HORIZON ASSISTED LIVING FACILITY

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)i the licensee did not comply with the section cited above due to Several window screens torn or missing, side gate not properly fixed-drags scrapes and/or scrapes across concrete, bolts exposed hangs, front and/or back yard overgown, patio area overgrowth tripping hazard, multiple wasp nest under the eaves of roof, walk path has growth of weeds/crabgrass which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/24/2026 Plan of Correction Licensee/administrator will have maintenance/landscaper address issues and send pictures to LPA by POC: 03/24/26.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation] Food on hand does not meet requirement to have both nonperishable (1 week) and perishable (2days) on the premises which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/24/2026 Plan of Correction Licensee/administrator will send proof of food on premises in addition to daily purchases by POC: 03/24/26

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 and 4 pressure injuries. This requirement was not met as evidenced by: Based on record reviews & interviews, R1 wounds not healing, developed unstageable wounds while in care which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee shall submit a written plan describing how the facility shall prevent injuries to residents in care as a result of this deficiencies. Licensee shall submit to CCL no later than 11/02/2023

Deadline recorded: Nov 2, 2023. 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

87465(g) 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 This requirement was not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited, as staff did not seek medical attention for R1 in a timely manner, which posed an immediate health and safety risk to R1

Official plan of correction

The Administrator agreed to do the following: Submit a Statement of Understanding, and the steps the facility will take to avoid similar issues from happening and to ensure compliance to the cited regulation Licensee shall submit to CCL no later than 11/02/2023

Deadline recorded: Nov 2, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(I)(5)

Regulation authority

CCR

What the official deficiency says

The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement is not being met as evidenced by Based on observation and interview the licensee did not comply with the section cited by locking the backyard exit doors/gates of the facility without the approval of the fire department which poses an immediate health and safety and personal rights violation to persons in care.

Official plan of correction

Staff removed the locks from the gates. Licensee/administrator will submit a dated and signed written statement that exit doors will not be pad locked at any time. This is a zero tolerance violation therefore a civil penalty in the amount of $500.00 has been issued. Civil penalties will continue to accrue until plan of correction is submitted.

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

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

FIRE CLEARANCE. All facilities shall maintain a fire clearance. Prior to accepting persons over 60 years of age none ambulatory and/or bedridden the licensee shall notify the licensing agency and obtain an appropriate fire clearance. This requirement is not met as evidenced by: This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited by retaining bedridden resident in room with non ambulatory fire clearance (R1)which poses an immediate health, safety and personal rights risk to R1.

Official plan of correction

Licensee/Administrator will submit a dated, signed written statement notifying the department how this deficiency will be corrected. This is a zero tolerance violation therefore civil penalty in the amount of $500 has been issued. Civil penalties in the amount of $100 dollars per day will accrue until POC is received.

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

Official classification

Type A

Official code

87611(c)

Regulation authority

CCR

What the official deficiency says

In addition to Section 87411(d), facility staff shall have knowledge and the ability to recognize and respond to problems and shall contact the physician, appropriately skilled professional, and/or vendor as necessary. This requirement was not being met as evidenced by: Based on Information obtained during the course of the investigation the facility staff did not comply with the cited section by not having knowledge and ability to properly document respond and obtain medical care of R1's various pressure injuries not being treated by the hospice agency which posed an immediate health and safety, and personal rights risk to resident in care.

Official plan of correction

Licensee/Administrator will submit a Detailed written explanation why they have been continuously operating non-compliant as evidenced by the various complaints received by the department. Licensee/Administrator will also need to submit a detailed plan regarding the steps that will be taken to ensure compliance of all deficiencies issued since licensure. Licensee/Administrator will also provide in service training to all staff regarding the cited. Certification of the training will need to be submitted as POC.

Deadline recorded: Jun 27, 2022. A deadline is not proof that correction was completed.

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. This requirement was not met as evidenced by. Based on information obtained during the course of the investigation the licensee/ administrator did not comply with the cited section by not having knowledge of R1's various pressure injuries not being treated by hospice and ensuring proper medical care was obtained prior to hospitalization which posed an immediate health and safety, and personal rights risk to resident in care.

Official plan of correction

Licensee/Administrator will submit a Detailed written explanation why they have been continuously operating non-compliant as evidenced by the various complaints received at the department. Licensee/Administrator will also need to submit a detailed plan regarding the steps that will be taken to ensure compliance of all deficiencies issued since licensure. This is a repeat citation therefore civil penalty in the amount of $250 dollars has been issued, civil penalty will continue to accrue until plan of correction is submitted to the LPA. First citation issued on 4/7/2022.

