BRITTANY HOUSE

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: Based on interviews and records review facility staff failed to reposition R1 as required by residents Home Health which resulted in the R1 developing a stage 4 pressure injury. This poses an immediate health & safety risk to residents in care.

Official plan of correction

Licensee shall ensure all staff receiving training on personal rights, provisions for providing care and supervision and resident care plans. License shall submit proof of training by POC due date. Email proof to LPA Brown at Zina.Brown@dss.ca.gov An immediate $500 civil penalty assessed.

Deadline recorded: Aug 5, 2026. 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

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: Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on records review and interviews conducted the facility failed to request an exception from Licensing when R1 developed a Stage 4 pressure injury, which is a prohibited health condition. This poses an immediate health & safety risk to residents in care.

Official plan of correction

Licensee shall ensure staff receive training on prohibited health conditions and submit proof of the training to the department by POC due date. Email proof to LPA Brown at Zina.Brown@dss.ca.gov

Deadline recorded: Aug 5, 2026. 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

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: Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on records review and interviews conducted the facility failed to request an exception from Licensing when R1 developed a Stage 4 pressure injury, which is a prohibited health condition. This poses an immediate health & safety risk to residents in care.

Official plan of correction

Licensee shall ensure staff receive training on prohibited health conditions and submit proof of the training to the department by POC due date. Email proof to LPA Brown at Zina.Brown@dss.ca.gov

Deadline recorded: Aug 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.655(a)(b)

Regulation authority

HSC

What the official deficiency says

If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 90 days' prior written notice.This requirement is not met as evidenced by: Based on interviews conducted and records reviewed the licensee failed to give the responsible party 90 days notice of a rate increase including details of the reason for the increase. This poses a potiential personal rights issue to the residents in care.

Official plan of correction

POC was cleared on 05/06/2026.

Deadline recorded: May 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.655(a)(b)

Regulation authority

HSC

What the official deficiency says

If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 90 days' prior written notice.This requirement is not met as evidenced by: Based on interviews conducted and records reviewed the licensee failed to give the responsible party 90 days notice of a rate increase including details of the reason for the increase. This poses a potiential personal rights issue to the residents in care.

Official plan of correction

Licensee shall review the Health and safety code regarding rate increases and rescind the rate increase notice. Licensee may re-issue a correct notice that is in-complaiance with Health and Safety Code 1569.655. License to sumbit documents to LPA by POC due date 05/07/2026.

Deadline recorded: May 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(d)

Regulation authority

CCR

What the official deficiency says

Incidental Medical & Dental Care if the resident is unable to determine their own medication cannot communicate symptoms clearly. . . (3) The date, time, dosage taken, and resident's response shall be documented and maintained in the resident's facility record. This requirement is not met by: Based on observation, interviews and records review: From 10/2025 - 01/14/2026, critical medications for R1's primary diagnoses of Heart Failure, Chest Pain, and anxiety—including Furosemide, Bisoprolol, Losartan, and Sertraline—were routinely omitted for weeks at a time.

Official plan of correction

The facility will ensure all medtechs complete the weekly medtech log before end of shift to document all medication administrations, refusals, and exceptions. The Administrator or designee will conduct audit logs on a weekly bases The administrator and or designee will submit proof of the weekly medtech logs completion for Monday 4/27 - Monday 5/11 by the plan of correction due date and email proof to LPA Brown at Zina.Brown@dss.ca.gov

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

Official classification

Type B

Official code

87413(a)(1)

Regulation authority

CCR

What the official deficiency says

87413 Personnel - Operations (a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement is not met as evidenced by: Based on interview and record review the licensee did not ensure that one (1) resident, resident 9 (R9), would not elope from the facility, which poses a potential health risk to residents in care.

Official plan of correction

The facility shall retrain staff on supervision of residents in care along with elopement strategies. S9 and LPA have agreed that S9 will submit training paperwork and the number of staff who have attended to LPA at MARIO.LEON@DSS.CA.GOV on or prior to the POC due date.

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

Official classification

Type B

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

Incidental Medical & Dental Care if the resident is unable to determine their own medication cannot communicate symptoms clearly. . . (3) The date, time, dosage taken, and resident's response shall be documented and maintained in the resident's facility record. This requirement is not met by: Based on observation, interviews and records review: From 10/2025 - 01/14/2026, critical medications for R1's primary diagnoses of Heart Failure, Chest Pain, and anxiety—including Furosemide, Bisoprolol, Losartan, and Sertraline—were routinely omitted for weeks at a time.

