JBM RESIDENCE HOME, INC.

Official classification

Type A

Official code

87224(a)(5)(A)(1)

Regulation authority

CCR

What the official deficiency says

87224 Eviction Procedures (a) The licensee may evict a resident for ... (5) Change of use of the facility. (A) ... sixty (60) days written notice, evict ... 1. ... written notice ... shall be made to the resident or the resident’s responsible person ... This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above in not providing resident R1 and R2 and their responsible person(s) a proper 60 day written eviction notice which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee is moving forward with forfeiture of license. Licnsee will provide 60 day written eviction notices to RPs and submit copy of notice to the department.

Deadline recorded: Jul 14, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

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 interview and record review, the licensee did not comply with the section cited above in not obtaining liability insurance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/03/2026 Plan of Correction The licensee will obtain liability insurance by POC due date 07/006/2026

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in one (1) out of two (2) resident's medication being transferred from one bottle to another which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/04/2026 Plan of Correction The licensee will contact R1's physician and request a refill of the medication. Licensee will conduct vendorized training regarding medication and provide copy registration to training to the department by POC due date.

Official classification

Type B

Official code

1569.618(a)

Regulation authority

HSC

What the official deficiency says

(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. 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 the administrator has not been present at the facility during normal working hours in the last month which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/17/2026 Plan of Correction The licensee will complete time sheets when the administrator is present at the facility for the next two weeks and provide time sheets to the department by POC due date.

Official classification

Type B

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. 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 2 out of 2 residents not having physician orders for their medication which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/10/2026 Plan of Correction The Licensee will obtain prescription orders from the residents' physicians by POC due date.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. 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 residents not having reappraisals once every 12 months or as necessary which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/10/2026 Plan of Correction The licensee will update resident appraisals for both residents and send a copy to the department 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 interview and record review, the licensee did not comply with the section cited above in not conducting quarterly emergency drill each shift which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/10/2026 Plan of Correction The licensee will conduct two emergency drills, one for earthquake and one for fire for every shift and send documentation of completion with staff names for each shift completed to the department by poc due date.

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis... This requirement is not met as evidenced by: Based on interviews the licensee failed to call 911 immediately after the licensee suspected R1 had a " mini stroke " on 09/12/25 at approximately noon and waited to call 911 on 09/13/25 at approximately 11:00AM, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agreed to complete training on the regulation cited from a consultant. Licensee will provide the name of the consultant and training information along with the date the training is scheduled to LPA by POC due date 09/23/2025. Licensee will send a copy of the training completion certification to LPA.

Deadline recorded: Sep 23, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87224(a)

Regulation authority

CCR

What the official deficiency says

Eviction Notification (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required... This requirement is not met as evidenced by: Based on interviews the licensee failed to reassess R1 and failed to provide a 30 days written eviction notice to R1 and/or their responsible person, which posed an immediate health and safety risk to residents in care.

Official plan of correction

According to R1's responsible person, R1 will not be returning to the facility. Licensee agreed to complete training on the regulation cited from a consultant. Licensee will provide the name of the consultant and training information along with the date the training is scheduled to LPA by POC due date 09/23/25. Licensee will send a copy of the training completion certification to LPA.

Deadline recorded: Sep 23, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

...all residential care facilities for the elderly,... 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, ... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in not maintaining liability insurance which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will obtain liability insurance and send a copy of certification to LPA by POC due date.

Deadline recorded: Sep 6, 2025. A deadline is not proof that correction was completed.

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...Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance...(2)Bedridden persons. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above in that the facility has fire clearance for one bedridden resident and the facility currently has two bedridden residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The Licensee will ensure that the facility is in compliance with the fire clearance approved by the city or county fire department at all times. The Licensee will submit a written plan of action that will be implemented to ensure that the facility comes back into compliance and LIC200 with updated facility sketch to obtain additional bedridden fire clearance.

Deadline recorded: Sep 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on record review and interviews the licensee did not comply with the section cited above by retaining R1 who is not receiving hospice services and has a unstageable wound which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee agreed to submit an exception letter and required documentation to CCLD to retain resident with a prohibited health condition by POC due date.

Deadline recorded: Sep 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's ... appraisal... 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. This requirement is not met as evidenced by: Licensee did not comply with the section cited above by not obtaining a written order from a physician indicating the need for bed rail that extends from the head half the length of the bed which poses an immediate health, safety personal rights risk.

Official plan of correction

Licensee agreed to obtain a written order from a physician indicating the need for the bed rail. A copy of the order will be provided to LPA by POC due date.

