HOME OF PERPETUAL CARE

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways shall be kept free of obstruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above LPA observed discarded bedding, chairs and matress in back yard near patio shaded area, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/25/2026 Plan of Correction Administrator will clear the back yard of the matress, chairs and bedding. Send picture of cleared area and receipt of the pick-up.

Official classification

Type B

Official code

87458(3)

Regulation authority

CCR

What the official deficiency says

(3) A record of current prescribed medication and an indication of whether the medication has been administered to the residents in care. 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 the facility did not mark the medications on a medication administrator record (MAR)s which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/25/2026 Plan of Correction Administrator will create and mark medications precribed to residents and send copy of MAR's by due date.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city,city and county fire department. Prior to accepting or retaining any of the followingtypes of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city,or city and county fire department, or the State Fire Marshal. This requirement was not met as evidenced by: R1 is bedridden and the facility fire clearance is not approved for bedridden. This poses an immediate risk to the health, safety, or personal rights of persons in care.

Official plan of correction

The facility will develop a plan to either obtain an updated medical assessment for R1 or assist to coordinate alternative placement for R1 based on their assessed needs and required services.

Deadline recorded: Aug 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87633(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department. 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 which R1 was placed on hospice care on 7/17/25 however, the facility does not have an approved hospice care waiver, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2025 Plan of Correction Licensee agreed to develop a plan to apply for a hospice care waiver exception for R1, noting that the facility currently lacks an approved hospice waiver, and outlining protocols for addressing potential future hospice care needs of residents. Plan must be received by POC DUE DATE.

Official classification

Type B

Official code

87463(b)(1)(E)

Regulation authority

CCR

What the official deficiency says

(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. (1) Significant changes in condition, as defined in Section 87101, Definitions, include, but are not limited, to: (E) Illness or injury that results in a significant change in the health care or dietary needs of the resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in which R1 had a significant change in health care and licensee did not document these changes on reppraisal, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/21/2025 Plan of Correction Licensee will document reppraisal and send proof of reppraisal by POC DUE DATE.

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 record review, the licensee did not comply with the section cited above in which no proof of documentation of emergency drills was provided when requested, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/21/2025 Plan of Correction Licensee will conduct emergency drill by POC DUE DATE and send proof of drill. Licensee will certify a plan outlining procedures for conducting and documenting quarterly emergency drills at the facility.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. 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 which the licensee did not furnish a report to this agency regarding a recent hospitalization of R1 in April of 2025 due to an illness, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/21/2025 Plan of Correction Licensee will furnish a report(LIC 624) regarding R1's hospitalization in April of 2025 by POC DUE DATE and re-train staff on this regulation. Proof of re-training must be received by POC DUE DATE.

Official classification

Type B

Official code

87457(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria. (1)The appraisal shall document, at a minimum: (A) An evaluation of the prospective resident's functional capabilities, mental condition, and social factors. This was not met as evidenced by: No documentation of R1's pre-appraisal was observed. This poses a risk to the health, safety, or personal rights of persons in care.

Official plan of correction

Licensee will conduct re-training on this regulation and send proof of re-training by 5/16/2025. Proof must be submitted via email.

Deadline recorded: May 16, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This requirement was not met as evidenced by: Licensee did not retain original signed and dated admission agreement in R1's resident file. This poses a risk to the health, safety, or personal rights of persons in care.

Official plan of correction

Licensee will conduct re-training on this regulation and send proof of re-training by 5/16/2025. Proof must be submitted via email.

Deadline recorded: May 16, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.652(c)

Regulation authority

HSC

What the official deficiency says

A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days, after the personal property is removed. This requirement was not as evidenced by: Facility did not issue refund within 15 days to R1's responsible party. This poses a potential risk to the health, safety, or personal rights of persons in care.

Official plan of correction

Licensee agreed to certfy plan to address when a refund will be issued to R1's responsible party no later than 05/16/2025, via email to LPA Ramirez.

Deadline recorded: May 16, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

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, the licensee did not comply with the section cited above the facility did not have suffcient supply of 2 day perishable food and 7 day non perishable food which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/10/2024 Plan of Correction Administartor will provide proof of receipt and pictures to LPA via email that food was bought.

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, the licensee did not comply with the section cited above scissors where accessible to residents and R1 was walking around with them during visit with no supervision which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/10/2024 Plan of Correction Administartor will conduct training to all staff to insure all sharps are locked and inaccessible to residents and send proof of training to LPA.

Official classification

Type A

Official code

87468(b)

Regulation authority

CCR

What the official deficiency says

(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: 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 one (1) out of three(3) shared bedrooms resident R2 and R3 had a camera in room which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/10/2024 Plan of Correction Administartor will take out camera and go over residents personal rights and send LPA proof that training was conducted.

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 residents medication was observd in refrigerator not locked in seprate box which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/10/2024 Plan of Correction Administartor will buy a lock box and send LPA pictures as proof.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. 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 one (1) out of five (5) residents did not have medication that was ordered by physcian at facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/10/2024 Plan of Correction Gabapentin 30 mg 1 cap 2x a day, Citalopran 10 mg 1 tablet a day,and Melatonin ! tablet at bedtime a day will be ordered and proof will be sent via email to LPA.