Official plan of correction

The facility will ensure all medtechs complete the daily medtech log before end of shift to document all medication administrations, refusals, and exceptions. The Administrator or designee will audit logs on a weekly bases. The administrator and or designee will submit proof of the daily medtech logs completion for the month of February 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

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. Based on observation and interview, staff failed to answer the call light in a timely manner. On 02/23/2026, LPA conducted a call light test in Rm 104, RM 105, 310, 405 observed staff not responding. This violation poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

The facility will implement a new call light system in all units and will notify the department upon beginning and completion of installation. The administrator and or designee will submit an notification letter of the estimated time for the completion of installation 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 A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental… functioning and that appropriate assistance is provided when such observation reveals unmet needs. When…deterioration …are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews and record reviewed, the licensee failed to ensure that appropriate assistance was provided to R1 when changes in their physical condition were found (swelling in foot and toe) resulting in the toe being amputated. Which posed a potential risk to the health, safety and personal rights of the resident in care.

Official plan of correction

The administrator will create a plan of correction to ensure that observations of residents are conducted when significant change in the resident’s condition is observed and review and conduct in-service training for staff of 87466 Observation of Resident. In-service training with signatures of staff and plan of corrections will be submitted prior to POC due date of 2/6/26, via email, to perry.scott@dss.ca.gov to avoid monetary penalties. An IMMEDIATE CIVIL PENALTY of $500.00 will be assessed for the resident’s toe being amputated. Citation cleared on today’s visit.

Deadline recorded: Jan 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) 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.... This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee failed to ensure a sufficient number of competent staff to meet R1’s needs. R1’s foot was swollen for several weeks, no one followed up with hospital visits, and ultimately R1’s toe became infected and had to be amputated. This poses a potential health risk to residents in care.

Official plan of correction

The Licensee shall create a plan to follow Title 22 87411(a) regulations and retrain staff on how to provide competent services necessary to meet residents’ needs while ensuring that staff provide personal assistance and care. In-service training with signatures of staff and plan of corrections will be submitted prior to POC due date of 2/6/26, via email, to perry.scott@dss.ca.gov to avoid monetary penalties.

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

Official classification

Type B

Official code

87405(b)(2)

Regulation authority

CCR

What the official deficiency says

87405(b)(2) Administrator - Qualifications and Duties. (b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by: Based on interviews and records reviewed, the Licensee/Administrator failed to adhere to Title 22 regulations, by properly ensuring facility staff were providing appropriate care for R1 in accordance with Title 22 regulations, which poses a potential health and safety risk to residents in care.

Official plan of correction

The Licensee will create a plan to ensure that the administrator performs and adheres to their duties and has knowledge of and conform to all applicable laws, rules and regulations. A written statement from the administrator stating they have reviewed and understood Title 22 87405(b)(2) Administrator-Qualifications and Duties. Plan of corrections will be sent to LPA Perry Scott by 02/6/26 at perry.scott@dss.ca.gov to avoid monetary penalties.

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

Official classification

Type B

Official code

87211(a)(B)(D)

Regulation authority

CCR

What the official deficiency says

87211(a)(B)(D) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department...(B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety, or health of any resident... This requirement was not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report associated with the incident for R1 that resulted in hospitalization and amputation of R1s toe. The facility did not have proof of certified confirmations that an LIC 624 was faxed to CCL. This violation poses a potential health, safety, or personal-rights risk to persons in care.

Official plan of correction

The Licensee shall submit a serious incident report LIC624 for R1 about the swelling of their foot and toe, and the hospitalization that resulted in the resident having to have their toe amputated because of infection. The report shall be submitted prior to POC due date of 1/22/26, via email, to perry.scott@dss.ca.gov to avoid monetary penalties. This citation was cleared during today’s visit.

Deadline recorded: Jan 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

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 interview, observation & record review Staff 11 (S11) did not have any documented medication administration training on file but was administering medication to the residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The facility will review all staff training for all medication technicians to ensure they have proper medication administration training and schedule a refresher training for all medication technicians. 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: Jan 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

Observation of the Resident: The licensee shall ensure residents are regularly observed for changes in physical, mental, emotional, and social functioning, and appropriate assistance is provided when observations reveal unmet needs. This requirement was not met as evidenced by: Based on interviews and records review, facility staff observed Resident 9 (R9) in distress & the facility did not provide timely medical attention. Narcan was administered without a prescription from R9's primary care doctor, posing an immediate health and safety risk to persons in care.

