Background checksType A
- Official classification
- Type A
- Official code
- 87355(e)(3)
- Regulation authority
- CCR
What the official deficiency says
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 that staff (S4) is not associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/28/2026 Plan of Correction Administrator agreed to associate staff (S4) to the facility via Guardian. Submit proof of correction. Civil penalty was assessed.
Medication handling and storageType A
- Official classification
- Type A
- Official code
- 87465(h)(5)
- Regulation authority
- CCR
What the official deficiency says
Incidental Medical and Dental Care Services (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 that there were 3 unlocked medication bottles without a label on top of the kitchen table, staff stated they belonged to R1 and are transferred to bottles without labels when the medications are not adminestered and R1's levetiracetam 100mg/ml solution and daily liquid multi-vitamins were unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/28/2026 Plan of Correction Administrator agreed to submit a written plan of correction and proof of staff training regarding Title 22 regulation 87465.
Health conditions and treatmentsType A
- Official classification
- Type A
- 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, the licensee did not comply with the section cited above in that R2's bed has full bed rails, but R2 is not enrolled in hospice services; additionally, R1's bed has three-quarter length bed rail, which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/28/2026 Plan of Correction Licensee/Administrator removed R2's full bed rails and R1's three-quarter length bed rails during the visit. Submit copies of R1 & R2's half length bed rail physician order.
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 record review, the licensee did not comply with the section cited above in that residents (R1, R3 & R4's) appraisals are over 12 months old, which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/24/2026 Plan of Correction Administrator agreed to submit copies of R1, R3, and R4's appraisals.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(h)
- Regulation authority
- CCR
What the official deficiency says
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. 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 that residents (R1, R3 & R4's) Medical Assessments are more than 12 months old, which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/24/2026 Plan of Correction Administrator agreed to submit updated copies of R1, R3 and R4's Medical Assessments.
Health conditions and treatmentsType A
- Official classification
- Type A
- Official code
- 87615(a)(2)
- Regulation authority
- CCR
What the official deficiency says
Prohibited Health Conditions (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: (2) Gastrostomy tubes. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in that R1 has a prohibited health condition (G-Tube), which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/28/2026 Plan of Correction Administrator agreed to submit a written plan that includes understanding that a facilty may not retain or accept residents with prohibited health conditions, contact R1's physician, and submit a relocation plan to a higher level of care facility if applicable.