Deadline recorded: Sep 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above in not meeting R1's grooming needs which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Licensee has trimmed R1's nails twice as of admission. Submit a grooming schedule for R1 to LPA by POC due date.

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

Official classification

Type B

Official code

87464(d)

Regulation authority

CCR

What the official deficiency says

(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs...This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above in not meeting R1's ambulating needs which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Licensee will submit a physical therapy schedule and what the staff at the facility most assist with regarding physical therapy plan to LPA by POC due date.

Deadline recorded: Sep 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

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)... (B)Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care...This requirement is not met as evidenced by: Licensee did not comply with the section cited above by utilizing full bed rails for R1 who does not receive hospice care services which poses an immediate health, safety personal rights risk .

Official plan of correction

Licensee will remove bed rails that extend the entire length of the bed for R1 send a picture to LPA by POC due date . Half bed rails may be obtained if a written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.

Deadline recorded: Aug 12, 2025. A deadline is not proof that correction was completed.

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...Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance...(2)Bedridden persons. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above in that the facility has fire clearance for one bedridden resident and the facility currently has two bedridden residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The Licensee will ensure that the facility is in compliance with the fire clearance approved by the city or county fire department at all times. The Licensee will submit a written plan of action that will be implemented to ensure that the facility comes back into compliance and Licensee will submit an LIC200 and updated facility sketch to obtain a bedridden fire clearance if they decide to retain a second bedridden resident.

Deadline recorded: Aug 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on record review and interviews the licensee did not comply with the section cited above by retaining R1 who is not receiving hospice services and has a unstageable wound which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee agreed to submit an exception letter to CCLD to retain resident with a prohibited health condition. Licensee will request Wound Care Plan from wound care agency and facilities own care plan (LIC622) submit it to LPA by POC due date.

Deadline recorded: Aug 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

...all residential care facilities for the elderly,... 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, ... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in not maintaining liability insurance which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will obtain liability insurance and send a copy of certification to LPA by POC due date.

Deadline recorded: Aug 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87632(a)

Regulation authority

CCR

What the official deficiency says

(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department... and any future residents who may request acceptance, ... This requirement is not met as evidenced by: Based on record review and interviews the licensee did not comply with the section cited above in accepting a second resident receiving hospice services when the facility has a hospice waiver for only one resident which posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Currently facility is back to serving only one(01) resident with Hospice services. The Licensee will ensure that the facility is in compliance with their hospice waiver at all times. The Licensee will submit a written statement of understanding about their current Hospice waiver and Licensee will submit statement to LPA by POC due date.

Deadline recorded: Aug 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87207

Regulation authority

CCR

What the official deficiency says

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. Based on interviews the licensee did not comply with the section cited above in false or misleading statements on two different days regarding the same question about the number of residents receiving Hospice services in the facility which posed an potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Licensee will submit a written statement of understanding about the cited regulation and submit statement to LPA by POC due date.

Deadline recorded: Aug 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained... This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above in four (04) out of four (04) residents' centrally stored medication not being properly recorded which poses a potential health, safety or personal rights risk to persons in care

Official plan of correction

The Licensee has agreed to updated Centrally Stored Medication and Destruction Records (LIC622) for each resident as per facility program. Copy of LIC 622 will be sent to LPA by POC due date.

Deadline recorded: Aug 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(b)(2)

Regulation authority

CCR

What the official deficiency says

(b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range... or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement is not met as evidenced by: Based on LPA's interviews and observation the facility's air conditioning system was observed to be inoperable which poses an potential Health, Safety or Personal Rights risks to persons in care.

Official plan of correction

The licensee will email LPA Rios the receipt of service showing the air-conditioning (AC) was fixed. Licensee will purchase portable AC units for each room with a residnet if the AC is not working on August 12, 2025.

Deadline recorded: Aug 15, 2025. A deadline is not proof that correction was completed.

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 and interview, the licensee did not comply with the section cited above in the back exterior door leading to the backyard was missing a door knob which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2025 Plan of Correction Licensee will submit a picture of the fixed door with a door knob to LPA POC due date.