Official plan of correction

The facility will schedule a training with all caregivers and medication technicians on Observation of the Resident per Title 22 Regulations. 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: Jan 22, 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. Based on observation and interview, staff failed to answer the call light in a timely manner. On 01/21/2026, LPA conducted a call light test observed staff not responding. This violation poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

The facility will conduct an in service staff training in regards to answering call lights. 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: Jan 26, 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: (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)...This requirement was not met as evidence by: Based on records review, the department did not receive a LIC 624 regarding R9 being administered a controlled medication dosage nor proof of medical attention being provided on 10/30/2025 or 10/31/2025. This violation poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

The facility will conduct an in service staff training in regards to how to proper report to licensing in a timely manner. 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: Jan 28, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Based on observation and interview, 3 of 12 staff are not associated to the facility at the time of unannounced inspection which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The facility shall associate staff: Leticia Velasco, Cristina Valencia & Alma Soto in Guardian and submit proof of being associated with the facility via email zina.brown@dss.ca.gov by POC due date.

Deadline recorded: Jan 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, 3 of 12 staff are not associated to the facility as the time of unannounced inspection which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/16/2026 Plan of Correction The facility shall associate staff: Leticia Velasco, Cristina Valencia & Alma Soto in Guardian and submit proof of being associated with the facility via email zina.brown@dss.ca.gov by POC due date.

Official classification

Type B

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

(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: (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. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above for 6 out of 10 residents who have incomplete registration on the MAR which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/29/2026 Plan of Correction Licensee will adhere to Title 22 Reg 87465 at all times. Licensee will ensure shalll receive in-service training by licensed medical profession. Proof of correction must be sent to LPA Zina.Brown@dss.ca.gov

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 This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above for 1 of 12 staff - no personnel record on file, 2 of 12 staff - no TB Test on file, 3 of 12 staff : no health screening on file & 6 of 12 staff - no CPR on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/29/2026 Plan of Correction Licensee will adhere to Title 22 Reg 87411 at all times. Licensee will ensure all staff have complete required documents file records. Proof of correction must be sent to LPA Zina.Brown@dss.ca.gov

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation: Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above for the water testing in Unit 2 shower Room 101.1F, bathroom in Room 223 tested at 72.8F, & Room 231 water tested at 80.4F, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/16/2026 Plan of Correction Licensee will adhere to Title 22 Reg 87303 at all times. Licensee will ensure that water supply remain in compliance with hot water temperature of not less than 105 degrees F and not more than 120 degree F. Proof of correction must be sent to LPA Zina.Brown@dss.ca.gov *Correction during visit 01/15/26

Official classification

Type B

Official code

87307(2)(B)

Regulation authority

HSC

What the official deficiency says

Personal Accommodations & Service: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. 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 rooms 402 , 412, 214,236, 223, 231, 305 are missing a lamp and in rooms 236 223 231 305 missing chair which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/29/2026 Plan of Correction Licensee will adhere to Title 22 Reg 87307 at all times. Licensee will ensure that all resident's in care are provided with required furnishing and accomodation. Proof of correction must be sent to LPA Zina.Brown@dss.ca.gov

Official classification

Type B

Official code

1569.626(a)(b)

Regulation authority

HSC

What the official deficiency says

Training Requirement for Direct Care Staff (a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1)Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia... (2) Eight hours of in-service training per year on the subject of serving residents with dementia. This training shall be developed in consultation with individuals or organizations with specific expertise in dementia care or by an outside source with expertise in dementia care... Deficient Practice Statement Based on observation, interview, & record review the licensee did not comply with the section cited above for all staff who assist resident with activities of daily living do not have the required training to be in compliance with Title 22 Health & Safety Code which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/15/2026 Plan of Correction Licensee shall adhere to H & S 1569.626 and ensure that all direct staff complete the required trianing as stated in H & S 1569.626. Proof of correction must be submitted to LPA Zina.Brown@dss.ca.gov.

Official classification

Type B

Official code

87211(a)(1)

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... (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)... This requirement was not met as evidence by: Based on observation and record review, facility staff failed to ensure to report to (R#1)'s responsible party regarding (R#2)'s health condition.This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee will adhere to Title 22 at all times. As part of the plan of correction, the facility will conduct an in-service with facility nurses, medtechs, and facility administrators regarding reporting requirements. Proof of in-service will be sent to LPA Iniguez via email before the POC due date.

Deadline recorded: Jan 27, 2026. 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

Prohibited Health Conditions (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 & 4 pressure injuries. Based on records review the facility retained R1, who had a unstageable pressure injury which is prohibited by title 22 regulations. The facility failed to submit an exception request from the department to retain R1.

