THREE SYCAMORES ON GOULD

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

87307(d)(6) Personal Accommodations and Services. All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: The licensee did not ensure that outdoor passageways are free of obstruction. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above there are several pieces of lumber with sharp edges leaning against back wall of the facility which poses an immediate health, safety risk to persons in care.

Official plan of correction

POC Due Date: 02/22/2025 Plan of Correction At the time of visit lumber was removed and POC cleared on 02/21/2025.

Official classification

Type A

Official code

87208

Regulation authority

CCR

What the official deficiency says

87208 Plan of Operation The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation This requirement is not met as evidenced by: The licensee failed to follow their own plan of operation. Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above facility retains two (02) hospice residents, but hospice waiver is approved for 1. This possess an immediate health and safety hazard to clients in care.

Official plan of correction

POC Due Date: 02/22/2025 Plan of Correction Licensee will submit a hospice waiver/acception to CCL or remove resident from facility by POC due date.

Official classification

Type A

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. This requirement is not met as evidenced by: Gate leading outside was broken. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above licensee did not ensure that the facility is in good repair. Facility retains dementia residents and one (01) of the gates leading outside was broken. This possess an immediate health and safety to residents in care.

Official plan of correction

POC Due Date: 02/22/2025 Plan of Correction At the time of visit the broke gate was repaired and POC cleared on 02/21/2025.

Official classification

Type A

Official code

87303(b)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation. (b) A comfortable temperature for residents shall be maintained at all times. This requirement is not met as evidenced by: Licensee did not ensure that facility temperature is comfortable for all residents. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above the thermostat was broken for a while and the rooms were heated by portable heaters which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/22/2025 Plan of Correction Licensee will submit proof of thermostat repaired by POC due date.

Official classification

Type B

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Licensee did not ensure that the facility has qualified Administrator. Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above that the facility has qualified Administrator that could confirm applicable law, rules and regulations. Facility in noncompliance with title 22 regulations leading to serious deficiencies which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2025 Plan of Correction Licensee will submit a written document to LLC indicating that reviewed and understood all the deficiencies that were issued by POC due date.

Official classification

Type B

Official code

87555(27)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (27) All … areas shall be kept clean and free of litter, rodents, vermin, and insects. This requirement is not met as evidenced by: Licensee did not ensure that the facility is free of vermin. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above LPA was informed that there are rat droppings in the facility which poses a potential health, safe risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2025 Plan of Correction Licensee will submit proof of pest control invoice to CCL by due date.

Official classification

Type B

Official code

7506(a)

Regulation authority

CCR

What the official deficiency says

7506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility. This requirement is not met as evidenced by: Residents records were missing information. Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above documents on the records identify other facilities names. Physician reports were not signed by the doctors which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2025 Plan of Correction Licensee will submit a complete physician report for each resident to CCL by POC due date.

Official classification

Type A

Official code

1569.1(a)(1)

Regulation authority

HSC

What the official deficiency says

H & S Code1569.73(a) (1) The facility agrees to retain the terminally ill resident, …and to seek a waiver on behalf of the individual…, provided the individual…is capable of deciding to obtain hospice services. This requirement is not met as evidenced by: Facility retains two (02) hospice residents but is approved for one (01) hospice waiver. Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above facility retains two (02) hospice residents. Hospice waiver is approved for one (01) resident which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/22/2025 Plan of Correction Licensee will submit hospice waiver/accept to CCL for approval by POC due date.

Official classification

Type A

Official code

87608(a)(5)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (a) ...The facility shall provide... care for the resident in those activities... unable to do for themself. Postural supports may be used ...conditions. (5) Under no circumstances shall postural supports...limiting the use of a resident's hands or feet. This requirement is not met as evidenced by. The licensee did not ensure that postural support provided to R1 is not depriving R1s’ movement. R1 was restrained to the wheelchair and had no ability to release it. This possess an immediate health and safety hazard to residents in care.

Official plan of correction

The licensee will provide in-service for postural support to ensure the safety of residents in care and will ensure care staff is schedule to assist R1. Licensee will submit in-service and staff schedule to LPA by due date.

Deadline recorded: Feb 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(b)(2)

Regulation authority

CCR

What the official deficiency says

All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidence by: Based on interview and review of Guardian Background System staff S1 & S2 are not Criminal Background Clearanced or Transfer & Associated to this facility. No documentation has been submitted to CCLD. This poses a potential risk to residents in care.

Official plan of correction

Administrator will completed Criminal Background Clearance or Transfer & Associated S1 & S2 to facility. Administrator will provide documentation to LPA. S1 & S2 exit the facility and will not return until Background Clearance and Associated.

Deadline recorded: Feb 20, 2025. A deadline is not proof that correction was completed.