PROMISE ASSISTED LIVING, LLC.

Official classification

Type A

Official code

87629(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain a resident who requires intramuscular, subcutaneous, or intradermal injections if the injections are administered by the resident or by an appropriately skilled professional. This regulation is not met as evidenced by: Based on interviews, LPA determined that the facility did not meet the above requirement in three (3) out of twenty-two (22) residents, as staff and resident interviews revealed caregivers are assisting R1, R2, and R3 with insulin injections, which poses an immediate health and safety risk to residents.

Official plan of correction

Licensee/Administrator is to ensure that insulin injections are performed either by the residents themselves or a an appropriately skilled professional at all times. Administrator is to submit the facility's plan to LPA by email on how this requirement will be met by the POC due date.

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

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in five bathrooms did not have the required temperature for bathroom 1-151.5F, bathroom 2-153.5 F, bathroom 3: 192.2F, bathroom 4: 151.6F and bathroom 5:129.3F which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/10/2026 Plan of Correction Staff will lower water temprature and send picture to LPA by POC date. Staff will create a water log for two week and send log to LPA after two weeks of logging water temperatur for all five bathrooms.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(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: (2) Once ordered by the physician the medication is given according to the physician's directions. 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 in four (4) out of five (5) residents medication for R1-R3, and R5 are not documented as either missed or destroyed medication for residents and Medication review was not able to determine the status of medication which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/10/2026 Plan of Correction The administrator will ensure all resident's medication once ordered by physician is given according to physician direction, and will send the staff training registration by licensed professional by POC due date. Once training completed, Administrator will send list of all staff who completed training to CCLD.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair. This requirement was not met as evidence by: During tour LPA observed multiple window screens missing throughout the facility, specifially in dining room and the following resident bedrooms: room #’s 8, 9/10, and 17/18.

Official plan of correction

Licensee/Administrator to ensure all windows have window screens and add window screens to the areas mentioned in report. Photos of the windows with screens shall be emailed to LPA by POC due date. tena.herrera@dss.ca.gov

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

Official classification

Type A

Official code

1569.311

Regulation authority

HSC

What the official deficiency says

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. 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 facilty did not have working carbon moxide detectors at time of visit which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2025 Plan of Correction Staff ordered new dectors at time of visit. Staff will send picture to LPA once recieved and installed by POC due date.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in three bathrooms did not have the required temperature upstairs bathroom 68.1,downstairs bathroom #1 140, and bathroom #2 127.2 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2025 Plan of Correction Staff will lower and higher water temprature and send picture to LPA. Staff will create a water log for one week and send log to LPA by POC.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above cleaning solutions were left unlocked in laudry room which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2025 Plan of Correction Staff locked up cleaning solution at time of visit. Staff will conduct training with staff and send log to LPA by POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above kitchen floor was dirty which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/02/2025 Plan of Correction Staff will provide in-service training on section 87555 to kitchen staff and will ensure kitchen floor's are maintain clean at all times, will submit in-service training and pictures of clean floors to the department by POC due date 05/02/2025..

Official classification

Type B

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above auditory devices on two doors did not work which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/02/2025 Plan of Correction Staff ordered new devices at time of visit and will send LPA pictures when installed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not being met as evidenced by: LPA learned that resident #1 was assisted by resident #2 in the bathroom while resident #1 was not dressed.

Official plan of correction

Administrator will ensure that Title 22 regulations are being adhered to, and will ensure that residents personal rights are not being violated. Administrator will conduct an in service training with all staff on resident personal rights and will send proof of staff training to LPA by POC due date.

Deadline recorded: Mar 8, 2024. 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

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 car This requirement is not being met as evidenced by: LPA learned that resident #1 was not sent out to be medically assessed after falling on 6/21/22.

Official plan of correction

Administrator will ensure that Title 22 regulations are being adhered to, and will ensure that residents who require a medical assessment receive it as required. Administrator will send LPA facility plan on incidental medical and dental care, and proof of staff training on plan by POC due date.

Deadline recorded: Mar 8, 2024. 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

(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 being met as evidenced by : LPA observed that facility did not submit a special incident report for resident #1's fall on 6/21/22.