Official plan of correction

The facility will develop & schedule a mandatory in-service training for all staff on the topic: Prohibited Health Conditions to be in compliance with Title 22 requirements. Also, if necessary the facility will submit any exception requests for Prohibited Health Condition to the department as required. . . upon the residents change in condition 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: Dec 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87609(b)(2)

Regulation authority

CCR

What the official deficiency says

Allowable Health Conditions and the Use of Home Health Agencies(b)Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (2) The licensee provides the supporting care & supervision needed to meet the needs of the resident receiving home health care. Based on interviews and record review, the facility did not have a restricted health care plan for the cholecystostomy tube, and staff were not informed of the type of tube inserted or the required care & supervision need.

Official plan of correction

The facility will submit a plan to the department outlining how the facility will be in compliance with Title 22 regulations. 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: Jan 26, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(g)(3)(B)(1)

Regulation authority

CCR

What the official deficiency says

Admission Agreements...(B)Rate for additional items and services, including: (1) A comprehensive description of and the corresponding fee schedule for all additional items and services not included in the fees for basic services shall be listed. Based on record review and interviews, the licensee did not ensure R1 admission agreement contained a comprehensive description of additional fees or the fee schedule for services not included in the basis services.

Official plan of correction

The facility will submit a updated resident Admission Agreement which will be in compliance with Title 22 regulations for the Department to review. 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: Jan 26, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental… functioning and that appropriate assistance is provided when such observation reveals unmet needs. When…deterioration …are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on interviews and record reviewed, the licensee failed to ensure that appropriate assistance was provided to R1 when changes in their physical condition were found (swelling in foot and toe) resulting in the toe being amputated. Which poses a potential risk to the health, safety and personal rights of the resident in care.

Official plan of correction

The administrator will create a plan of correction to ensure that observations of residents are conducted when significant change in the resident’s condition is observed and review and conduct in-service training for staff of 87466 Observation of Resident. In-service training with signatures of staff and plan of corrections will be submitted prior to POC due date of 12/05/25, via email, to perry.scott@dss.ca.gov to avoid monetary penalties.

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

Official classification

Type B

Official code

87211(a)(B)(D)

Regulation authority

CCR

What the official deficiency says

87211(a)(B)(D) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department...(B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety, or health of any resident... This requirement was not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report associated with the incident for R1 that resulted in hospitalization and amputation of R1s toe. The facility did not have proof of certified confirmations LIC 624 was faxed to CCL. This violation poses a potential health, safety, or personal-rights risk to persons in care.

Official plan of correction

The Licensee shall submit a serious incident report LIC624 for R1 about the swelling of their foot and toe, and the hospitalization that resulted in the resident having to have their toe amputated because of infection. The report shall be submitted prior to POC due date of 12/05/25, via email, to perry.scott@dss.ca.gov to avoid monetary penalties.

Deadline recorded: Dec 5, 2025. 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

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 & /or related experience shall provide knowledge of & skill in the following: (5) Knowledge necessary in early signs of illness & the need for professional help.

Official plan of correction

This requirement was not met as evidenced by: based on observation and interview staff did not provide emergency first responders with the proper documentation such as medical insurance card, primary care physician information, etc. needed for the resident to be admitted to the hospital

Deadline recorded: Dec 5, 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

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 occurance 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 for the incident that occur on 09/09/2025 with the resident who had symptoms of chill and fevers. The report must be fax to 424-544-1016 to department by POC due date.

Deadline recorded: Nov 28, 2025. 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

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 & /or related experience shall provide knowledge of & skill in the following: (5) Knowledge necessary in early signs of illness & the need for professional help.

Official plan of correction

This requirement was not met as evidenced by: based on observation and interview staff did not provide emergency first responders with the proper documentation such as medical insurance card, primary care physician information, etc. needed for the resident to be admitted to the hospital

Deadline recorded: Dec 5, 2025. 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

87463 Reappraisals: 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.... based on records review and interviews LPA did not observe a re-aappraisal on file for when R11 returned to the facility nor a care plan for catheter which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee/Executive Director to review regulation cited and submit a plan to CCLD detailing how facility will get into compliance. In service to be conducted on reappraisal procedures, LPA to obtain copy of in-service sign in sheet and materials reviewed. Citation was already cleared, prior to superceded report.

Deadline recorded: Dec 5, 2025. 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 is not met as evidenced by: Based on observation and interviews the licensee did not comply with the section cited above by R1 not being accorded a safe environment by not having access to their equipment such as their call button which posed a potential health, safety or personal rights risk to person in care.

Official plan of correction

On 11/13/2025, the licensee corrected this deficiency by placing a call button on the wall next to R1's bed.

