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Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type A

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. 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 [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidence by: LPA Ramirez observed a cloth room divider near corner of garage, that was sectioning off an area of the garage. LPA Ramirez observed a bed with linen, several shoes, and various articles of clothing in bags and boxes.

Official plan of correction

Licensee will obtain proper city permits for the room built inside the garage, currently used for live-in staff, or demolish the room if not permitted by the city. Proof to be submitted to LPA via email by POC due date. Licensee will submit picture proof by due date of demolished room if unable to obtain permit.

Deadline recorded: Mar 21, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2)Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met as evidence by:

Official plan of correction

Staff removed cleaning products and placed in secure location. **This will clear 24hr POC** Licensee will retrain staff on above regulation by 3/21/24. Proof of re-training must be sent by 3/21/24. LPA Ramirez observed cleaning products to be accessible to residents in care during visit.

Deadline recorded: Mar 8, 2024. 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 was not met as evidence by: LPA Ramirez observed blaskish spots and stains in bathroom#3 shower, near toilet wall and around window frame.

Official plan of correction

Licensee will clean area and send picture proof to LPA by 03/21/2024.

Deadline recorded: Mar 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

Alterations to Existing Building or New Facilities: (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. There is a unpermitted room in the garage.

Official plan of correction

Licensee will obtain a proper city permit for the room built inside the garage or demolish the room if not permitted by the city by 11/19/2023.

Deadline recorded: Nov 19, 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: (a)The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by: Based on observation, interview, and record review, 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 unpermitted room in the garage has been deemed a fire hazard by a Building Inspector and Code Compliance Officer

Official plan of correction

Licensee will obtain a proper city permit for the room built inside the garage or demolish the room if not permitted by the city by 11/19/2023.

Deadline recorded: Nov 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. 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 1 of 4 residents medication not having record of dosages for several centrally stored medications, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/22/2023 Plan of Correction Licensee will obtain record of prescribed medications for R4 and submit proof to LPA via email by POC due date.

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

Prior to construction or alterations, all facilities shall obtain a building permit. 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 building a room inside the garage without proper city permits/notification to licensing and using it as a live-in staff room, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2023 Plan of Correction Licensee will obtain proper city permits for the room built inside the garage, currently used for live-in staff, or demolish the room if not permitted by the city. Proof to be submitted to LPA via email by POC due date.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h)The following requirements shall apply to medications which are centrally stored:(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: 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) of (4) residents without accurate records of centrally stored medications, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2023 Plan of Correction Licensee to send LPA, via email, accurate records for centrally stored prescription medications for 4 residents, by POC due date.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a)(2) To be accorded safe, healthful,and comfortable accommodations, furnishings, and equipment. This requirement is not met as evidenced by: LPA observed taht upon entry into the facility, Staff #1-2 were not wearing masks. Witnesses also indicate that during an unannounced visit to the facility on 9/29/22 and 6/14/22, Staff were not wearing masks which posed a potential risk for residents in care.

Official plan of correction

Licensee shall provide additional training to all staff regarding COVID-19 protocols and about wearing mask indoors and fax the completed in-service training log to CCLD on or before the POCdue date. Note: Staff present during LPA's visit wore a mask throughout their shift. LPA advised all staff present to follow COVID-19 protocol.

Deadline recorded: Oct 8, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87470(c)(1)(F)

Regulation authority

CCR

What the official deficiency says

87470 - Infection Control Requirements..An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (F) Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance. The requirement is not met as evidenced by: LPA's observations, interviews and records review. LPA observed that staff did not perform the Covid-19 protocols/screening for visitors upon entry to the facility which posed a potential risk for residents in care.

Official plan of correction

The Administrator will do in-service training for all the staff regarding COVID-19 protocols and symptom screening to all visitors. Administrator will follow the infection control plan and will fax a copy of the completed in-service training signed by all the staff on or before the POC due date.

Deadline recorded: Oct 8, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87035(a)

Regulation authority

CCR

What the official deficiency says

87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. The requirement was not met as evidenced by LPA observation- LPA observed there's a live in staff room in the garage which was not indicate on the facility sketch and administrator admitted there's no city permit.

Official plan of correction

The administrator will ensure prior to construction or alteration, all facilities shall obtain a building permit. The administrator will go and obtain a city permit and also updated the facility sketch and send it to LPA by POC date.

Deadline recorded: Oct 17, 2022. A deadline is not proof that correction was completed.