GLEN PARK AT LONG BEACH

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required... This requirement is not met as evidence by: Based on interview, Licensee failed provide necessary supervision services to meet resident needs and eloped from the facility unattended. This violation possesses a potential Health and Safety risk to residents in care.

Official plan of correction

The Licensee will adhere to the regulations and ensure review of Title 22, Section 87411. The Licensee will provide care staff training to address (NCD) wandering and elopement behaviors—proof of correction, including a sign sheet, to be sent by fax to the El Segundo Regional office at 424-544-1016 by 08/27/26.

Deadline recorded: Aug 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87505(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. Based on observations, interviews, and record review Staff failed to ensure medications were documented as administered or refused for R1, R13, R14, R16-R21, This poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator will develop a plan to ensure that medication administration records are checked frequently to avoid discrepancies. Administrator will submit plan to LPA by POC due date.

Deadline recorded: Jul 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (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...(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. This requirement was not met based on record review, interviews, and observations, there was no incident reports submitted to CCL for the incidents of R1 on 4/13/2026 or of R1's Emergency Room visit on 04/17/2026, which poses a heath and safety risk.

Official plan of correction

Staff retraining regrading reporting incidents to CCL and Responsible party was conducted in June 2026. The Administrator will email the staff training log to LPA at Wendy.Gibbs@dss.ca.gov by POC due date.

Deadline recorded: Jul 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(d)(5)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. This requirement was not met based on an incident of R1 who was observed with feces in their mouth on 04/13/2026 and was not evaluated by a medical professional on 04/17/2026 due to abdominal pain.

Official plan of correction

Administrator will retrain staff on documenting communication with the Primary Care Physician and Responsible Party of resdients regarding incident that occur. Administrator will email the staff training log to LPA at Wendy.Gibbs@dss.ca.gov by POC due date.

Deadline recorded: Jul 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

HSC

What the official deficiency says

87303 Maintenance and Operation (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 was not met based on interviews and observations, LPA observed on 04/30/2026, in room 245 the handle on the closet door was broken and the shower head spayed outside the shower, which poses a health and safety risk

Official plan of correction

During a visit on 06/02/2026, LPA observed the handle and shower head were replaced. Administrator

Deadline recorded: Jul 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465)(c)(2) Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need .. facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on the records review, staff administered (R1) Buspirone, Hydrocodone, Metformin, and Metoprolol in error. The facility reported a medication not prescribed to (R1). This violation poses/posed an immediate risk to persons in care.

Official plan of correction

Licensee shall provide medication administration retraining. This training shall be provided by pharmacy and/or registered nurse. Submit proof of training by POC due.07/09/26.

Deadline recorded: Jul 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)(A-F)

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...(A-F) records for centrally stored medications...based on records review the Department identified that for July 2026 there were 16 medication documentation errors that affected 4 residents, indicating medications were not documented as required which poses a potential health and safety, and personal rights risk to persons in care.

Official plan of correction

Executive Director will retrain all medication staff on MAR documentation requirements in order to get into compliance with title 22 regulation. A weekly MAR review will be implemented to ensure all entries are completed correctly with signatures and correct dates tht match. LPA to receive proof by POC due that the med room staff was retrained. Training materials, staff sign in sheet, and a documented from Executive Director self certifying the review and understandment of the regulation being cited. Lizeth.villegas@dss.ca.gov

Deadline recorded: Jul 21, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(8)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services including ongoing evaluations... This requirement was not met as incident reports dated 07/08/2025, 10/11/2025, 11/23/2025, and 01/21/2026 showed “No” contact made with R1’s authorized representative, with no documentation of communication. This poses a potential health and safety risk.

Official plan of correction

The Administrator shall retrain staff on required notification procedures for authorized representatives by ensuring responsible parties are notified of all incidents and requests, with documentation completed accordingly. The facility shall submit proof of training to the Department via email at Zina.Brown@dss.ca.gov by the POC due date.

Deadline recorded: Jul 21, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465

Regulation authority

CCR

What the official deficiency says

87465)(c)(2) Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on the records review, facility staff did not verify the medication record and administered medication Metform that was not prescribed to (R1). The facility reported a medication error: administering the wrong medications intended for another resident with the same last name. This violation poses/posed an immediate risk to persons in care.

Official plan of correction

Licensee shall provide medication administration in-service training to all staff that dispense medications. This training shall be provided by pharmacy and/or registered nurse. Submit proof of training by POC due.06/16/26. Citation was cleared during the visit. Medication training took place on 06/10/26 with a registered nurse.