Deadline recorded: Nov 13, 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 submit serious incident reports to the licensing agency such as 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: LPA observed no LIC 624 Unusual Incident/Injury Report nor a LIC624A Death Report for Resident 1 was not submitted to the department within 7 day of incident occurring

Official plan of correction

The facility will submit a LIC 624 Unusual Incident/Injury Report & a LIC624A Death Report for Resident 1 (R1). Also the facility will conduct an in-service training for Medtechs, Licensed Nurses & Department Directors on Reporting Requirement per Title 22 regulations. 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: Nov 12, 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

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 for the incident that occur on 09/09/2025 with the resident who had symptoms of chill and fevers. The report must be fax to 424-544-1016 to department by POC due date.

Deadline recorded: Oct 24, 2025. 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

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 & /or related experience shall provide knowledge of & skill in the following: (5) Knowledge necessary in early signs of illness & the need for professional help. This requirement was not met as evidenced by: based on observation and interview staff did not provide emergency first responders with the proper documentation such as medical insurance card, primary care physician information, etc. needed for the resident to be admitted to the hospital

Official plan of correction

The facility will conduct an in service training for all staff to be trained on how to provide all necessary documentation needed upon request by emergency first responders. Also the facility shall create form to be signed by the emergency first responders for proof of receiving resident records before . . . transporting the resident to the hospital. The facility will submit proof of staff in-service training with signatures and the proof of resident record form provided to emergency first responders to department by POC due date via email Zina.Brown@dss.ca.gov

Deadline recorded: Oct 27, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87623(b)(2)(B)(C)

Regulation authority

CCR

What the official deficiency says

87623 Indwelling Urinary Catheter In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for thefollowing:Ensuring that the bag and tubing are changed by an appropriately skilled professional should the resident require assistance. There should be written documentation by an appropriately skilled professional outlining the instruction of the procedures delegated and the names of the facility staff who have been instructed...This requirement was not met as there was no plan in place for catheter care which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee/Executive director to review section cited and submit a plan on how to get into compliance. Facility will ensure there are care plans available for review, plan should detail what staff will oversee the care.

Deadline recorded: Dec 4, 2025. 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

87463 Reappraisals :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.... based on records review and interviews LPA did not observe a re-assessmnet on file for when R11 returned to the facility which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee/Executive Director to review regulation cited and submit a plan to CCLD detailing how facility will get into compliance. In service to be conducted on reappraisal proceudres, LPA to obtain copy of inservice sign in sheet and maerials reviewed.

Deadline recorded: Nov 3, 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

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 for the incident that occur on 09/09/2025 with the resident who had symptoms of chill and fevers. The report must be fax to 424-544-1016 to department by POC due date.

Deadline recorded: Oct 24, 2025. 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

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 & /or related experience shall provide knowledge of & skill in the following: (5) Knowledge necessary in early signs of illness & the need for professional help. This requirement was not met as evidenced by: based on observation and interview staff did not provide emergency first responders with the proper documentation such as medical insurance card, primary care physician information, etc. needed for the resident to be admitted to the hospital

Official plan of correction

The facility will conduct an in service training for all staff to be trained on how to provide all necessary documentation needed upon request by emergency first responders. Also the facility shall create form to be signed by the emergency first responders for proof of receiving resident records before . . . transporting the resident to the hospital. The facility will submit proof of staff in-service training with signatures and the proof of resident record form provided to emergency first responders to department by POC due date via email Zina.Brown@dss.ca.gov

Deadline recorded: Oct 27, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(a)

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)... This requirement was not met as evidence by: Based on interviews with (S#1), the facility failed to ensure that resident (R#1) was properly assessed prior to hospital discharge. (S#1) informed the hospital social worker that (R#1) required more assistance than the facility could provide, which resulted in (R#1) not being able to return to the facility upon discharge. This poses a potential health and safety risk to the residents in care.

Official plan of correction

License will adhere to Title 22 at all times. As Plan of Correction, the licensee will conduct a proper discharge assessment of (R#1) and accommodate their medical needs at the facility. A proof of correction will be provided to the department before POC due date.

Deadline recorded: Oct 17, 2025. 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. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidence by: Based on record reviews and interviews conducted the licensee failed to ensure that supervision was provided to meet the residents’ needs. On 01/14/2025 staff S1 and S2 left R1 unsupervised which resulted to R1 falling and sustaining a fracture which posed an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

POC: The licensee agreed to create a plan to ensure that staff are sufficient in numbers and competent to provide the services necessary to meet resident needs. Proof of correction will be submitted to jose.calderon@dss.ca.gov.