Official classification

Type A

Official code

87633(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department. 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 one (1) out of five (5) residents are on hospice care and facility did not obtain a waiver which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/10/2024 Plan of Correction Administartor will submit documents and request waiver to department for R3.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above LPA observed hospital bed and mattress outside in back yard against wall where shaded patio is at which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2024 Plan of Correction Administrator will clear backyard area and send picture via email as proof to LPA.

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 record review, the licensee did not comply with the section cited above facility did not have any records of any drills which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2024 Plan of Correction Administrator will conduct drills withh all staff and send a copy of drills via email to LPA. Administartor agrees to conduct and record drill quarterly.

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 record review, the licensee did not comply with the section cited above in one out of five residents did not have a physician order for full bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2024 Plan of Correction Administartor will obtain a physcians order for bed rails and send proof via email to LPA.

Official classification

Type A

Official code

87208(c)

Regulation authority

CCR

What the official deficiency says

(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). 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 obtaining approval of a dementia care plan in their plan of operations, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/30/2023 Plan of Correction Licensee will submit a plan in writing to LPA, via email by the POC due date, of when an updated Plan of Operations for approval of Dementia Care Plan will be submitted to Centralized Applications Bureau.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. 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 auditory devices not installed at entrances and exits, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/30/2023 Plan of Correction Licensee will purchase and install aditory devices at all entrances and exits of the facility and provide receipt of purchase and pictures of installed devices to LPA, via email, by POC due date.

Official classification

Type B

Official code

87470(c)

Regulation authority

CCR

What the official deficiency says

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. 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 an Infection Control Plan submitted and approved to licensing, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/06/2023 Plan of Correction Licensee provided a copy of the infection control plan during the visit on 9/29/23. This deficiency is cleared.

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, the licensee did not comply with the section cited above in broken parts of roof boards above the exit from the living room to the patio and outide the pantry door, which pose a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/20/2023 Plan of Correction Licensee will make reparations needed to the roof boards and submit proof of work started/completed to LPA via email by the POC due date.

Official classification

Type B

Official code

87705(k)(9)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (k) The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors or perimeter fence gates: (9) The licensee shall not accept or retain residents determined by a physician to have a primary diagnosis of a mental disorder unrelated to dementia. 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 admitting and retaining a resident with a primary diagnosis of a mental disorder unrelated to dementia, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/20/2023 Plan of Correction Licensee will have R4 reassessed by a physician to determine any changes, otherwise will find placement of the resident. Update Physician's Report and Appraisal will be submitted to LPA via email by the POC due date.

Official classification

Type B

Official code

87208(a)(7)(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:(7) Sketches, showing dimensions, of the following: (A)Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents and for bedridden residents, other than for a temporary illness or recovery from surgery as specified in Sections 87606(d) and (e) 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 changing the room occupancy of resident rooms and not providing licensing with a request for approval of change, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/06/2023 Plan of Correction Licensee will submit an updated facility sketch to LPA via email by POC due date to reflect changes of the physical plant/resident room use.

Official classification

Type B

Official code

87468.1

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. 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 locking a resident's food in a caibinet to keep them from eating too much, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/06/2023 Plan of Correction Staff unlocked the cabinet immediately and Licensee will keep cabinet unlocked to allow residents access to food, as they please.

Official classification

Type B

Official code

87468.2(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. 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 installing surveillance cameras in common areas of the facility without an updated plan of operations, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/06/2023 Plan of Correction Licensee removed the surveillance cameras during the visit and informed LPA will submit an updated Plan of Operations in the future for security cameras.

Official classification

Type B

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87608 Postural Supports (a)Based on the individual's preadmission appraisal, and subsequent changes to that ........Postural supports may be used under the following conditions.(3)written order from a physician indicating the need for the postural support shall be maintained in the resident’s record The requirement is not met as evidenced by LPA was not able to observe the doctor's order for Resident#1(R1)'s half bed rail which posed a potential risk for residents in care.

Deadline recorded: Sep 27, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(4)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, LPA observed there's no grab in the shower of the bathroom#2 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/10/2021 Plan of Correction The administrator will ensure Grab bars shall be maintained for each toilet; bathtub and shower used by residents. LPA will installed the grab bar in the shower of bathroom#2 and send the picture to LPA by POC due date

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, LPA observed the toilet in the bathroom#2 was not working and its clogged which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/10/2021 Plan of Correction The administrator will ensure the facility shall be clean, safe, sanitary and in good repair at all times. The administrator will fix the toilet in the bathrom#2 and send the receipt to LPA by POC due date

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, LPA observed Staff#1 (S1) does not have the health screening and chext x ray result in the file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/17/2021 Plan of Correction The administrator will ensure 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 administrator send S1 health screening report with TB test result to LPA by POC due date