AMELIA ROSE SENIOR CARE COTTAGE

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on record revieiw, the licensee did not comply with the section cited above R1 did not have LIC 627 or LIC 603 in folder which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/16/2026 Plan of Correction Administrator will email forms to LPA by POC due date.

Official classification

Type A

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. 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 did not observe enough 2 day non perishable food for six (6) residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/08/2025 Plan of Correction Administrator had food purchased at time of visit dificiency cleared at time of visit.

Official classification

Type B

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, the licensee did not comply with the section cited above in one (1) out of three (3) bathrooms did not deliver the required water temperature of 105 in bathroom #2 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/21/2025 Plan of Correction Administrator will correct water temperature and create a water log for one week and send to LPA by POC due date.

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 paint and other obstructions in backyard side of house which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/21/2025 Plan of Correction Administrator will remove items and send LPA picture by POC due date,

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 two (2) out of six (6) residents did not have updated 602 physician reports which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/21/2025 Plan of Correction Administrator will obtain an updated physician report for R2 and R4 and send to LPA by POC due date.

Official classification

Type B

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or perimeter fence gates and that facility staff on all shifts have access to, and know how to use, equipment needed to unlock exterior doors or perimeter fence gates. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above combination lock was observed on perimeter fence without waiver from this licensing agency, no approval from on fire clearance inspection sheet and/or notification from Licensee's intent to lock perimeter gates which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/14/2025 Plan of Correction Administrator removed both locks at time of visit. POC cleared.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidence by: Based on observation and document review licensee did not ensure staff was accurately noting the medication sheets to show current medication which poses a potential risk to the health, safety, and personal rights of the persons in care.

Official plan of correction

Administrator will provide training to staff on medication logs and create procedures to provide and record medication and provide a copy to the department by POC due date

Deadline recorded: Jul 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency …the following: (1) A written report shall be submitted … within seven days of the occurrence of any of the events … Based on interviews and documents reviewed the licensee did not ensure to report R3 was taken to the hospital via emergency personnel which poses a potential risk to the health, safety, and personal rights of the persons in care.

Official plan of correction

Administrator will submit incident report for R3 to the department and will certify in writing that will report to the department per 87211 regulations and will submit a copy to the department by POC due date

Deadline recorded: Jul 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(C)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement is not met as evidence by: Based on observations and document review licensee did not ensure that S2 received, and records were maintained for training provided which poses a potential risk to the health, safety, or personal rights of the persons in care.

Official plan of correction

Administrator will provide training to facility’s staff and will provide a copy of training logs, with date, duration of training, and staff signatures to the department by POC due date

Deadline recorded: Jul 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management … Based on observation and document review licensee did not ensure to notify or appoint via LIC 308 a designee of responsibility before going on vacation which poses a potential risk to the health, safety, or personal rights of the persons in care.

Official plan of correction

Administrator will certify in writing that will appoint and notify the department whenever is out of the facility for an extended period of time and submit a copy to the department by POC due date

Deadline recorded: Jul 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

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: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by: S4 did not have proof of criminal clearance prior to gaining employment at the facility.

Official plan of correction

*24HR CORRECTION met due to S4 removing herself from the facility until criminal clearance is submitted.* Licensee will retrain staff on this regulation and send proof of re-training by 9/9/24 via email.

Deadline recorded: Sep 9, 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

(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 is not met as evidenced by: 1 bottle of laundry sanitizer and 1 spray bottle of disinfectant spray was observed in bathrooms#1 and 2.

Official plan of correction

*24HR CORRECTION met due to Administrator Dallas removing the chemicals and securing in staff office.*Licensee will retrain staff on this regulation and send proof of re-training by 9/9/24 via email.

Deadline recorded: Sep 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87755(a)

Regulation authority

CCR

What the official deficiency says

(a) Any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter and inspect the entire premise of any place providing services at any time, with or without advance notice. This requirement was not met as evidenced by: LPA Ramirez was denied entry to backyard to complete inspection.

Official plan of correction

Licensee will allow any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter and inspect the entire premise of any place providing services at any time, with or without advance notice. Licensee will certify a plan to address how the facility plans to comply with the above regulation. Due via email by 9/2/24.

Deadline recorded: Sep 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)

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: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, S4 did not have proof of criminal clearance prior to gaining employment at the facility, the licensee did not comply with the section cited above in 5 out of 5 residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/09/2024 Plan of Correction *24HR CORRECTION met due to S4 removing herself from the facility until criminal clearance is submitted.* Licensee will retrain staff on this regulation and send proof of re-training by 9/9/24 via email.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(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 is not met as evidenced by: Deficient Practice Statement Based on observation, 1 bottle of laundry sanitizer and 1 spray bottle of disinfectant spray was observed in bathrooms#1 and 2, the licensee did not comply with the section cited above in 3 out of 5 out of residents with dementia, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/09/2024 Plan of Correction *24HR CORRECTION met due to Administrator Dallas removing the chemicals and securing in staff office.*Licensee will retrain staff on this regulation and send proof of re-training by 9/9/24 via email.

Official classification

Type B

Official code

87113

Regulation authority

CCR

What the official deficiency says

The license shall be posted in a prominent location in the licensed facility accessible to public view. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, license was not posted in prominent location in the facility, the licensee did not comply with the section cited above in 5 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/09/2024 Plan of Correction Licensee will post license in prominent location in the facility and send picture proof of posted license via email by 9/9/24.

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,facility door bell is in disrepair, 1 out of 3 light bulbs in bathroom#1 and #2 were in disrepair, the licensee did not comply with the section cited above in 5 out of 5 residents, staff and/or vistors which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/09/2024 Plan of Correction Licensee will replace light bulbs and send picture proof by 9/9/24 via email.

Official classification

Type B

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 record review, R5 was missing centrally stored medications record, the licensee did not comply with the section cited above in 1 out of 5 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/09/2024 Plan of Correction Licensee will complete record and send proof via email by 9/9/24.

Official classification

Type B

Official code

87456(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, R1 did not have any recent medical assessment, the licensee did not comply with the section cited above in 1 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/09/2024 Plan of Correction Licensee provide recent medical assessment for R1 and send via email by 9/9/24.

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, no proof of documented drills for 2024, the licensee did not comply with the section cited above in 5 out of 5 residents, staff and/or visitors which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/09/2024 Plan of Correction Licensee will conduct drill and document drill according to above regulation. Proof must be submitted via email by 9/9/24.

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 and record reviewed, R2 does not have an order for full bed rails, the licensee did not comply with the section cited above in 1 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/09/2024 Plan of Correction Licensee will obtain an order for full bed rails or remove full bed rails by 9/9/24. Licensee will retrain staff on this regulation by 9/9/24 and send proof via email.

Official classification

Type B

Official code

87705(I)(1)(2)(3)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates. (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. (3) The licensee shall obtain a waiver from Section 87468(a)(6), to prevent residents from leaving the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, combination lock was observed on perimeter fence without waiver from this licensing agency, no approval from on fire clearance inspection sheet and/or notification from Licensee's intent to lock perimeter gates, the licensee did not comply with the section cited above in 5 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/09/2024 Plan of Correction Licensee will apply for waiver by 9/9/24 or remove perimeters with locks. Picture proof must be submitted by 9/9/24 if licensee removes locks.