AYANNA HOME CARE

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. 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 LPA observed liquid dishwashing soap,kleenking stainless steel copper cleaner,and zevo bug spary unlocked under kitchen sink which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/24/2026 Plan of Correction Staff removed cleaners at time of visit. Administrator will conduct training with staff and send to LPA by POC due date.

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 R5 had full bed rails with no hospice care which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/24/2026 Plan of Correction Administrator will remove bed rails and send LPA picture or provide hospice care information 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 record review, the licensee did not comply with the section cited above infection control plan was not avaliable at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/30/2026 Plan of Correction Administrator will email LPA infection control plan by POC due date.

Official classification

Type B

Official code

87706(a)

Regulation authority

CCR

What the official deficiency says

(a) In addition to the requirements in Section 87705, Care of Persons with Dementia, licensees who advertise, promote, or otherwise hold themselves out as providing special care, programming, and/or environments for residents with dementia or related disorders shall meet the following requirements: 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 Administrator did not have dementia plan of operation which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/30/2026 Plan of Correction LPA had requested plan of operation since 12/19/2025 and still has not received. Administrator will sent to LPA by POC due date.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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 liability insurance at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/30/2026 Plan of Correction Administrator will email LPA INS by POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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 is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above room two had bed rails/mattress on floor of room which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/30/2026 Plan of Correction Administrator will send pictures as proof of items removed in bedrooms to LPA by POC due date.

Official classification

Type B

Official code

87412(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: 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 personnel files were not available during visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/30/2026 Plan of Correction Administrator will send files for 3 staff and Admin file toLPA by POC due date.

Official classification

Type B

Official code

87412(c)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. 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 staff training was not avaliable at time of visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/30/2026 Plan of Correction Administrator will send all required training for staff by POC due date.

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, the licensee did not comply with the section cited above facility did not have a medication log with prescribed by physician with dosage which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/30/2026 Plan of Correction Administrator will send log to LPA by POC due date for all 5 residents.

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 review, the licensee did not comply with the section cited above residents files were not avaliable during visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/30/2026 Plan of Correction Administrator will send 5 resident files to LPA by POC due date.

Official classification

Type B

Official code

1569.695(a)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: 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 emergency disaster plan was not avaliable during visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/30/2026 Plan of Correction Administrator will send updated emergency disaster plan to LPA 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 facility did not have any drills avaliable during visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/30/2026 Plan of Correction Administrator will send drills to LPA by POC due date.

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 in (A) through (D) 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. Based on record review Admiistrator did not report to CCLD when resident was in hospital which poses a potential risk to the persons safety, health, or personal rights of the persons in care.

Official plan of correction

Administrator will go over section 87211 reporting requirements and develop a plan to insure incidents are reported to CCLD and send LPA plan.

Deadline recorded: Jan 2, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

87208 Plan of Operation (a)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 and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. 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: Based on record review facility does not have a dementia care plan and currently has three residets with dementia which poses a potential risk to the persons safety, health, or personal rights of the persons in care.

Official plan of correction

Administrator will send LPA Plan of Operation with an addendum to include Dementia to LPA by POC due date.

Deadline recorded: Jan 2, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (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: (2) Obtain a California clearance or a criminal record exemption as required by the Department This requirement was not met as evidenced by: S3 did not have record of criminal clearance . This poses an immediate risk to the health, safety, or personal rights of persons in care.

Official plan of correction

Staff 3 clocked out and facility will ensure S3 is finger prited and cleared before returning to work.

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

Official classification

Type B

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 two (2) residents R1 R4 did not have all prescribed medication which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/09/2025 Plan of Correction R4 was missing Tolterodine Tartrate 4 MG and Fosamax 70 MG. R1 Dulcolax 10 MG and Cyanocobalamin 2500. Administrator will refill presciption or get order for discontinued medication and send to LPA by email.

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 drill ready for review 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 will conduct drills with staff and send to LPA by POC due date.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above during physical plant tour LPA observed a large knife on kitchen counter drying rack which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2025 Plan of Correction Staff removed knife and locked knife up at time of visit. Administrator will conduct training on section 87309(a) and email to LPA by POC due date.

Official classification

Type A

Official code

87606(c)

Regulation authority

CCR

What the official deficiency says

(c) To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance. 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 two (2) out of the five (5) residents physicians reports stated they were both bedridden which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2025 Plan of Correction The facility will develop a plan to eithe robtain an updated medical assessment for R1 and R2 or asssit to coordinate alternative placement for R1 and R2 based on their needs and required service. Administrator will contact local fire department that they have 2 residents that are bedridden and do not have approved bedridden fire clearance.

