Staffing, personnel, and trainingType B
- 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 observation and record review, S5 and S6 did not have TB test results on file. The licensee failed to comply with the section cited above in two (2) out of six (6) staff files reviewed (S5 and S6). which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/28/2026 Plan of Correction Administrator to provide proof of TB test for S5 and S6 by POC due date.
Background checksType B
- Official classification
- Type B
- Official code
- 87355(j)
- Regulation authority
- CCR
What the official deficiency says
(j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file as required in Section 87412, Personnel Records. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, S3 did not have a criminal record clearance on file. Follow-up was conducted with Guardian, and there are pending steps to be completed by the Administrator. The licensee did not comply with the section cited above in one (1) out of six (6) staff files reviewed (S3) which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/28/2026 Plan of Correction Administrator to submit a plan detailing how the facility will ensure all employees have a criminal record clearance and are associated with the facility prior to beginning work and providing care to residents. Administrator will also follow up by the POC due date regarding the instructions provided by Guardian during the LPA’s visit and provide LPA with a copy of S3’s criminal record clearance and facility association.
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87608(a)(5)(B)
- Regulation authority
- CCR
What the official deficiency says
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review the licensee did not comply with the section cited above in one (1) out of four (4) R2 was observed to have full bed rails without that exception and resident was not on hospice which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/28/2026 Plan of Correction Administrator to submit and exception request for full bed rails for R2 by POC due date.