Official classification

Type B

Official code

87506(b)(17)(E)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (E) Section 87463, Reappraisals; and This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews and record review, the licensee did not comply with the section cited above in one (01) out of four (04) resident who do not have a reappraisal and were identified as having a wound which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2025 Plan of Correction Licensee will submit a reappraisal for resident #1(R1) by POC due date.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained... 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 three (03) out of four (04) residents' medication not being properly recorded with required information which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2025 Plan of Correction The Licensee has agreed to updated Centrally Stored Medication and Destruction Records (LIC622) for each resident as per facility program. Copy of LIC 622 will be 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 in not maintaining liability insurance which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2025 Plan of Correction Licensee will obtain liability insurance and send a copy of certification to LPA by POC 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...Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance...(2)Bedridden persons. This requirement is not met as evidenced by: Based on observation and record review the licensee did not comply with the section cited above in that the facility has fire clearance for one bedridden resident and the facility currently has two bedridden resdients which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The Licensee will ensure that the facility is in compliance with the fire clearance approved by the city or county fire department at all times. The Licensee will submit a written plan of action that will be implemented to ensure that the facility comes back into compliance by 5/09/2025 and Licensee will submit an LIC200 and updated facility sketch to obtain a bedridden fire clearance if they decide to retain a second bedridden resident.

Deadline recorded: May 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

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: Licensee did not comply with the section cited above by utilizing full bed rails for R1 and R5 who are no longer on hospice which indicates the need which poses an immediate health, safety personal rights risk .

Official plan of correction

Licensee will remove bed rails that extend the entire length of the bed for R1 and R5 and send a picture to LPA by POC due date 05/08/2025. Half bed rails may be obtained if a written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.

Deadline recorded: May 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

87458(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: Based on record review the licensee did not comply with the section cited above in that the facility did not obtain a medical assessment with TB test for R1 prior to admittance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee states R1's doctor has the form and is waiting for it to be completed and provided. Licensee will provide a statement of understading regarding the regulaton cited and submit to LPA by POC due date 05/16/2025. Licensee will obtained and a copy of R1's medical assessment/Physician's Report (LIC602A) with TB test results and will submit a copy as proof of correction.

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

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... (1) The appraisal shall document, at a minimum:(A)An evaluation of the prospective resident's functional capabilities...This requirement is not met as evidenced by: Licensee did not comply with the section cited above in two out of five resdients had no preplacement appraisal on file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Licensee will complete the appraisal forms for R1 and submit a copy of the forms to LPA by POC due date 5/16/2025.

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

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: Based on observation the licensee did not comply with the section cited above in that LPA smelled a urine odor in bedroom #1 and the section of the facility where the bedroom is located by the formal dining area smelled of urine which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will make sure that the residents rooms are free of odors and sanitary at all times. Licensee will submit a plan to LPA for how the facility will return and remain in compliance by POC due 05/16/2025.

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

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... each employee. Each personnel record shall contain the following information:(11)A health screenings specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above in that staff #1's (S1's) record was incomplete missing health screening and TB test result which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee stated she will not return to work until health screening with TB is completed. Licensee will provide a copy S1's health screening with TB test results by POC due 05/16/2025.

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

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on record review and interviews the licensee did not comply with the section cited above by retaining R3 who is not receiving hospice services and has a stage 4 wound which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Resident expressed they do not wish to live anywhere else at this time but will eventually like to live somewhere else. Licensee will submit an exception letter to CCLD to retain resident with a prohibited health condition. Licensee will request Wound Care Plan from wound care agency and submit it to LPA by POC due date 05/08/2025.

Deadline recorded: May 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87470(4)(A)(3)

Regulation authority

CCR

What the official deficiency says

(4) All facility staff and volunteers shall use gloves...(A)Gloves shall always be worn when: 3...assisting with incontinence when there is a risk of contact with blood, body fluids or other potentially infectious material. This requirement is not met as evidenced by: Based on observation LPA Rios observed the Licensee change a resident without using gloves, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will take vendorized training on infection coltrol porocedures and submit certificate of completion to LPA by POC due date 05/16/2025.

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

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training...(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: Based on the LPA's record review and interviews, the licensee did not comply with the section cited above in 6 staff not having active 1st aid and CPR certification which poses an potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator has AGREED to submit 1st aid CPR certification to LPA by POC date.

Deadline recorded: Nov 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87407(e)(1)

Regulation authority

CCR

What the official deficiency says

87407 (e)To apply for recertification after the expiration date of the certificate, but within four (4) years of the certificate expiration date, the certificate holder shall submit to the Department’s Administrator Certification Section: (1) A completed Application for Administrator Certification form LIC 9214. (2)Evidence of completion of the required continuing education hours…(3)Payment of a non-refundable delinquency fee… This requirement is not met as evidenced by: During today's inspection, the Administrator has failed to renew Administrator's certificate, or provide proof payment or training submission has been sent to Sacramento which poses an potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator has AGREED to submit a change of administrator to LPA by POC date.