Deadline recorded: Jun 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities(a)...in all residential care facilities for the elderly...all of the following personal rights:(2)To be accorded safe...accommodations...This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee failed to ensure R1’s personal rights were protected. R1 experienced repeated sleep disruption due to R2’s loud television. This poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Licensee agreed to find a better room for R1 in order to help R1's personal rights by due date and email LPA: jose.anguiano@dss.ca.gov

Deadline recorded: Jun 10, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medication as needed Based on observation and record review, the Department identified eight (8) residents and nine (9) medications remaining in bubble packs despite being initialed as administered, posing a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Administrator will complete an immediate medication audit & ensure all medications are administered & documented correctly. Also Administrator will provide proof of scheduled in-service training from a contracted pharmacy on proper administration of medication & proper MAR documentation... for all staff who handle meds. Proof of the completed medication audit in detail and scheduled date and time for the in-service training with contracted pharmacy on proper medication administration by the POC due date to LPA Brown at Zina.Brown@dss.ca.gov.

Deadline recorded: Jun 4, 2026. 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 a record of centrally stored prescription medications for each resident is maintained ...(A-F) records for centrally stored medication... Based on record review, the Department identified 42 undocumented medication administrations affecting eight (8) residents, indicating medications were not documented as required, which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Administrator will retrain all medication staff on MAR documentation requirements under 87465(h)(6)(A–F). A weekly MAR review will be implemented to ensure all entries are complete, accurate & must be signed & dated daily. The administrator will submit proof of completed retraining for... MAR documentation requirements & weekly MAR review entries are conducted & must be reviewed by being signed & dated for confirmation of review being completed by the POC due date and email proof to LPA Brown at Zina.Brown@dss.ca.gov

Deadline recorded: Jun 24, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on observations, interviews, and record review, the licensee did not comply with the section cited above, in not ensuring that R1's room was free of excessive items, vermin, and vermin droppings. This poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

The Executive Director has agreed to create a plan with R1 to maintain R1’s room free of clutter, human waste, and vermin. A plan to maintain R1’s room and bathroom free of clutter, human waste, and vermin will be emailed to Socorro.Leandro@dss.ca.gov. Progress of R1's room will be submitted to the Department on a weekly basis up until 07/03/2026. Pictures of R1's room/bathroom along with an Unusual Incident/Injury Report (UIR) will be faxed to the Departments at 424-544-1016.

Deadline recorded: May 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements (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. This requirement is not met as evidence by: Based on record review, the licensee did not comply with the section cited above in not submitting Unusual Incident to the department for incidents with Resident 1 on 2/20/2025, 3/20/2025, 3/11/2025, 3/22/2025, and 2/17/2025. This posed a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

The Executive Director has agreed to retrain staff on Reporting Requirements. Email trainings to Socorro.Leandro@dss.ca.gov.

Deadline recorded: Jun 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

Reappraisals (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 evidence by: Based on record review, the licensee did not comply with the section cited above in not having a yearly reappraisal for Resident 1 (R1). This posed a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

The Executive Director has agreed to create an updated reappraisal with R1 and email updated reappraisal to Socorro.Leandro@dss.ca.gov.

Deadline recorded: Jun 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(h)(1-3)

Regulation authority

CCR

What the official deficiency says

Reappraisals (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. (2) Documentation of a resident's refusal to receive an annual routine visit, or if applicable, their representative's refusal on their behalf, shall be added to the resident's record. (3) If a resident refuses to receive an annual routine visit, or if applicable, their representative refuses an annual routine visit on their behalf, but later agrees to one, documentation of the annual routine visit shall be added to the resident’s record. This requirement is not met as evidence by: Based on record review, the licensee did not comply with the section cited above in not having a documented annual medical routine visit for R1. This posed a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

On 5/29/2026, the Executive Director provided LPA with an updated physician's report for R1.

Deadline recorded: Jun 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

Incidental Medical & Dental Care (a) A plan for incidental medical care shall be developed by each facility. The plan shall encourage routine medical care & assist in obtaining care, by compliance with..: (4) the licensee shall assist residents with self-administered medication as needed This requirement was not met as evidenced by interviews, observations, and record review showing medications for R1, R5, and R9 were not administered as prescribed. However, LPA observed medications not given but signed out, posing a health and safety risk to residents.

Official plan of correction

The Administrator will have a licensed Pharmacist provide additional medication training for all the medtech and the LVN will conduct daily audits for Medication Administration for the next 30 days. The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

Deadline recorded: Jun 3, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medication as needed Based on observation and record review: The Department observed medications remaining inside bubble packs despite being initialed as administered and or not being initialed on the MAR which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Administrator will arrange an in‑service medication‑management training with the facility’s contracted pharmacy for all medication‑assisting staff. Training will include proper MAR documentation and ensuring medications are initialed at the time of administration. The Administrator will submit proof of completed pharmacy in-service training to the Department by the due date.

