VILLA VICTORIA

Official classification

Type A

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. 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 LPA observed live roach activity in kitchen drawers, kitchen cabinets and on dining room table which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2026 Plan of Correction Licensee agreed to schedule pest control service to treat the facility for live roach/insect activity. Licensee agreed to submit to LPA via email the date of scheduled service by POC due date.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (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 of the centrally stored medication. 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 LPA observed Lispro Insulin injections in the refrigerator door, not in a locked place making them accessible to persons other than employees which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2026 Plan of Correction Corrected at the time of visit. Licensee placed Lispro Insulin injections in a lock box and placed them back in the refrigerator.

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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 LPA observed pill boxes labeled with days of the week and residents names and 3 of 5 pill boxes contained pills which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2026 Plan of Correction Corrected at the time of visit. Staff removed the pills and pill boxes.

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 3 staff files reviewed did not contain TB clearance which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2026 Plan of Correction Licensee agreed to submit proof to LPA once TB clearance is obtained for S1. Licensee will submit proof via email by POC due date.

Official classification

Type B

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 record review, the licensee did not comply with the section cited above in 1 out of 3 staff files reviewed were not maintained at the facility which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2026 Plan of Correction Licensee will print documents and maintain a personnel record for the administrator at the facility.

Official classification

Type B

Official code

87506(b)(17)(B)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (B) Section 87459, Functional Capabilities; 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 5 out of 5 residents files reviewed did not contain functional capabilities assesment which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2026 Plan of Correction Licensee will complete the functional capabilities for 5 out of 5 residents and submit to LPA by POC due date.

Official classification

Type B

Official code

87506(b)(17)(E)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (E) Section 87463, Reappraisals; and 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 5 resident files reviewed did not contain reappraisals which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/14/2026 Plan of Correction Reappraisals shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first. Licensee will submit to LPA via email a reappraisal for R4 by POC due date.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(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 for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. 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 4 out of 5 resident beds had half bed rails and no physician's orders for bedrails in their facility file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/30/2026 Plan of Correction Corrected at time of visit. Staff removed bed rails from all residents beds. Licensee agreed to obtain physician's orders prior to using bed rails.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (1) Nonambulatory persons. This requirement was not met as evidence by:

Official plan of correction

Licensee is operating beyond approved fire clearance. Licensee will contact Fire Department and notify regarding fire clearance, and apply and receive approvement of for fire clearance or obatin new medical assessment of residents in question. Licensee will provide LPA Ramirez with contact name, and phone number of fire personnel that was notified regarding fire clearance. Licensee must submit POC via email.

Deadline recorded: Jul 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(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 is not met as evidenced by: Licensee did supply nonperishables but did not send proof of retraining by 7/22/2024.

Official plan of correction

Licensee will send proof of retraining on this regulation by 7/24/2024 via email.

Deadline recorded: Jul 24, 2024. 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

(h) The following requirements shall apply to medications which are centrally stored: (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 of the centrally stored medication. This requirement is not met as evidenced by: Licensee secured medication in fridge but did not send retraining by 7/22/2024.

Official plan of correction

Licensee will retrain staff on this regulation by 7/24/2024.

Deadline recorded: Jul 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (1) Nonambulatory persons. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, 4 out of the 6 residents are nonambulatory, facility may only retain 3 nonambulatory, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/22/2024 Plan of Correction Licensee will contact Fire department for new fire clearance or submit new medical assessment for residents and send proof to LPA Ramirez by POC date.

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, LPA Ramirez observed 7 previously opened bags sandwich bread and 1 bag cookies, that smelled rancid, the licensee did not comply with the section cited above in 6 out of 6 residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/22/2024 Plan of Correction Staff removed rancid food during inspection. Licensee will retrain staff on this regulation and send proof to LPA Ramirez by 8/2/2024. Proof must be submitted via email.

Official classification

Type A

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(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 is not met as evidenced by: Deficient Practice Statement Based on observation, minimum of one week or nonperishable food for 6 residents was not observed, the licensee did not comply with the section cited above in 6 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/22/2024 Plan of Correction Licensee will purchase nonperishables for a minimum of one week for 6 residents and will retrain staff on this regulation by 7/22/2024. LPA Ramirez will return to clear deficiency.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (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 of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, 2 out of the 6 residents had medication stored in the fridge that was accessible to residents and visitors, the licensee did not comply with the section cited above in 6 out of 6 residents and visitors which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/22/2024 Plan of Correction LIcensee will secure medications that must be refrigerated and retrain staff on this regulation. Licensee will submit proof via email.

