KINGSLEY MANOR

Official classification

Type B

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, water temperature measured 97.5 - 121.0 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/10/2026 Plan of Correction Administrator adjusted water and will keep a log for 3 days and send to LPA as proof of correction.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on observation, interview, record review, the licensee did not comply with the section cited above in R1 was able to leave facility unassisted even though R1's physician's report stated that R1 was not to be allowed to go out of the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator agreed to: 1. Adhere to approved Plan of Operation Staffing Plan and Hours. 2. Submit a written plan regarding staffing schedules, and a copy of staff in-service training to prevent eloping. Licensee shall provide CCLD with plan and training sign by all staff by POC date.

Deadline recorded: Oct 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)(b)(1)(D)

Regulation authority

CCR

What the official deficiency says

Reappraisal The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101 The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition and significant including those required to be documented as specified in Section 87466, Observation of the Resident. Definitions, include, but are not limited, to: (D) A mental or social trauma, such as the loss of a loved one.” This requirement is not met as evidenced by: Appraisal wasn't updated and Resident R1 not being provided safety checks, proper assessment, which caused a potential risk to residents in care.

Official plan of correction

Facility to submit a reassessment of Resident R1 and submit to Licensing by POC due date. Deficiency cleared. Assessment completed.

Deadline recorded: Jul 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

Basic Services Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Facility did not monitor Resident R1's blood pressure and didn't conduct room checks which caused a potential risk to residents in care.

Official plan of correction

Facility to conduct room checks and check blood pressure for Resident R1 as noted on reassessment. Deficiency cleared. Assessment completed and room checks conducted.

Deadline recorded: Jul 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(a)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services: (a) The services provided by the facility shall be conducted so as to continue and promote ,... independence and self-direction for all persons... shall be encouraged to participate as fully... in daily living activities... This requirement is not met as evidence by: Based on interviews and observations licensee did not ensure staff were promoting resident's independence and self-direction by allowing choices during meal service which is a potential risk to the health, safety, or personal rights of the persons in care.

Official plan of correction

Administrator has implemented dining staff allowing resident to be provide or bring own cereal if necessary into the dining room since LPAs last visit on 2/18/25 and training was provided to staff on resident's rights on 3/3/25. Deficiency cleared as of 3/20/25.

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

Official classification

Type B

Official code

87468.2(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(3) To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights.

Official plan of correction

This requirement was not met as evidenced by: staff is not allowing residents to bring outside food to eat, into the dinning room. Licensee will retrain all staff on this regulation and send proof of retraining by 3/04/2025 via email to LPA Ramirez.

Deadline recorded: Mar 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(3) To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights.

Official plan of correction

Licensee will retrain staff on this regulation and send proof of retraining by 10/15/2024 via email to LPA Ramirez.

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

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1 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: (3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature.. Based on record review and interviews that S2 grabbed R2’s arm while in the elevator which poses an immediate personal rights risks to residents in care.

Official plan of correction

Licensee shall provide In-Service Training for all staff focusing on Residents Personal Rights as defined by Title 22 regulations. Licensee shall provide CCL with a copy of the attendance sheet documenting the topics, duration of training, and person that conducted the training by POC Due Date.

Deadline recorded: Aug 21, 2024. 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). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph... This requirement is not met as evidenced by: Based on LPA interviews and record review, Facility / administrator refusal to accept R1 back to the facility upon discharge from hospital and not providing R1 with the 30 day eviction notice which poses a potential health, safety or personal rights risk to the residents in care.

Official plan of correction

Administrator will review Title 22 Regulations, Section 87224 on Eviction Procedures, and submit a written statement to CCL ensuring that he/she understands and will comply with Title 22 Regulations pursuant to this section by the POC due date.

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

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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... Based on record review and interviews, the licensee did not ensure staff are providing the required needs and supervision to Resident #1 which poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

The licensee shall provide in-service training to all care staff to ensure they meet the needs of residents. The training log will be emailed to LPA by 5/8/24.

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

Official classification

Type B

Official code

87303(i)(1)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met evidenced by: Four (4) out of (6) staff stated at times they respond within 30 minutes, because the staff pendants at times take 5-15 minutes to register/summons the call on staff pagers, and then it may take an additional 10 minutes to reach the resident. This poses an immediate health and safety risk.

Official plan of correction

Executive Director agreed to: 1. Submit a written POC by tomorrow. 2. Proof of staff in-service due 3/8/2024. 3. Proof that the entire building's pager/ signal system and pendants were tested and are receiving the page within facility protocols response time.

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

Official classification

Type B

Official code

87208(a)(9)

Regulation authority

CCR

What the official deficiency says

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. (9) A statement whether or not the applicant will handle residents' money and/or valuables. If money or valuables will be handled, the method for safeguarding pursuant to Sections 87215, Commingling of Money, 87216, Bonding and 87217, Safeguards for Resident Cash, Personal Property and Valuables. This requirement is not met as evidenced by: Facility is now classifying employee appreciation funds as tips and taxable and requiring the resident council to cut a check to corporate to distribute the funds. the plan of operation is not up to date and is missing a statement on how resident's cash will be safeguarded.