Official classification

Type A

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 observation and record review, the licensee did not comply with the section cited above in four out of five residents had bed rails and no orders from physician. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/29/2025 Plan of Correction Administrator removed three residents bed rails and will obtain a written order for R1 and R2 and send to LPA by POC due date.

Official classification

Type B

Official code

87412(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above Administrator file was not available during time of visit. Administrator could not provide personnel records in a timely manner which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/04/2025 Plan of Correction Administrator will email completed file to LPA by PPC due date.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. 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 staff #1 and staff #2 had no training in file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/10/2025 Plan of Correction Administrator will submit staff required training to LPA by POC due date.

Official classification

Type B

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

(g) All personnel records shall be maintained at the facility. 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 4 out of 4 staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/19/2024 Plan of Correction Licensee is to comply with Title 22 Section 87412 at all times. Additionally, licensee will submit copies of Staff 1 - Staff 4 files to the Community Care Licensing Division (CCLD) by 09/19/2024.

Official classification

Type B

Official code

87465(f)(1)(2)(3)

Regulation authority

CCR

What the official deficiency says

(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff. (2) The name, address and telephone number of each emergency agency to be called in the event of an emergency, including but not limited to the fire department, crisis center or paramedical unit or medical resource, shall be posted in a location visible to both staff and residents. (3) The name and telephone number of an ambulance service shall be readily available. 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 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. Resident 1 (R1) had blank Identification and Emergency Information form (LIC 601).

Official plan of correction

POC Due Date: 09/19/2023 Plan of Correction Licensee is to ensure that Title 22 Section 87465 regulations are met at all times. Additionally, the Licensee will complete the Identification and Emergency Information form (LIC 601) for Resident 1 (R1) and submit a copy to CCLD by 09/19/2023.

Official classification

Type B

Official code

87459(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living... 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 6 out 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. All 6 residents did not have a Functional Capabilities form (LIC 9172) in their file

Official plan of correction

POC Due Date: 09/19/2023 Plan of Correction Licensee is to ensure that Title 22 Section 87459 regulations are met at all times. Additionally, the Licensee will complete the Functional Capabilities form (LIC 9172) for all 6 residents and submit a copy to CCLD by 09/19/2023.

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.....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.... This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. There is a caregiver's bed and belogings in an area in the facility that is labeled as an " Open Area " on the facility floor plan sketch. This area should not be use as a caregiver sleeping or living area.

Official plan of correction

POC Due Date: 09/19/2023 Plan of Correction Licensee is to ensure that Title 22 Section 87208 regulations are met at all times. Additionally, the Licensee will remove the caregiver's bed and belongings from the Open Area and submit a statement that they will comply with this section code to CCLD by 09/19/2023.

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 5 out 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. Resident 1 (R1) through Resident 5 (R5) all had a bed rail and LPA did not observe a doctor's order for the bed rails on file. The staff could not find the orders either.

Official plan of correction

POC Due Date: 09/19/2023 Plan of Correction Licensee is to ensure that Title 22 Section 87608 regulations are met at all times. Additionally, the Licensee will a doctor's order for the bed rails for all 5 residents and submit a copy to CCLD by 09/19/2023.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. 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 which poses an immediate health, safety or personal rights risk to persons in care. During medication review, LPA observed discrepencies in Resident 1 (R1), Resident 2 (R2), and Resident 3 (R3). There were empty medication containers/bubble packs, some bubble packs were full even though it is the 5th of the month, some bubble packs had more than 5 pills missing, pills were taken out of the bubble pack in an out of order way (dates are on the bubble pack for each pill) which made it difficult to verify if residents are getting their medication daily, and staff stated for some residents medication was discontinued, but medication is still in their basket. LPA is unable to determine if medication is being given as prescribed because staff could not provide an explaination for some of the discrepencies, did not have a list with all the medicaiton for each resident written by a doctor, and there was no doctor's discontinuation orders for the medication that staff claimed where discontinued.

Official plan of correction

POC Due Date: 09/06/2023 Plan of Correction Licensee is to ensure that Title 22 Section 87465 regulations are met at all times. Additionally, the Licensee will an in-service training regarding this regulation with all staff and submit a sign in training sheet to CCLD by 09/19/2023. LPA recommended that this facility uses a Medication Administrattion Record (MAR) for each resident to track when medication is given.