Deadline recorded: Sep 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care. 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). This requirement was not met as evidence by: Based on records and interviews conducted the licensee failed to ensure that 911 was called after R1’s unwitnessed fall on 11/14/2024, which posed an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

The licensee agreed to provide additional training to staff on PIN 25-06-ASC Calling 9-1-1 in Residential Care Facilities for the Elderly (RCFE), proof of correction will be submitted to jose.calderon@dss.ca.gov.

Deadline recorded: Sep 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and the appropriate assistance is provided when such observations\ reveals unmet needs…This requirement was not met as evidence by: Based on observation and interviews, staff did change resident, however due to the frequency of the urination, the resident continued to be in soiled clothing for a period of time due to the resident urinating on themselves and in their bed. This violation poses a potential health and safety or personal rights risk to residents in care.

Official plan of correction

Licensee/Administrator shall read Title 22 Section 87466 Observation of the Resident. Licensee to do in-service training with staff on observation of residents and send proof of the in-service with signatures of staff working in assisted living and acknowledgement of the regulation. The facility will submit the plan of correction by the due date of 09/12/25 and email it to LPA Perry Scott’s email at perry.scott@dss.ca.gov to avoid monetary penalties.

Deadline recorded: Sep 12, 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(a) 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. This requirement was not met as evidence by: Based on observation, the resident’s bedroom #207 has a strong odor of urine and the carpet was observed to have liquid stains, possibly urine stains based on the odor emanating from the carpeting. This violation poses a potential health and safety or personal rights risk to residents in care.

Official plan of correction

The Administrator will develop a plan of correction that will address the resident urinating in the room; and ensure that the carpeting in the room is cleaned and sanitized regularly to ensure the health and safety of the resident, employees, and visitors. The facility will submit the plan of correction by the due date of 09/12/25 and email it to LPA Perry Scott’s email at perry.scott@dss.ca.gov to avoid monetary penalties.

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

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance - (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing, or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on review of records, the licensee did not comply with the section. LPA identified that one staff member did not have a Criminal Clearance Background, Clearance Transfer associated with this facility. This violation poses an immediate health, safety, or personal rights risk to the person in care.

Official plan of correction

Licensee to ensure that all staff, before working in the facility, obtain a Criminal Background Clearance and Criminal Background Transfer Request and provide proof of correction to CCLD by the POC due date. Proof of Correction due date: 08/22/25. Antonine.Richard@dss.ca.gov

Deadline recorded: Aug 22, 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 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. This requirement was not met as evidence by: Based on observation and interviews conducted S1 could not locate or find R1 file. This is a safety risk to clients in care.

Official plan of correction

Administrator to move all closed and open resident files to a centeral location which is locked. Administrator to have a sign in sheet for residents files which are pulled by staff.

Deadline recorded: Aug 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

Personnel Records (a) - (h) 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 was not met as evidenced by: LPA reviewed staff 1-9 files and observed that there were no annual tranings, mectech certifications for S1-S7 This violation poses a potential health, safety, or personal rights risk to residents in care.

Official plan of correction

Joel Niblett-Administrator has agreed to conduct an audit of all staff files monitouring progress daily to esure files are completed with all documents by the POC date. Joel has agreed to provide proof of annual training to all staff members, including medtech trainings . Details of the course prvided and signed by all staff will be emailed to LPA by the POC date of 6/6/2025.

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

Official classification

Type B

Official code

87465(c)(3)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (c) (3)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:... This requirement was not met as evidenced by: LPA observed R1 and R2 medications were not signed as being dispensed and there was medication signed off as being disspensed but in package. This violation poses a potential health, safety, or personal rights risk to residents in care.

Official plan of correction

Joel Niblett-Administrator has agreed to conduct training to all medtecs LVNs on documentation requirements policy and procedures standards by the POC date of 6/6/2025. Proof of traing signed by all staff and certifications will be emailed to LPA by the POC date 6/6/2025.

Deadline recorded: Jun 6, 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 submit serious incident reports to the licensing agency such as 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

Official plan of correction

The facility need submit a serious incident report of the incident that occurred with Resident #6 & Resident #7. Also facility need to review Title 22 Regulations for Reporting Requirements and self certify that all staff read Title 22 Regulations.

Deadline recorded: Apr 7, 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(a)(4) 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... When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observations and a review of records, the licensee failed to comply with the aforementioned section. The LPA observed inconsistencies and gaps in the medication administration records, which posed a potential risk to the health, safety, or personal rights of the individuals in care.