Deadline recorded: May 6, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(f)(1)

Regulation authority

CCR

What the official deficiency says

Personnel Records: All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. . .information is otherwise readily available in another document or format. Based on observation and record review, the facility did not provide staff training upon request in a timely manner for staff from hire date to present. This posed a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

Facility will submit all staff training records for the employees listed on the LIC811 from Complaint Control #11-AS-20251104162513. and submit the plan of correction by due date and email proof to LPA Brown at Zina.Brown@dss.ca.gov

Deadline recorded: May 13, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by: Based on interviews, observations, and records review, the licensee failed to ensure a safe and healthful environment for R1, as the resident was subjected to ongoing roommate conflict, including noise disturbances and disruption of sleep, despite having a medical condition requiring dialysis and rest. Staff were aware of the issue for several months and completed incident reports; however, the facility failed to implement timely and effective corrective action to resolve the situation. This violation poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

PLAN OF CORRECTION (POC): Licensee agrees to submit a Plan of Correction to LPA Jose Anguiano by due date and emailed to: Jose.Anguiano@dss.ca.gov

Deadline recorded: Apr 1, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility.The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by Based on observation, records, and interviews, the facility failed to ensure that routine, time-sensitive medications for Resident R1 were administered at the prescribed times. This violation poses/posed a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to send LPA a plan of correction on due date. jose.anguiano@dss.ca.gov

Deadline recorded: Mar 11, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met by: Based on interviews & records review, the facility did not have any written refusals of showers for R1 on file nor could staff provide an exact date of the last time R1 received a shower and or bed bath.

Official plan of correction

The Administrator will conduct training on personal rights and the necessary reporting requirements for CDSS CCL. Additionally, the Administrator will implement an internal data sheet to track resident refusals of ADLs. The administrator submit proof of training and internal data sheet for resident refusals of ADLs by the plan of correction due date and email proof to LPA Brown at Zina.Brown@dss.ca.gov

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

Official classification

Type B

Official code

87224(d)

Regulation authority

CCR

What the official deficiency says

87224 Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement is not met as evidenced by: Based on interviews and records review the licensee did not comply with the section cited above in the 30-day notice issued by the licensee on 05/07/2025 did not state specific facts on why R1 was not an appropriate fit for the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Interim Executive Director, Catherine Dacara has agreed to re-read CCR 87224 Eviction Procedures (d), create a plan to stay in compliance with CCR’s Eviction Procedures, and to retrain staff on eviction procedures and email proof of corrections. Email to: Socorro.Leandro@dss.ca.gov Zina.Brown@dss.ca.gov Janae.Hammond@dss.ca.gov

Deadline recorded: Feb 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents: (3) To be free from punishment, humiliation, intimidation, abuse, or actions of a punitive nature, such as withholding money or interfering with daily living functions. This requirement was not met as evidenced by: Based on interview & records review, facility Staff 1 (S1) sexually abused Resident 1 (R1) by kissing R1 on the neck & touching their own groin area in front of R1. This violation poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator shall ensure a training for all staff on Title 22, Section 87468.1 “Personal Rights” is conducted & send the sign in sheets and training materials to the CCLD by the Plan of Correction (POC) due to the attention of: Zina.Brown@dss.ca.gov

Deadline recorded: Jan 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (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 centrally stored medications. This requirement was not met as evidence during record review, observation, and interviews, during medication audit staff were unable to locate 3 of R4’s PRN medications, 4 of R6’s medications, and 1 of R9’s medications.

Official plan of correction

The Licensee agrees to retrain staff on properly storing centrally stored medications and ensuring they are secured and will work with TSP to implement new procedures they feel is needed. Training Logs will be emailed to LPA by POC.

Deadline recorded: Jan 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements(a)(1)Each licensee shall submit serious incident reports to. . . the Department may require, including the following: (1) A written report shall be submitted to the licensing agency & to the person responsible for the resident within 7 days of the occurrence of any of the events This requirement was not met as evidenced by: based observation, LPA observed that the facility did submit a LIC 624 to the department within 7 day of incident occurring.

Official plan of correction

The facility shall will submit a serious incident reports (by 01/08/2026) for the incident that occur on 12/09/2025 with the resident (R10) who had an unwitnessed fall & went to the hospital. Also the facility will conduct an in-service training on reporting requirement for all staff. The completion of training must be fax to 424-544-1016 or zina.brown@dss.ca.gov to department by POC due date.

