Facility condition and maintenanceType A
- 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, the licensee did not comply with the section cited above in one (1) out of two (2) bathrooms water temperature read at 125.7 which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/20/2025 Plan of Correction Administrator will adjust water temperature and send LPA picture. Administrator will create water log for one week and send to LPA by 12/26/2025.
Health conditions and treatmentsType A
- Official classification
- Type A
- Official code
- 87608(a)(5)(B)
- Regulation authority
- CCR
What the official deficiency says
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in one (1) resident had full bed rails with half bed rail order by physician which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/20/2025 Plan of Correction Administrator will remove full bed rails for R4 and send LPA pictures with half rails.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 1569.625(b)(2)
- Regulation authority
- HSC
What the official deficiency says
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online 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 S4 did not have 20 hrs annual training which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/02/2026 Plan of Correction Administrator will send annual training to LPA by POC due date.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87458(c)(1)(A)
- Regulation authority
- CCR
What the official deficiency says
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. 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 a TB on file which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/02/2026 Plan of Correction Admiistrator will send TB test for R2 to LPA by POC due date.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(h)(1)
- 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. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. 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 five (5) residents did not have annual visit with medical professional which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/02/2026 Plan of Correction Administrator will send LPA current 602 for R2 and R4 by POC due date.