Official plan of correction

The licensee will ensure that facility staff consistently use medication administration records (MARs) accurately. As part of the correction plan, a retraining program will be implemented to reinforce proper documentation procedures. Proof of this training will be submitted to the License Program Analyst (LPA) before the deadline for the plan of correction (POC). *CIVIL PENALTY ISSUED*

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

Official classification

Type B

Official code

87465(h)(6)(A-H)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored: The licensee shall be responsible for assuring that a record of centrally stored prescription medications.... The name of the resident for whom.... Based on interviews and record reviews, the licensee and Administrator did not comply with the section cited above as medications passes were not properly documeted which is a potential a potentila health and safety risk for residents in care.

Official plan of correction

Licesee and Administrator will develope a plan detailing how the facility will ensure all medications are properly administered and documented. Plan to be submitted to LPA by POC due date. Lizeth.villegas@dss.ca.gov

Deadline recorded: Jan 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(c)(1-2)

Regulation authority

CCR

What the official deficiency says

87412 personnel records Licensees shall maintain in the personnel records verification of required staff training and orientation. The following staff training and orientation shall be documented: For staff who assist with personal activities of daily living.... Based on interviews and record reviews, the licensee and Administrator did not comply with the section cited above as there was no documentation confirming Staff 5-7 have obtained and passed required training(s).

Official plan of correction

Licesee and Administrator will enure all staff have required training by an appropriate skilled professional and provide the department with training sign in sheets, and instructures contact info and crendials by POC due date. LPA provided a copy of section 87412 for refrence.

Deadline recorded: Jan 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87221

Regulation authority

CCR

What the official deficiency says

87221 Resident Councils The facility shall permit the formation of a resident council by interested residents, provide space and post notice for meetings, and provide assistance in attending meetings for those residents who request it. In order to permit a free exchange of ideas, at least part of each meeting shall be allowed to be conducted without the presence of any facility personnel. Residents shall be encouraged, but shall not be compelled to attend. The purpose of such an organization shall be to work with the administration in improving the quality of life for all residents by enriching the activity program and to discuss the services offered by the facility and make recommendations regarding identified problems. This requirement was not met as evidenced by: Based on interviews and record reviews, facility staff did not assist residents in the formation of a resident council. This poses a possible personal rights violation to all residents in care.

Official plan of correction

Please provide provide proof that there is a Resident Council in place by Plan of Correction date of 12/30/24. Please send to LPA Felisa Shirley at felisa.shirley@dss.ca.gov or fax to 424-544-1016 by POC date.

Deadline recorded: Dec 30, 2024. 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(a)(4) 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. This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above as during medication reviews, LPA observed discrepancies in all 5 residents medication administration records which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will ensure facility staff use correctly medication administrator records at all time. As plan of correction, licensee will re-train facility staff on the importance on how to document properly on the resident's MARs. proof of training will be sent to LPA before POC due date.

Deadline recorded: Dec 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87457(c)(1)

Regulation authority

CCR

What the official deficiency says

87457 (c)(1) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1)The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the facility did not comply with the section cited above for 5 out of 10 clients which poses a potential health, safety or personal rights risk to persons in care. .

Official plan of correction

POC Due Date: 01/07/2025 Plan of Correction The facility will submit proof of needs and appraisal plan for resident #1 - #4 and resident #10, via email zina.brown@dss.ca.gov by POC due date.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465(a)(4) 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. This requirement is not met as evidenced by: 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 residents missed taking medication throughout the week and or no MAR documentaion for new residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/07/2025 Plan of Correction The executive director will ensure an 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

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 as specified in Health and Safety Code sections 1569.625 and 1569.69. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview record review, the licensee did not comply with the section cited above in 4 out of 10 staff have expired and or no First Aid/CPR Certification which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/07/2025 Plan of Correction The facility will submit proof of completed First Aid/CPR certification for Staff #1 and Staff #4 - Staff #6 via email zina.brown@dss.ca.gov by POC due date.

Official classification

Type B

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. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on record reviews, the licensee did not comply with the section cited above in 7 out of 10 staff which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/07/2025 Plan of Correction The facility will submit proof of LIC 503 Health Screening with TB results for Staff #2 - Staff #4 and Staff #6 - Staff #9 via email zina.brown@dss.ca.gov by POC due date.