Deadline recorded: Jan 21, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87628(b)(1-3)

Regulation authority

CCR

What the official deficiency says

Diabetes (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (1) Assisting residents with self-administered medication as specified in Section 87465, Incidental Medical and Dental Care Services. (2) Ensuring that sufficient amounts of medicines, testing equipment, syringes, needles and other supplies are maintained and stored in the facility as specified in Section 87465(c). (3) Ensuring that syringes and needles are disposed of as specified in Section 87303(f)(2). This requirement is not met as evidenced by: Based on observation, interviews and records reviewed the licensee did not comply with the section cited above in not assisting residents with self-administering medications such as insulin injections and glucose testing with a glucometer, the facility did not ensure that sufficient amounts of testing equipment such as glucometers were in the facility, and the facility has improperly disposed of needles, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Executive Director has agreed to read Diabetes 87628 (b)(1-3) and create a plan to stay in compliance. The Executive Director has agreed to train Medical Technicians (MedTechs) on “hand-over-hand.” The plan and trainings will be emailed to Socorro.Leandro@dss.ca.gov

Deadline recorded: Jan 15, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(1)(A)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (A) The preservation of medicines requires refrigeration, if the resident has no private refrigerator. 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 preserving medication as required because the medication that required refrigeration was in a refrigerator that was too hot, the refrigerator was at 55 degrees Fahrenheit and insulin medication and other medications needed to be refrigerated at 36 to 46 degrees Fahrenheit, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

On 12/12/2025, staff placed a new refrigerator in the medication room The Executive Director has agreed to create a plan to preserve medication that requires refrigeration, follows medication guidelines and at correct temperature. The Executive Director has agreed to train staff on said plan. The plan and trainings will be emailed to Socorro.Leandro@dss.ca.gov

Deadline recorded: Jan 15, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87628(a)

Regulation authority

CCR

What the official deficiency says

Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee did not comply with the section cited above by not ensuring a skilled professional was administering insulin through injections to residents in care which poses/posed a potential health and safety risk to persons in care.

Official plan of correction

The Executive Director has agreed to ensure that a skilled professional will administer insulin through injections to residents who are unable to perform their own injections. The Executive Director will create a plan to ensure that a skilled professional will be in the facility during the times that residents require their insulin injections. The plan will be emailed to Socorro.Leandro@dss.ca.gov

Deadline recorded: Dec 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements - General: All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. Based on observation and interviews, the facility failed to ensure all caregivers complete the required 2025 training per Title 22 regulations.

Official plan of correction

The facility will ensure all caregivers will complete all annual training needed to be in compliance with Title 22 regulations. The facility will submit proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016, Attn: Zina Brown, or via email at zina.brown@dss.ca.gov by the POC due date.

Deadline recorded: Jan 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a-j)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. (3) When residents require prosthetic devices, vision and hearing aids, the staff shall be familiar with the use of these devices, and shall assist such persons with their utilization as needed. (4) The licensee shall assist residents with self-administered medications as needed. (5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician. (B) Medications during an illness determined by a physician to be temporary and minor. (C) Assistance required because of tremor, failing eyesight and similar conditions. (D) Assistance with self-administration does not include forcing a resident to take medication, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication. (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. (7) There shall be adequate privacy for first aid treatment of minor injuries and for examination by a physician if required. (8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. (B) Sterile first aid dressings. (C) Bandages or roller bandages. (D) Scissors. (E) Tweezers. (F) Thermometers. (9) The licensee shall ensure that infection control practices are maintained in the facility as specified in Section 87470, Infection Control Requirements. (b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. (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 in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation. (2) Once ordered by the physician the medication is given according to the physician's directions. (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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) Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. (2) The date and time of each contact with the physician, and the physician's directions, shall be documented and maintained in the resident's facility record. (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. (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 residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (1) The specific symptoms which indicate the need for the use of the medication. (2) The exact dosage. (3) The minimum number of hours between doses. (4) The maximum number of doses allowed in each 24-hour period. (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. (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 except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). (h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (A) The preservation of medicines requires refrigeration, if the resident has no private refrigerator. (B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others. (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. (3) Each container shall carry all of the information specified in (6)(A) through (E) below plus expiration date and number of refills. (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy (F) Instructions, if any, regarding control and custody of the medication. (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: (1) Name of the resident. (2) The prescription number and the name of the pharmacy. (3) The drug name, strength and quantity destroyed. (4) The date of destruction. (j) In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated as having primary responsibility for assuring that each resident receives needed first aid and needed emergency medical services and for assisting residents as needed with self-administration of medications. The names of the staff employees so responsible and the designated procedures shall be documented and made known to all residents and staff. This requirement is not met as evidenced by: Based on interviews, observation, and records reviewed, the licensee did not comply with the section cited above, the facility did not ensure that residents received their required medical care, in not having a skilled professionals provide injections and blood sugar checks for residents in care, thus, residents missed said medical care and medication, furthermore, insulin medication/medication that had to be kept refrigerated was in refrigerator that was too hot; moreover, needles were improperly discarded, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Executive Director has agreed to read California Code of Regulations (CCR) Incidental Medical and Dental Care and create a plan to follow said regulations. The Executive Director has agreed to create a plan to ensure that a skilled professional will provide medical care and medication as required by their residents. The Executive Director will include in their plan training to their MedTechs: on hand over hand, disposing of needles, infection control, what happens if they get pricked by a needle, daily documentation of medication room refrigerators, MAR documentation, and what to do when residents miss their medication and blood sugar check. Email proof of correction to Socorro.Leandro@dss.ca.gov