Deadline recorded: Nov 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on the LPA's record review and interviews, the licensee did not comply with the section cited above in 2 staff not having on going training on file and S1 and administrator who was also working other shifts providing care for 5 residents which posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee has hired a second staff and S1 has orientation and ongoing training on file as of todays visit. Licensee will submitt required orientation training for new staff, S6 and an updated LIC500.

Deadline recorded: Nov 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.618(a)

Regulation authority

HSC

What the official deficiency says

(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. 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 not providing the department notice of a designated manager when they were not aviable which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2024 Plan of Correction LIcensee will provide LPA the LIC308 and a statement of understanding for the cited regulation by POC due date 10/31/2024.

Official classification

Type B

Official code

87755(c)

Regulation authority

CCR

What the official deficiency says

(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b). This requirement is not met as evidenced by: Deficient Practice Statement Based interview and record review, the licensee did not comply with the section cited above in not making themselves available to provide records upon request which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2024 Plan of Correction Licensee will contact LPA once they are available (M-F 8 a.m. to 5:00 p.m.). Licensee will provide a statement of understanding on the cited regulation to LPA by POC due date 10/31/2024.

Official classification

Type B

Official code

87457(c)(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 his/her individual service needs...(A)The licensee shall be permitted to use the form LIC 603 (Rev. 6/87), Preplacement Appraisal Information, to document the appraisal. This requirement was not met as evidenced by: Based on interview and record review conducted with the administrator, they failed to complete an appraisal for R2 which poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator will complete an appraisal for R2 and submit to LPA by POC due date.

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

Official classification

Type B

Official code

87211(a)(1)(A)

Regulation authority

CCR

What the official deficiency says

87211(a)(1)(A) Reporting Requirements. The licensee shall send a written report to the licensing agency and the person responsible for the resident when a resident dies, regardless of cause or where death occurred, within seven days of the death. This requirement was not met as evidenced by: Based on interview conducted with the administrator, revealed that they failed to submit a death report for R3 to CCL which poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator will submit Death Report along with the death certificate for R3 to LPA by POC due date.

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

Official classification

Type A

Official code

87632(a)

Regulation authority

CCR

What the official deficiency says

(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department... This requirement is not met as evidenced by: Based on interview and record review, Administrator did not comply with the above section by failing to obtain a hospice care waiver and accepted or retained two (2) terminally ill residents, which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

As of todays visit facility only has one (1) resident receiving hospice care. Administrator will sign a declaration that they will ensure the facility abides by the regulation cited. Signed declaration will be sent to LPA by POC date.

Deadline recorded: Feb 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87608(a)(5)(D)

Regulation authority

CCR

What the official deficiency says

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: Based on observations made and record review, the licensee did not comply with the section cited above by utilizing full bedrails for R2 who is not on hospice which poses an immediate health, safety and personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator will 1. Remove full bed rails on R2's bed and submit a picture to LPA 2. Request a current physician order indicating the need for a bed rail by POC date.

Deadline recorded: Jan 27, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5)Each resident with dementia shall have an annual medical assessment...and a reappraisal done at least annually... This requirement is not met as evidenced by: Based on record reviews, the licensee did not comply with the section cited above by not ensuring a annual medical assessment for three(3) out of four(4) residents with dementia which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

Licensee/ Administrator will schedule medical assessments for 3 (R1, R2, R3) out of the 4 resident's in care and the most recent Medical Assessment / Physicians Report to LPA by 01/27/2023.

Deadline recorded: Jan 27, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87625(b)(2)

Regulation authority

CCR

What the official deficiency says

87625(b) ... the licensee shall be responsible for the following:(2)Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This requirement is not met as evidenced by: Based on interview and record review, Administrator did not comply with the above section by failing to check R1 incontinent resident in regular intervals including during the night, which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

The administrator has agreed to the following:1. Update resident's Appraisal and Needs and Service plan to include the incontinent care plan. Plan shall come from an appropriate skilled professional. Submit to CCL. 2. Conduct incontinent care training for staff.

Deadline recorded: Jan 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the administrator did not comply with the section cited as the fire extinguisher was purchased on 2/24/2020 and has not been serviced since which poses an immediate health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/17/2022 Plan of Correction The licensee will have the fire extinguisher serviced or purchase a new one by the POC due date. Proof of service or new purchase of fire extinguisher date to be sent to LPA by e-mail.