Official classification

Type B

Official code

87211(a)(B)(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...(B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety, or health of any resident...This requirement is not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report associated with the death of (R1) . The facility did not have proof of certified confirmations LIC 624 was faxed to CCL. This violation poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator will review Title 22 Sec. 87211 and agreed to provide training to staff pertaining to CCL Reporting Requirements. Licensee will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC date Lizeth.villegas@dss.ca.gov

Deadline recorded: Oct 16, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(b)(1)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia…(1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator…when a resident’s behavior or condition changes. This requirement is not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to notify the responsible person/conservator for (R1) when (R1) was hospitalized on 08/05/24. This violation poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator will review Title 22 Sec. 87705 and agreed to provide training to staff pertaining caring for resident with dementia. Licensee will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC date via email: ernand.dabuet@dss.ca.gov

Deadline recorded: Sep 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(B)(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...(B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety, or health of any resident... This requirement is not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report associated with an incident with (R1) change in condition and hospitalization on 08/05/24. The facility did not have proof of certified confirmations LIC 624 was faxed to CCL. This violation poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator will review Title 22 Sec. 87211 and agreed to provide training to staff pertaining to CCL Reporting Requirements. Licensee will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC date via email: ernand.dabuet@dss.ca.gov

Deadline recorded: Sep 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(b)

Regulation authority

CCR

What the official deficiency says

87217 Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement is not as evidenced by: Based on document review and interviews, facility staff did not take appropriate measures to safeguard residents belongings. This poses a potential personal rights risk to persons in care.

Official plan of correction

The Office Manager shall submit in writing a better plan and training for all staff to safeguard residents personal belongings and provide receipts for all such articles to CCLD via fax or email by POC due date of 7/24/24. Proof of correction can be emailed to felisa.shirley@dss.ca.gov.

Deadline recorded: Jul 24, 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(a)(2) 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 interviews conducted, the administrator failed to ensure a resident's personal rights due to the facility not letting them know that they would be relocated to a different unit in the building, causing confusion and feeling unsafe in the facility, which posed a potential health risk to residents in care.

Official plan of correction

Administrator to review Personal Rights of Residents 87468.1(a)(2) and submit a statement acknowledging understanding of Title 22 Regulations by POC due date of 6/28/24 and email it to LPA Perry Scott at perry.scott@dss.ca.gov

Deadline recorded: Jun 28, 2024. 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

87468.1(a)(8) 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 is not met as evidence by: Based on interviews conducted and records reviewed the administrator failed to inform the responsible parties about the construction of the facility and movement of the residents. Which poses a potential health risk to residents in care.

Official plan of correction

Administrator to review Personal Rights of Residents 87468.1(a)(8) and submit a statement acknowledging understanding of Title 22 Regulations by POC due date of 6/28/24 and email it to LPA Perry Scott at perry.scott@dss.ca.gov

Deadline recorded: Jun 28, 2024. A deadline is not proof that correction was completed.

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 was not met as evidence by based on records reviewed and interviews, med tech failed to give medication to resident which poses a potential health, safety risk to persons in care.

Official plan of correction

Licensee will provide a training for all med techs to attend regarding policies and procedures for medications. Licensee will send LPA Gonzalez the sign in sheet and description of the type of training given by POC due date 06/05/24.

Deadline recorded: Jun 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(2)

Regulation authority

CCR

What the official deficiency says

87465(a)(2) 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: The licensee shall provide assistance in meeting necessary medical and dental needs… This was not met as evidence by based on records reviewed and interviews, med tech admitted to LPA that he was notifying the nurse about refilling medications last minute and that would cause a delay, where resident would go days without medication.

Official plan of correction

Licensee will provide a training for all med techs to attend regarding policies and procedures for medications. Licensee will send LPA Gonzalez the sign in sheet and description of the type of training given by POC due date 06/05/24.

Deadline recorded: Jun 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(4)

Regulation authority

CCR

What the official deficiency says

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not ve admitted or retained in a residental care faclity for the elderly: (4) Staphylococcus aureus ( " staph " ) infection or other serious infection. This regulation was not met based on evidence by: Record review and interviews, the licensee failed to ensure resident R1 did not have a phohibited health condition

Official plan of correction

Administrator will review Tittle 22, Division 6 Chapter 8 Article 11 Health Related Services and conditions. Adminsitrator will submit a signed letter to LPA upon completion stating it was reviewed. Administrator will submit an excemption request to CCL and a Care Plan for the R1 by the POC.

Deadline recorded: Apr 4, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87204(a)

Regulation authority

CCR

What the official deficiency says

87204Limitations-Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum numbe of persons who my receive sedrvice at any one time. An exceptio my be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity, This regeulation was not met based on: Interviews and file review, C1 has paid to come and stay at the faclitily during the day, meals and services are porvided.

Official plan of correction

Administrator will review Title 22, 87204 Limitations and submit a signed letter stating it has been reviewed by POC. Administrator will ensure C1 no longer being left at the facility unless a resident.

Deadline recorded: Apr 4, 2024. A deadline is not proof that correction was completed.