Deadline recorded: Jan 3, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(8)(9)(28)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements (b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above in not having all food of good quality, not having all food in storage, and not protecting food from contamination, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Executive Director has agreed to read California Code of Regulations (CCR) General Food Service Requirements and create a plan to follow said regulations. The Executive Director has agreed to include in the plan: daily observation of food and discard food if it is not of good quality,... properly store food, and protect all food from contamination. The Executive Director has agreed to retrain kitchen staff. Email proof of correction to Socorro.Leandro@dss.ca.gov

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

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

Incidental Medical & Dental Care (a) A plan for incidental medical care shall be developed by each facility. The plan shall encourage routine medical care & assist in obtaining care, by compliance with..: (4) the licensee shall assist residents with self-administered medication as needed This requirement was not met as evidenced by interviews, observations, and record review showing medications for R1, R5, and R9 were not administered as prescribed. However, LPA observed medications not given but signed out, posing a health and safety risk to residents.

Official plan of correction

The Administrator will have a licensed Pharmacist provide additional medication training for all the medtech and the LVN will conduct daily audits for Medication Administration for the next 30 days. The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

Deadline recorded: Dec 17, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87224(a-f)

Regulation authority

CCR

What the official deficiency says

87224 Eviction Procedures (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.(1) Nonpayment of the rate for basic services within ten days of the due date ...(3) Failure of the resident to comply with general policies of the facility. Said general policies must be in writing, must be for the purpose of making it possible for residents to live together and must be made part of the admission agreement. (4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident...(f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by: Based on interviews and records review the licensee did not comply with the section cited above in not describing how R1 did not follow the general policies of the facility nor explain how R1 is not an appropriate fit for the facility. Furthermore, the facility did not provide a written report to the department within 5 days of providing an eviction to R1.

Official plan of correction

The Assistant Administrator has agreed to edit R1's Thirty Day Notice to Quit to be in compliance with CCR Eviction Procedures and re-submit it to the department. Once the department reviews the Thirty Day Notice to Quit and indicates that it is within compliance of CCR Eviction Procedures, the facility will be able to provide R1 with the updated Thirty Day Notice to Quit. The facility will also, notify the department in writing within 5 days of serving R1 of an eviction. Email LPA Leandro, LPA Brown, and LPM Hammond.

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

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (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. This requirement is not met as evidenced by: Based on interviews and records review the licensee did not comply with the section cited above in not submitting Unusual Incident Reports to the facility regarding having Sherriffs coming out to the facility and providing R1 with a L.A. Superior Court, Long Beach, Eviction Restoration Notice dated 10/06/2025.

Official plan of correction

The Assistant Administrator has agreed to: fax Unusual Incident Reports regarding R1 to the department; re-read CCR Reporting Requirements and understand the regulation; re-train staff on how to submit Unusual Incident Reports. Email proof of correction to Socorro.Leandro@dss.ca.gov

Deadline recorded: Oct 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)(A-F)

Regulation authority

HSC

What the official deficiency says

Incidental Medical and Dental Care. The following...shall apply to medications...stored: The licensee shall be responsible for assuring that a record of...medications for each resident is maintained...medication. This requirement was not met as evidence by: Based on observation and record review, the licensee did not comply with the section cited above,On 07/25/2025, 3 out of 3 resident medications were missing and unaccounted for this poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee agreed to create a plan to have all staff giving medications recount all the residents’ routine & PRN medications by the end of their shift. All staff assisting residents with medication to be re-trained by a licensed professional pharmacist. Proof of correction to be submitted to the department via email Jose.anguiano@dss.ca.gov by POC due date.