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, Smell of urine omitting from #5, Blinds missing and broken in room#5, Broken and disgarded fridge in backyard, Bubbling, peeling and yellow-brown on ceiling in livingroom area the licensee did not comply with the section cited above in 6 out of 6 residents, staff and/or visitors which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/02/2024 Plan of Correction Licensee will clean and disinfect room# 5, replace or replair window blinds in room#5, remove dicarded fridge from backyard, repair ceiling in livingroom area by 8/2/2024. LPA Ramirez will return to clear deficiency.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, room#5 window screens were observed to contain dust debris, the licensee did not comply with the section cited above in 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/02/2024 Plan of Correction Licensee will clean screens and keep them clean by 8/2/2024. Licensee will retrain staff on this regulation. Proof of retraining must be submitted by 8/2/2024. LPA Ramirez will return to clear deficiency.

Official classification

Type B

Official code

87303(g)(1)

Regulation authority

CCR

What the official deficiency says

(g) Facilities which have machines and do their own laundry shall: (1) Have adequate supplies available and equipment maintained in good repair. Space used to sort soiled linen shall be separate from the clean linen storage and handling area. Except for facilities licensed for fifteen (15) residents or less, the space used to do laundry shall not be part of an area used for storage of anything other than clean linens and/or other supplies normally associated with laundry activities. Steam, odors, lint and objectionable laundry noise shall not reach resident or employee areas. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interviews, facility dryer has been in disrepair for months, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/02/2024 Plan of Correction Licensee will repair or place dryer ny 7/26/2024. LPA Ramirez will return to clear deficiency.

Official classification

Type B

Official code

87555(b)(21)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (21) Freezers of adequate size shall be maintained at a temperature of 0 degree F (-17.7 degree C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degree F. (4 degree C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, freezer and fridge were observed to contain dead insects, hair and food debris on the floor of fridge and freezer the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/02/2024 Plan of Correction Licensee will clean facility fridge and freezer. LPA Ramirez will return to clear deficiency.

Official classification

Type B

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 is not met as evidenced by: Deficient Practice Statement Based on observation, live and dead insects were observed in kitchen cabinets, the licensee did not comply with the section cited above in 6 out of 6 residents, staff and/or visitors which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/02/2024 Plan of Correction Licensee will submit pest control services plan by 8/2/2024 and submit via email to LPA Ramirez.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(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 as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, R1's last medical assessment in R1's file was dated 2019, the licensee did not comply with the section cited above in 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/02/2024 Plan of Correction Licensee will obtain new medical assessment for R1 and retrain staff on this regulation by 8/2/2024. Proof must be submitted via email.

Official classification

Type B

Official code

87705(8)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (8) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, present staff could not locate drills or recall drill being conducted in the last three months, the licensee did not comply with the section cited above in 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/02/2024 Plan of Correction Licensee will retrain staff on this regulation and conduct and document drill. Proof must be submitted via email.

Official classification

Type A

Official code

87618(b)(3)(C)

Regulation authority

CCR

What the official deficiency says

87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611 (3) Ensuring that the use of oxygen equipment...(C) Smoking shall be prohibited where oxygen is in use. This requirement is not met as evidenced by: Based on observation, the licensee did not ensure that residents are not smoking inside the facility which poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

The licensee shall conduct a staff in-service training to ensure that residents are smoking only in designated areas. The POC is due 4/19/24.

Deadline recorded: Apr 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(6)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement is not met as evidenced by: Based on observation and interviews, Resident #1's room could not be opened on the inside without a key which poses a personal rights risk to residents in care.

Official plan of correction

The licensee shall ensure the residents can leave its room anytime. The lock shall be changed in Resident #1's room so that he/she can go in and out. **POC has been cleared as of today.***

Deadline recorded: Apr 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(g)(1)

Regulation authority

CCR

What the official deficiency says

(g) Facilities which have machines and do their own laundry shall: (1) Have adequate supplies available and equipment maintained in good repair. Space used to sort soiled linen shall be separate from the clean linen storage and handling area. Except for facilities licensed for fifteen (15) residents or less, the space used to do laundry shall not be part of an area used for storage of anything other than clean linens and/or other supplies normally associated with laundry activities. Steam, odors, lint and objectionable laundry noises shall not reach resident or employee areas. This requirement is not met as evidenced by Based on interviews, records review and observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. The facility currently has 1 dryers that is not working.