Deadline recorded: Jun 27, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

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 (1) Obtain a California clearance or a criminal record exemption as required by the Department . This requirement is not met as evidenced by Based on observation and interview the licensee/administrator did not comply with the section cited by allowing S2 to work at the facility prior to obtaining criminal record clearance which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator will ensure the staff member receives criminal record clearance prior to returning to the facility. Licensee/administrator will submit verification of Live scan and photo ID of volunteer who left the facility. This is a zero tolerance violation therefore a civil penalty in the amount of $500.00 has been issued. Civil penalties will continue to accrue until plan of correction is submitted.

Deadline recorded: Apr 8, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87207

Regulation authority

CCR

What the official deficiency says

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This Requirement was not met as evidenced by: Based on the information obtained by LPA during the visit the licensee/administrator and staff did not comply with he cited section by providing false/misleading statements to LPA regarding Staff/volunteer which posed an immediate personal rights violation to residents in care.

Official plan of correction

Licensee/Administrator designee will submit a written explanation to the department regarding their actions. Licensee/Administrator an all staff will also attend vendorized training for the following title 22 regulations. 87408: Denial or Revocation of a Certificate, 87777: Exclusions, Personal Rights 1) Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by 4/9/2022. 2) Verification of completed training will need to be submitted to the LPA by 4/19/2022.

Deadline recorded: Apr 9, 2022. A deadline is not proof that correction was completed.

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. the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's RP This requirement was not met as evidenced by: Based on IB investigation record review and interview, the licensee/administrator did not comply with the cited section by not having knowledge of R1’s pressure injuries prior to hospitalization which posed an immediate health and safety and personal rights risk to R1

Official plan of correction

Licensee/Administrator and all staff will attend vendorized training related to the cited sections. 1) Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by 4/9/2022 2) Verification of completed training will need to be submitted to the LPA by 4/19/2022. Licensee/Administrator will also submit a written statement notifying the department what steps will be taken to ensure compliance with cited regulation at all times.

Deadline recorded: Apr 8, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87631(a)(3)(A)

Regulation authority

CCR

What the official deficiency says

the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances:(3)Residents with a stage 1or2 pressure injury must have the condition diagnosed by a physician/appropriately skilled professional. (A)The resident shall receive care for the pressure injury from a physician/appropriately skilled professional. This requirement was not met as evidenced by: Based on IB investigation record review & interview, the licensee/admin did not comply with the cited section by not having R1's pressure injuries diagnosed & treated by a physician/appropriately skilled prof. Which posed an immediate health and safety risk to R1

Official plan of correction

Licensee, Administrator will schedule 6 hours vendorized training for themselves and all staff related to the cited section as well as the following title 22 regulations. 87615, 87609, 87611, 87612, 87613. 1) Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by 4/9/2022 2) Verification of completed training will need to be submitted to the LPA by 4/19/2022. Licensee/Administrator will also submit a written statement notifying the department what steps will be taken to ensure compliance with cited regulation at all times.

Deadline recorded: Apr 8, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)

Regulation authority

CCR

What the official deficiency says

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 was not met as evidenced by: Based on IB investigation record review and interview, the licensee/administrator failed to provide proper care and supervision by not having knowledge of R1's various pressure injuries, which due to neglect were diagnosed as prohibited health conditions upon hospitalization posed an immediate health and safety and personal rights risk to R1

Official plan of correction

Licensee, Administrators will schedule 2 hours vendorized training for themselves and all staff related to the cited section. 1) Verification of the scheduled training with the credentials of the trainer will need to be emailed to the LPA by 4/9/2022 2) Verification of completed training will need to be submitted to the LPA by 4/19/2022. Because this violation resulted in resident developing prohibited health conditions as a result of improper care an immediate civil penalty in the amount of $500 is issued.

Deadline recorded: Apr 9, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

Postural support-Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement was not met as evidenced by: Based on interviews conducted facility used two half bed rails on R1's bed when they were sleep when only a half bed rail was noted to be used by physician which created a full bed rail. This posed an immediate health and safety risk to residents in care.

Official plan of correction

Administrator will submit statement that all postural supports will be used as they are prescribed for. Statement will be sent to LPA.

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