Deadline recorded: Aug 21, 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

Basic Services. . .However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal . . . Based on conducted interviews and records review the licensee failed provide the dietary needs as specified in Replacement Appraisal and Appraisal/Needs & Service Plan for Resident (R1).This poses a potential Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

The licensee will honor the dietary needs of all the residents as specified in Pre-Admission, Replacement Appraisal and Appraisal Needs & Service Plan. The licensee will ensure the dietary need for all residents are posted in the kitchen and on all the tables of the dining room. The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

Deadline recorded: Aug 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)(A-F)

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 for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication. Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above for LPA observed 9 out of 9 resident MARs to indicate that medication was given but no signature. LPA also observed medication not administered but had signature indicated that it was administered, this poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/07/2025 Plan of Correction The licensee will have all staff who assist residents in care with medication administration to be re-trained by a licensed professional pharmacist. Proof of the training conducted to be submitted to the de[artment via email zina.brown@dss.ca.gov by POC due date and also the licensee to ensure medication audits are conducted regularly to avoid discrepencies.

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 observation, interview and records review the licensee did not comply with the section cited above as staff #9 did not have a personnel record on file for LPA to review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction The licensee will personnel records such as the LIC 501, LIC 503 with TB Test results, LIC 508, First Aid/CPR certification for Staff #9 and submit proof to the department by via email at zina.brown@dss.ca.gov by POC due date.

Official classification

Type B

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

87464(f)(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement was not met as evidenced by: Based on records reviewed and interviews, On 07/23/25, MAR's for R1, R3, and R4 for March-May 2025 revealed discrepancies, and various medications were missed on various dates for R1, R3, and R4, for the months of March, April, and May 2025which poses/posed a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee will provide training for all med techs to attend regarding policies and procedures for medications. Proof of training will be sent to LPA before POC due date.

Deadline recorded: Aug 6, 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

Basic Services. . .However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal . . . Based on conducted interviews and records review the licensee failed provide the dietary needs as specified in Replacement Appraisal and Appraisal/Needs & Service Plan for Resident (R1). This poses a potential Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

The licensee will honor the dietary needs of all the residents as specified in Pre-Admission, Replacement Appraisal and Appraisal Needs & Service Plan. The licensee will ensure the dietary need for all residents are posted in the kitchen and on all the tables of the dining room. The facility will submit the proof of correction to the CCLD/El Segundo ASC Office via fax at 424-544-1016 Attn: Zina Brown or via email at zina.brown@dss.ca.gov by the POC due date.

Deadline recorded: Jul 17, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Each licensee shall furnish to the licensing agency such reports as the Department may require...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. Based on interviews conducted and records review licensee failed to report that R1 was placed on a 5150 hold which poses a health and safety risk to residents in care

Official plan of correction

Director to submit a plan to ensure facility is in compliance with 87211 (a)(1) and submit plan outlining the steps that will be taken to ensure compliance of section cited. Plan to be submitted to LPA by POC due date

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

Official classification

Type B

Official code

87224(a)(4)

Regulation authority

CCR

What the official deficiency says

The licensee may evict a resident for one or more of the reasons... (30) days written notice to the resident is required except...If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant... and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. Based on interviews and record review the licensee did not comply with the section cited above as there was no indication that there was significant change in R1, R1 did not have a need that was not previously identified. which poses a health and safety risk to residents in care.

Official plan of correction

The licensee and executive director will review title 22 eviction regulations and submit a statement acknowleding the review and acknowledge the understanding of title 22 regulations. Licensee and executive director to submit a written plan detailing how facility will get into complaince of title 22 regulations. Plan to be submitted to LPA by POC due date.

Deadline recorded: May 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care Each facility shall develop a planned routine of medical and dental care and assisting in obtaining such care.When requested by the physician or Department, the facility shall maintain a record of centrally stored medication dosages. Based on observation, interview, and record review, the licensee did not comply with the cited section. During medication reviews, LPA observed MAR documentation showing resident didnt receive their medication which posing a potential health, safety, or personal rights risk.

Official plan of correction

The Executive Director will conduct in-service training and implement a plan to check medications regularly to prevent discrepancies. Proof will be submitted via email at zina.brown@dss.ca.gov by the POC due date.

Deadline recorded: Feb 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 (a) Resident Records 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 was not met as evidence by: On 01/23/25 around 2:15 PM, LPA received partial records controlled medication count records for Residents #1 - 5 which poses a potential personal rights risk to residents in care. LPA did not receive medication administration records issued by the former Executive Director (S1).

Official plan of correction

The Licensee will provided controlled medication count records from April 2024 - November 2024 for Residents #1 - 5. The Licensee will also provide July 2024 - Oct 1, 2024 Medication Administration Records issued by former Executive Director (S1) by the POC due date.