Official plan of correction

Administrator will repair or replace dryer by POC date and send proof to LPA.

Deadline recorded: Aug 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, the licensee did not comply with the section cited above. Facility has 3 bedridden residents and no fire clearance for that poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/17/2023 Plan of Correction Administrator will contact Fire department for fire clearance and send proof to LPA by POC date.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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. Raid canister was accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2023 Plan of Correction Staff put RAID can away. ****No further action required***

Official classification

Type A

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 and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the 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. Four residents did not have LIC602 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2023 Plan of Correction Administrator will obtain Updated LIC602 for all residents send proof to LPA by POC date.

Official classification

Type A

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(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 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. Facility does not have 7 days nonperishable food on hand which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2023 Plan of Correction Administrator will purchase 7 days nonperishable food send proof to LPA by POC date

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 is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above roaches were observed in kitchen cabinets which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2023 Plan of Correction Administrator will call exterminator to address roaches and rat infestation and send proof to LPA by POC date.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (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 of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Medications were accessible to residents and in their rooms which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2023 Plan of Correction Administrator will remove medications from residents room or purchase lock boxes if resident's MD allows self administration.

Official classification

Type A

Official code

87633(h)

Regulation authority

CCR

What the official deficiency says

(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident's record: 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. Their is no record of residents which receive hospice which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2023 Plan of Correction Administrator will send notice of hospice services for residents at facility who are under hospice by POC 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. LPAs observed knifes in kitchen accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2023 Plan of Correction Administrator will lock up sharps and all knifes and make them unaccessible to residents by POC and send proof to LPA by POC date.

Official classification

Type B

Official code

1569.618(b)(3)

Regulation authority

HSC

What the official deficiency says

(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following: (3) Training to effectively interact with emergency personnel in the event of an emergency call, including an ability to provide a resident’s medical records to emergency responders. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview the licensee did not comply with the section cited above . Administrator is at facility only one hour or two per week and has no offical designated substitute. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2023 Plan of Correction Administrator will designate a substitute to take care of her responsibilities when not availible and send proof to LPA by POC date

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: 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. Facility had not plan of operation on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2023 Plan of Correction Administrator will send plan of operation to LPA by POC date.

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 record review, the licensee did not comply with the section cited above. Facility did not have proof of liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2023 Plan of Correction Administrator will send proof of liability insurance by POC date to LPA.

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, interview the licensee did not comply with the section cited above. The clothes dryer and AC is not working which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/25/2023 Plan of Correction Administrator will repair or replace clothes dryer and AC unit by POC date and send proof to LPA.

Official classification

Type B

Official code

87303(a)(1)

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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, the licensee did not comply with the section cited above. Ramp in hall wall is in need of repair or replacement which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/25/2023 Plan of Correction Administrator will repair ramp and send proof to LPA by POC.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, record review, the licensee did not comply with the section cited above. Facility has not had an emergency drill which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2023 Plan of Correction Administrator will conduct emergecny drill and send proof to LPA by POC date.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(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 as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. 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. No residents with dementia had annual assessments which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/25/2023 Plan of Correction The administrator will get updated medical assessment on all residents with dementia and send proof to LPA by POC date.

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 as evidence by: Based on interviews, observation and records reviewed the licensee did not comply with the section cited above which poses a potential risk to the health, safety, or personal rights of the persons in care. There was hole in the living room's ceiling for 3-4 months.

Official plan of correction

Facility is to ensure that Title 22 Section 87303 regulations are met at all times. Additionally, a statement indicating facility understands and will comply with Title 22 Section 87303 will be submitted to CCLD by 01/20/2023. Hole was repaired on 01/06/2023.

Deadline recorded: Jan 20, 2023. 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 as evidence by: Based on interviews, observation and records reviewed the licensee did not comply with the section cited above which poses a potential risk to the health, safety, or personal rights of the persons in care. The dryer is not working.

Official plan of correction

Facility is to ensure that Title 22 Section 87303 regulations are met at all times. Additionally, facility will repair or replace the dryer and submit proof to CCLD by 01/20/2023.

Deadline recorded: Jan 20, 2023. 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

Maintenance and Operation 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 as evidenced by: Based on observation the licensee failed to keep the facility clean, safe and in good repair at all times with there being in the backyard area mattresses, bedsprings and a desk cluttering the backyard area causing it to be unsafe which causes an Immediate Health and Safety risk to residents in care.

Official plan of correction

Facility to have mattresses, bedsprings and desk removed by POC due date and submit proof to LPA.

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