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 and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Resident 6 (R6) has medication unlocked in the bedroom. R6's Physician Report states that R6 can manage own medication, but R6 shares the bedroom with Resident 5 (R5) and R5's physician report states that R5 cannot manage own medication. Therefore, medication needs to be locked for the safety of Resident 5.

Official plan of correction

POC Due Date: 09/06/2023 Plan of Correction Licensee is to ensure that Title 22 Section 87465 regulations are met at all times. Additionally, the Licensee will an in-service training regarding this regulation with all staff and submit a sign in training sheet to CCLD by 09/19/2023.

Official classification

Type A

Official code

87465(c)(1)

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: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information specified in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation. 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 which poses an immediate health, safety or personal rights risk to persons in care. During the visit, staff were unable to provide the LPA with a current/updated medication list for all residents written by the residents' physician. Due to this and not having a Medication Administration Record (MAR), the LPA could not verify if residents had all their medication at the facility and which medications were discontinued.

Official plan of correction

POC Due Date: 09/06/2023 Plan of Correction Licensee is to ensure that Title 22 Section 87465 regulations are met at all times. Additionally, the Licensee will contact the physician for all 6 residents to confirm and obtain a list of all the medications that each resident should be taking. A copy of these list will be submitted to CCLD by 09/19/2023.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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 poses/posed a potential health, safety or personal rights risk to persons in care. During the visit, the staff could not provide the LPA with a copy of the liability insurance.

Official plan of correction

POC Due Date: 09/19/2023 Plan of Correction Licensee is to ensure that Health and Safety Code 1569.605 regulations are met at all times. Additionally, the Licensee will obtain a liability insurance and submit a copy to CCLD by 09/19/2023.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: 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 poses/posed a potential health, safety or personal rights risk to persons in care. During the visit, the staff did not know the whereabouts of all staff files and therefore LPA was unable to review any staff files.

Official plan of correction

POC Due Date: 09/19/2023 Plan of Correction Licensee is to ensure that Title 22 Section 87412 regulations are met at all times. Additionally, the Licensee will ensure that all staff files are kept at the facility and submit a copy of the entire file for 4 staff to CCLD by 09/19/2023.

Official classification

Type B

Official code

87457(c)

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 his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. 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 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. Resident 5 (R5) did not have a Resident Appraisal (LIC 603A) on file during the visit.

Official plan of correction

POC Due Date: 09/19/2023 Plan of Correction Licensee is to ensure that Title 22 Section 87457 regulations are met at all times. Additionally, the Licensee will complete a Resident Appraisal (LIC 603A) for Resident 5 and submit a copy to CCLD by 09/19/2023.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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 2 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. Resident 1 (R1)'s Physician Report (LIC 602) did not have a physician's signature and Resident 2 (R2) had a blank Physician Report (LIC 602) on file.

Official plan of correction

POC Due Date: 09/19/2023 Plan of Correction Licensee is to ensure that Title 22 Section 87457 regulations are met at all times. Additionally, the Licensee will obtain a Physician Report for both Resident 1 and Resident 2 and submit a copy to CCLD by 09/19/2023.

Official classification

Type B

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. 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 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. Resident 1 (R1)'s Physician Report (LIC 602) did not have a TB exam results.

Official plan of correction

POC Due Date: 09/19/2023 Plan of Correction Licensee is to ensure that Title 22 Section 87458 regulations are met at all times. Additionally, the Licensee will obtain a Physician Report with TB results for both Resident 1 and submit a copy to CCLD by 09/19/2023.

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(a) ..... Postural supports may be used under the following conditions. (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (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 review, the licensee did not comply with the section cited above in 2 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care. Resident 3 and Resident 4 are not hospice and have a full bed rail.

Official plan of correction

POC Due Date: 09/19/2023 Plan of Correction Licensee is to ensure that Title 22 Section 87608 regulations are met at all times. Additionally, the Licensee will replace the full bed rails with half bed rails, but will need to have a doctor's order for half bed rails for both residents. A copy of the half bed rail doctor's order will be submitted to CCLD by 09/19/2023.

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA did not observe the Complaint Poster (PUB 475) posted at the facility.

Official plan of correction

POC Due Date: 09/19/2023 Plan of Correction Licensee is to ensure that Title 22 Section 87468 regulations are met at all times. Additionally, the Licensee will post the Complaint Poster at the facility by 09/19/2023.