Deadline recorded: Jan 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care. (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and records review, records revealed that there were three medications with dates with no entries made by Med Techs for R-1 and there were three prescribed medications that were not dispensed and still in the bubble pack. This action poses as an immediate health and safety risk to persons in care.

Official plan of correction

Licensee will submit plan informing the department medication training has been performed with all staff. A written proof of correction must included along with date, time and participants names. Correction must be submitted by due date: 3/6/25 to LPA's email: felisa.shirley@dss.ca.gov or fax attn: to LPA Felisa Shirley to 424-544-1016

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

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidence: Based on interviews, records review, Executive Director Gloriella Jara stated that an employee had physically assaulted R4, which posed an immediate health, safety, and personal rights risk to R4.

Official plan of correction

Licensee will ensure staff review and sign the facility General Personnel Policies, residents Personal Rights, and Violations or infractions of Company Policy, and email a copy to LPA by POC.

Deadline recorded: Jan 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. This requirement was not met as evidence: Based on interviews, records review, Executive Director Gloriella Jara stated that an employee had admitted to being under the influence while at work, which posed an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

Licensee will ensure staff review and sign the facility General Personnel Policies, residents Personal Rights, and Violations or infractions of Company Policy, and email a copy to LPA by POC.

Deadline recorded: Jan 7, 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

87303 Maintenance and Operation (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 was not met as evidenced by: Based on interviews and observations, R-9’s bathroom medicine cabinet is rusted in the inside which poses a possible health and safety risk to persons in care.

Official plan of correction

The Interim Administrator, Melissa Flores shall replace medicine cabinet and send proof of correction to LPA Felisa Shirley at felisa.shirley@dss.ca.gov or fax to 424-544-1016 by POC date of 12/30/24.

Deadline recorded: Dec 30, 2024. 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

Maintenance and Operation 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. There was a water leak on the right side of the resident's bed caused by the air conditioning unit, which dripped water onto the bed, soaking the linens and mattress. The violation poses a potential health and safety risk to residents in care.

Official plan of correction

The deficiency was corrected prior to the complaint visit.

Deadline recorded: Nov 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1 (a) (2) Personal Rights of Residents in All Facilities. To be accorded dignity in their personal relationships with staff, residents, and other persons. Staff engaged in an intimate relationship with a resident. This violation poses an immediate health and safety risk to residents in care.

Official plan of correction

The Licensee is required to submit a written plan addressing residents' personal rights, ensuring residents are provided with dignity in their personal relationships with staff, residents, and other persons. The plan must be submitted by the POC deadline of, Monday, November 18, 2024.

Deadline recorded: Nov 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87356(a)(2)(3)

Regulation authority

CCR

What the official deficiency says

87356 Criminal Record Exemption(a)The Department shall notify a licensee to act immediately to terminate the employment of, remove from the facility or bar from entering the facility any person described in Sections 87356(a)(1) through (5) below while the Department considers granting or denying an exemption. Upon notification, the licensee shall comply with the notice. (2) Any person who has been convicted of a felony;(3) Any person who has been convicted of an offense specified in Sections 243.4, 273a, 273d, 273g, or 368 of the Penal Code or any other crime specified in Health and Safety Code Section 1569.17(c)(3); This was not met based on observation, record review, and interview, the licensee failed to ensure S1 is fingerprint cleared prior to working in the facility. This poses a health, saftey, and/or persoanl rights risk to residents in care.

Official plan of correction

Administrator shall read Section 87356(a)(1) through (5) and shall self-certify understanding of the regulations and shall commit to comply. POC shall be submitted to CCLD via email to wendy.gibbs@dss.ca.gov by the POC due date.

Deadline recorded: Nov 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(7)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidenced by: based on interview, observation, and record review the licensee failed to ensure R1 received accomodations for a modified dieat prescribed by residents physician as a medical necessity.

Official plan of correction

Administrator will review Physicians report and orders and create a binder for the orders to be placed in and update the boards in the kitchen. Administrator will send LPA pictures of the new binder and boards updated in the kitchen, by the POC date via email at Wendy.Gibbs@dss.ca.gov.

Deadline recorded: Nov 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(a) In addition to the rights listed in section 87468.1... residents... shall have all of the following personal rights: (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on interviews and record review the licensee did not ensure R1's individual needs were met and delivered by staff during transfer which posed an immediate health, safety, and personal rights risk to R1.

Official plan of correction

The Administrator will email a plan of correction to regina.cloyd@dss.ca.gov by the POC due date.