Official plan of correction

Administrator will ensure that Title 22 regulations are being adhered to as required. Administrator will conduct an inservice training with all staff on reporting requirements and will send proof of training to LPA by POC due date.

Deadline recorded: Mar 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not being met as evidenced by: LPA learned that resident #1 was assisted by resident #2 in the bathroom while resident #1 was not dressed.

Official plan of correction

Administrator will ensure that Title 22 regulations are being adhered to, and will ensure that residents personal rights are not being violated. Administrator will conduct an in service training with all staff on resident personal rights and will send proof of staff training to LPA by POC due date.

Deadline recorded: Mar 1, 2024. 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

(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 being met as evidenced by: LPA learned that resident #1 was not sent out to be medically assessed after falling on 6/21/22.

Official plan of correction

Administrator will ensure that Title 22 regulations are being adhered to, and will ensure that residents who require a medical assessment receive it as required. Administrator will send LPA facility plan on incidental medical and dental care, and proof of staff training on plan by POC due date.

Deadline recorded: Mar 1, 2024. 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

(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 being met as evidenced by : LPA observed that facility did not submit a special incident report for resident #1's fall on 6/21/22.

Official plan of correction

Administrator will ensure that Title 22 regulations are being adhered to as required. Administrator will conduct an inservice training with all staff on reporting requirements and will send proof of training to LPA by POC due date.

Deadline recorded: Feb 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.695(a)

Regulation authority

HSC

What the official deficiency says

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all the following: This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above in LIC 610D and emergency disaster plan reviewed was not the currently updated to include S6 who is the sole staff during the overnight shift 10PM -6PM which poses/posed a potential health, safety or personal rights risk to persons in care

Official plan of correction

Administrator will provide emergency disaster training to S6 and will updated LIC610D and will submit a copy to the department by 6/6/23.

Deadline recorded: Jun 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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... This was not met as evidenced by: Facility staff was not aware of R1 walking out of the facility. R1 was not supervised by staff. According to files, R1 is not able to leave the facility unassisted. This poses an immediate Health and Safety risk for residents in care and supervision.

Official plan of correction

Faciltiy to provide in service training to staff on the importance of supervision and monitoring of residents in the faciltiy. Training Sign in sheet was provided to LPA by oringial POC Due date. 6/4/21. penl POC is cleared at time of visit. Civil Penalty Assessed

Deadline recorded: May 8, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in B1 tested at 157.9 degrees F., B2 tested at 136.0 degrees F., B3 tested at 141.4 degrees F., B4 tested at 89.4 degrees F., and B5 tested at 155.1 degrees F. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/29/2023 Plan of Correction Lincensee will ensure that water heater is at the required 105-120 degrees at all times and will certify via LIC 9098 by POC due date 4/29/23. Facility will maintain a water temperature log for the next 7 days and submitted to the department by 5/5/23.

Official classification

Type A

Official code

87465(h)(5)

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: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 1 out of 5 medicaitons reviewed, R1's medication was stored in plastic bag not in original container which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/29/2023 Plan of Correction Licensee will provide in-service training on section 87465 to staff and will send a copy of training and signing log to the depatment by POC due date 4/29/23.

Official classification

Type B

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. 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 kitchen and pantry's floor were observed dirty which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/05/2023 Plan of Correction Administrator will provide in-service training on section 87555 to kitchen staff and will ensure kitchen floor's are maintain clean at all times, will submit in-service training and pictures of clean floors to the department by POC due date 5/5/23.

Official classification

Type B

Official code

1569.695(a)

Regulation authority

HSC

What the official deficiency says

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in LIC 610D and emergency disaster plan reviewed was not the current version which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/05/2023 Plan of Correction Administrator will updated LIC610D and will submit a copy to the department by 5/5/23.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care...shall be maintained... 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 evidence by: Based on observation licensee failed to ensure water temperature in BR2,BR3,B#4,And BR5 is maintained within the required 105-120 degrees which is an immediated health, safety, or personal rights risk to the persons in care. *Civil Penalites have been asses for a repeated violation*

Official plan of correction

Administrator will certify on LIC 9098 to ensure that water temperature is maintain within the required 105-120 degrees F. by POC due date1/14/23.

