/Community Care Licensing Department
Licensing and administrationType B
- 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 the record review the licensee did not comply with the section cited above in three (3) out of three (3) staff did not have CPR/First Aid which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/11/2026 Plan of Correction The administrator/Licensee will make sure that the all staff receive CPR/Firstaid and put it in their file.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(f)
- Regulation authority
- CCR
What the official deficiency says
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by: Deficient Practice Statement Based on the record review the licensee did not comply with the section cited above in there was no staff files to review at the above facility for stafff that were working which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/11/2026 Plan of Correction The administrator/Licensee will make sure that the all staff files are kept at the facility for inspection/audit for the licensing agency/department to review.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(a)(11)
- Regulation authority
- CCR
What the official deficiency says
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on the record review the licensee did not comply with the section cited above in there was no health screening for any of the staff that were present at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/11/2026 Plan of Correction The administrator/Licensee will make sure that the all staff files have health screening for each staff present at the facility.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(d)
- Regulation authority
- CCR
What the official deficiency says
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by: Deficient Practice Statement Based on the record review the licensee did not comply with the section cited above in there was no staff that had their training which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/11/2026 Plan of Correction The administrator/Licensee will make sure that the all staff files have staff training for each staff present at the facility.
Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87506(b)(15)
- Regulation authority
- CCR
What the official deficiency says
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on the record review the licensee did not comply with the section cited above in that one (1) resident out of five (5) residents did not have an admission agreement/Pre-Admission Appriasal which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/11/2026 Plan of Correction The administrator/Licensee will make sure that one (1) resident out of the five (5) residents have their admission agreement/Pre-Admission Appriasal paperwork in their file.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87458(a)
- Regulation authority
- CCR
What the official deficiency says
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on the record review the licensee did not comply with the section cited above in there was one (1) physician's report/medical assessment missing from a resident which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/11/2026 Plan of Correction The administrator/Licensee will make sure that one (1) resident out of the five (5) residents have their physician report/medical assessment paperwork in their file.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(a)
- Regulation authority
- CCR
What the official deficiency says
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on the record review, the licensee did not comply with the section cited above in two (2) out of five (5) residents were missing resident appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/11/2026 Plan of Correction The administrator/Licensee will make sure that two (2) residents out of the five (5) residents have their resident appraisal paperwork in their file.