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

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: 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. Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above as during medication reviews, LPA observed documentation on the MAR indicating if residents refused or missed taking medication throughout the week which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/10/2024 Plan of Correction The executive director will ensure a in-service training regard medication documentation is completed by POC due date and provide proof of in-service training for all staff via email at zina.brown@dss.ca.gov

Official classification

Type B

Official code

87555(b)(5)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b)The following food service requirements shall apply: (5) Meals shall consist of an appropriate variety of foods and shall be planned... requirement was not met as evidenced by: Based on interviews and record reviews the licensee did not ensure that a diabetic meal plan is provided to 7 out of 8 residents who had diabetes, who poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

The administrator agreed to create a plan to ensure that a diabetic meal plan is provided to residents. Proof of corrections will be submitted to LPA via email at jose.calederon@dss.ca.gov.

Deadline recorded: Aug 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interview, observation, video, and record review the licensee failed to secure R1’s room after viewing R2 entering R1’s room 3 times and taking R1’s personal property which posed a potential health and safety to residents in care.

Official plan of correction

Administrator is to change lock for R1’s room and confirm R2 does not have any copies of R1’s door key or keys. Administrator to give notice to R2 regarding taking R1 property. Proof of correction (POC) must be sent to: jose.calderon@dss.ca.gov by due date: 02/09/24

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

Official classification

Type B

Official code

80087(a)(1)

Regulation authority

CCR

What the official deficiency says

87303Maintenance and Operation (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 interview, observation, and record review the licensee failed to ensure that the facility is free of, cockroaches as reported to LPA on 8/10/23, per 1 of 3 staff and 8 of 8 clients interviewed. Roaches were located in the rooms and hallways, which posed a Potential health and safety to residents in care.

Official plan of correction

Administrator will provide specific notes from pest control as to where and what type of pest they sprayed for and what plan do they have for future chemical spraying to LPA by 8/25/23.

Deadline recorded: Aug 25, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(7)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by: Based on interview, observation, and record review the licensee failed to ensure that the facility has a diabetic meal plan for residents in care as reported to LPA on 8/10/23. Per 3 of 3 staff and 7 of 8 residents facility did not provide a diabetic menu meal plan option which poses a Potential l health and safety to residents in care.

Official plan of correction

Licensee needs to provide 2 meal plans for residents in care. Need to provide a general meal plan and a diabetic meal plan by the POC date to LPA Calderon

Deadline recorded: Aug 25, 2023. 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

87303 Maintenance and Operation (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 in room 220 the fan in the bathroom did not have a cover over it, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/02/2022 Plan of Correction Administrator will ensure the fan will be covered and in good working condition by the plan of corrections date.

Official classification

Type A

Official code

87309(a)(1)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.(1)Storage areas for poisons, and firearms and other dangerous weapons shall be locked. 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 the activity room there was a paper cutter accesibe to residents and in the garden area there was a shovel and pick axe out and storage sheds 1 and 2 were unlocked whose contents contained chemicals and gardening tools which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 10/27/2022 Plan of Correction During the visit the Administrator put the paper cutter, shovel, pick axe in storage areas that are inaccessible to residents. The Administrator also ensured all storge spaces were locked. Cleared at the time of visit.

Official classification

Type A

Official code

1569.49(c)(1)

Regulation authority

HSC

What the official deficiency says

Any violation that the department determines resulted in the injury or illness of a resident. This requirement not met as evidenced by: On 09/28/2021 R1 had a fall and sustanined left femoral neck fracture. This poses an immediate health and safety risk to residents.

Official plan of correction

Submit written plan on how facility plans to ensure residents are provided with the services required, needs and serivces plan will be completed and updated as needed. (immediate civil penalty issued on today 4/25/2022.)

Deadline recorded: Apr 26, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

Reappraisals The pre-admission appraisal shall be updated, in writing... This requirement not met as evidenced by: LPA reviewed R1s file and found facility failed to reappraise resident after inital fall.

Official plan of correction

Facility will ensure that resident is reappriased to ensure facility can meet residents needs and provides adequate care and supervision.

Deadline recorded: Apr 29, 2022. 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

Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs...This requirement not met as evidenced by: Durin record review LPA observed inital Physician report dated 4/9/19, second report was dated 10/27/2020 which doesnt comply with required annual medical assessment.

Official plan of correction

Facility will ensure all dementia residents have updated mediacal assessement annually. Submit self certification indicating this requirment will be met.

Deadline recorded: Apr 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia. Safety measures to address behaviors such as wandering..This requirement not met as evidenced by: During interviews and observations R2 eloped from the facility. This poses a potential health and safety risk to resident in care.

Official plan of correction

The licensee will submit a plan of correction outlying steps to take to ensure that Dementia residents do not elope from the facility in the future.

Deadline recorded: Oct 13, 2021. A deadline is not proof that correction was completed.