Deadline recorded: Jan 14, 2023. 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

87303 Personal Accomodations 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 evidence by: Based on observatiosn licensee failed to ensure facility's flooring, BR1, and RR5 wardrobe and door lock is in good repair which poses a potential risk to the health, safety, or personal rights of persons in care.

Official plan of correction

Administrator will submit pictures of repairs of flooring, BR1,and RR5 to the department by POC due date 1/20/23.

Deadline recorded: Jan 20, 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 evidence by: Based on observation licensee failed to ensure RR2 and RR9 and RR10, common hallway, and medicaiton room were free of holes and/or water damage which poses a potential health, safety, or personal rights risk to the persons in care.

Official plan of correction

Administrator will email pictures of temporary tarp place on balcony roofs above RR2 and RR9/10 by end of day of1/13/23 and will send pictures of repairs done to the ceilings, wall, and roof by POC due date 1/20/23 to the department.

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

Official classification

Type B

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance ...(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidence by: Based on observation licensee failed to ensure facility is free of mildew and smells which poses a potential health, safety, or personal rights risk to the persons in care.

Official plan of correction

Administrator will conduct the proper repairs to remove mildew in flooring of RR7 and will ensure there is no mold/mildew throughout the facility and will ensure facility is free of smells will submit service receipt to the department by POC due date 1/20/23.

Deadline recorded: Jan 20, 2023. 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. Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met by evidence of: Based on observation, LPA observed that the majority of resident rooms with windows had sheer curtains that were see through; not providing resident's privacy during day and night hours; which poses a potential health and safety risk to clients in care.

Official plan of correction

Administrator shall ensure all residents shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Submit proof of purchase/corrections, and a wrtiten statement indicating which rooms had new curtains installed.

Deadline recorded: Sep 28, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(3)(C)

Regulation authority

CCR

What the official deficiency says

87307(a)(3)(C) Personal Accommodations and Services. Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths..... This requirement was not met by evidence of: Based on physical plant observations none of the resident beds had mattress pads; they only had plastic bed protectors; which poses poses a potential health and safety risk.

Official plan of correction

Administrator agreed to ensure that all resident beds have mattress pads, and sheets at all times. Submit proof of purchase receipt and pictures by POC due date.

Deadline recorded: Sep 28, 2022. 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

(a) Each licensee shall furnish to the licensing agency such reports...: (1) A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events specified in (A) through (D) below... (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: Facility did not submit Special Incident Report to CCLD regarding incident involving R1 on 06/16/22. This poses a potential health, safety, and/or personal rights risk to the residents in care.

Official plan of correction

Licensee/Administrator to submit a Special Incident Report explaining incident involving R1 at the facility on 06/16/22.

Deadline recorded: Jul 6, 2022. 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 Incidental Medical and dental Care (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: 2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the Administrator did not comply with the section cited above in 4 out of 5 residents' medications reviewed and observed Resident #1 was not given the Respiridone 2MG and for Residents #3 - 5, all the medications observed were not indicated on the MAR log which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/09/2022 Plan of Correction The Administrator shall review the Physician's Order for all the residents taking medication to ensure that they are being given medication as prescribed. The Administrator shall conduct a medication training for all staff handling medication and submit proof of training log to LPA by POC due date 3/9/22.

Official classification

Type A

Official code

87465(i)

Regulation authority

CCR

What the official deficiency says

87465 (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: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the Administrator did not comply with the section cited above in 4 out of 5 residents' medications where Staff could not indicate if the medication observed in their boxes were discontinued by the physician which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/09/2022 Plan of Correction The Administrator shall follow up with residents' medications to ensure they are not discontinued by the physician. An in-service training for medication shall be conducted to ensure residents are taking their medication as ordered by the physician and proof shall be provided to the LPA by POC due date 3/9/22.

Official classification

Type A

Official code

87303

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 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 Administrator did not comply with regulation cited above where the hot water temperature measured at 143 degree F for the bathroom upstairs between rooms #18 and room #19, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/09/2022 Plan of Correction The Administrator shall adjust the hot water setting and ensure that the hot water temperature is maintained between the range of 105 - 120 degree F. The log shall be submitted to LPA by POC due date 3/9/22.