Official plan of correction

Facility will update their plan of operation and send it to CCL for approval

Deadline recorded: Feb 21, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care. For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. Based on observation, R1 has multiple over the counter medications in the room that are not listed on medication records, and the resident is self-administering without a physician's order. According to the MD report, R1 cannot administer their own medications; this poses an immediate health and safety risk.

Official plan of correction

Staff shall remove all over the counter medications, conduct staff training, and contact MD to obtain physician's orders if applicable, and address foot care . Submit a written POC of how the deficiency was corrected. POC is due tomorrow.

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

Official classification

Type B

Official code

87465(a)(5)

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: (5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. This requirement was not being met as evidenced by : staff #1 dropped a medication pill belonging to another resident in resident #1's room. Staff then left the medication in the room. This poses a health and safety risk to residents in care.

Official plan of correction

The administrator will ensure that staff who distribute medication to residents are properly trained in assisting with medication administratrion. Administrator will provide an inservice traininig to all staff that administer medication, and will provide proof of training to LPA by POC due date.

Deadline recorded: Nov 17, 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 onobservation, the licensee did not comply with the section cited above in 2 out of 179 residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/12/2023 Plan of Correction Administrator is to ensure that water temperature measures within the required 105 F - 120 F at all times within the White House. Administrator cleared the citation during the visit by contacting the Maintenance Supervisor who adjusted the water temperature during the visit and showed proof that it was within the required range to the LPA.

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 required by: Based on interviews, the licensee did not ensure that both elevators in the LH building were working properly which poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

The licensee shall ensure the elevators are working at all times. The POC is due by 3/30/23. ***The POC has been cleared as of today due to both elevators were observed working properly.***

Deadline recorded: Mar 30, 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 did not ensure facility was free of bed bugs which is a potential health, safety, or personal rights risk to the persons in care.

Official plan of correction

Administrator provided LPA Flores a copy of Pest Control Customer Service Report dated: 10/25/22 which notes " no bedbug activity was found during treatment. " Deficiency cleared during visit as of 2/9/23.

Deadline recorded: Feb 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303

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 interviews conducted, and pest control document review, at least 3 rooms (AD-217, AD-210, MH-103) were under pest control treatment for bed bugs. Per pest control record review, a service date of 09/17/2020, found roaches in resident rooms LH-308 through LH-310. This pose(s) a potiential risk to the health, safety or personal rights of residents in care.

Official plan of correction

1. Provide a written plan to CCL outlining a revised approach to eradicate facility of bed bugs. 2. Inspect all rooms for cleanliness. 3. Provide training to all staff. 4. Submit training topic and staff attendance log to CCL. 5. Submit proof of corrections by POC due date. Facility did provide treatment to rooms affected. Facility has maintained pest control services since 06/23/2020 in an effort to prevent bed bugs and roaches.

Deadline recorded: Feb 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

Basic Services. Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement was not met by evidence of: Based on interviews and records reviewed, R1 has not been receiving assistance with showering which poses a potential risk to the health, safety, or personal right of the persons in care.

Official plan of correction

Facility will provide R1 shower assistance as required and additionally will contact R1's physician to have R1 re-assess and submit physician’s report to CCLD by 11/04/2022.

Deadline recorded: Oct 19, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(a)

Regulation authority

CCR

What the official deficiency says

Basic Services. Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement was not met by evidence of: Based on interviews and records reviewed, R1 has not been receiving assistance with showering which poses a potential risk to the health, safety, or personal right of the persons in care.

Official plan of correction

Facility will contact R1's physician to have R1 re-assess for higher level of care and will submit physican's report or physician's request for higher level of care to CCLD by 11/04/2022.

Deadline recorded: Nov 4, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents .... shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met evidenced by: On June 9, 2022 R1 tested positive for COVID-19 virus. The facility did not call CCL to report the case, and has not submitted an incident report to CCL; which poses a potential health and safety risk to persons in care.

Official plan of correction

Facility shall ensure that all Unusual Incident Reports (SIR's) are reported to CCL and all other necessary departments within 24 hours of COVID-19 incidents. Staff training shall be conducted on reporting requirements and send a copy of the inservice training log by POC due date.

Deadline recorded: Jun 21, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by: Based on interviews with residents and facility staff and LPA observations that revealed that R4 poured bleach onto R6's room door, which poses an immediate health and safety risk to the residents in care.

Official plan of correction

Executive Director to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Executive Director to submit a faxed or mailed copy of POC by due date.

Deadline recorded: May 17, 2022. 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) Personal Rights of Residents in All Facilities (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews with residents and facility staff that revealed that R4 has screamed at, intimidated and harassed facility resident 6, which a potential risk to residents in care.

Official plan of correction

Executive Director to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Executive Director to submit a faxed or mailed copy of POC by due date.

Deadline recorded: May 23, 2022. A deadline is not proof that correction was completed.