Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(a)(11)
- 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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 2 staff not having a health screening on file which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/05/2026 Plan of Correction Licensee agreed to have staff complete health screening and provide a copy of documentation to the deportment by POC due date.
Staffing, personnel, and trainingType B
- 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 in 2 out of 2 staff not having orientation and staff training documented as completed on file which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/05/2026 Plan of Correction Licensee agreed to complete training documentation and provide copies to the department by POC due date.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(c)(1)
- Regulation authority
- CCR
What the official deficiency says
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 2 staff not having first aid certification on file which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/05/2026 Plan of Correction Licensee agreed to send copy of first aid certification to the Department by POC due date.
Records and plan of operationType B
- 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 and interview, the licensee did not comply with the section cited above in 3 out of 3 residents not having complete current records in the facility which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/05/2026 Plan of Correction The Licensee agreed to complete missing documentation and provide copies to the Department by POC due date.
Fire safety and emergency preparednessType B
- 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 not conducting quarterly drills since March 2025 which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/29/2026 Plan of Correction Licensee agreed to complete drills and documentation of completion and provide copy to the Department by POC due date.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87458(a)
- Regulation authority
- CCR
What the official deficiency says
87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in 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 1 out of 3 residents did not have a medical assessment on file which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 06/05/2026 Plan of Correction Licensee agreed to obtain a medical assessment for R1 and provide a copy of medical assessment to the Department by POC due date.