AMY'S PARADISE HOME OF ANGELS INC.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) ...by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interview and record review the licensee did not comply with the section cited above as the facility did not seek timely medical attention for R1 following the presentation of symptoms of a medical emergency which posed an immediate health risk to clients in care.

Official plan of correction

Administrator agreed to conduct training with all staff members of the facility covering the importance of noticing signs and symptoms of a medical emergency and seeking medical attention in a timely manner. Administrator agreed to submit proof of completed training to CCLD no later than POC due date.

Deadline recorded: Apr 10, 2026. 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

87468.1 Personal Rights of Residents... (a) Residents... 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 met as evidenced by: Based on interviews and record review the licensee did not comply with the section cited above as S1 entered into an inappropriate relationship with R1 through their marriage and subsequent divorce which posed a potential personal rights risk to clients in care.

Official plan of correction

Administrator agreed to conduct a meeting with staff members of the facility covering what constitutes appropriate staff/resident relationship and what behaviors are acceptable for facility staff. Administrator agreed to submit proof of the meeting to CCLD no later than POC due date.

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

Official classification

Type B

Official code

87465(a)(8)(A)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) ... by compliance with the following: (8) ...The kit...shall contain at least the following: (A) A current edition of a first aid manual... This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as the facility did not have a current edition of a first aid manual which poses a potential health or safety risk to clients in care.

Official plan of correction

Administrator agreed to obtain a first aid manual and to send proof of the manual at the facility to CCLD no later than POC due date.

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

Official classification

Type B

Official code

87705(d)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates... This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as the side and front gates were missing properly functioning auditory alarms which poses a potential safety risk to clients in care.

Official plan of correction

Administrator agreed to send proof of appropriately installed and functioning auditory alarms on the identified gates to CCLD no later than POC due date.

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

Official classification

Type B

Official code

87309(c)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space and Access (c) ... the licensee shall...ensure that ... other potentially toxic substances... are stored so as not to pose a hazard to residents. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as a Clorox spray air freshener was unsecured and paints were stored in a resident's room who was at risk if allowed access to toxic substances which posed a potential health and safety risk to clients in care.

Official plan of correction

S2 secured the items at the time of the visit. Administrator agreed to conduct training with all staff on the importance of securing toxic substances. Administrator agreed to submit proof of the completed training to CCLD no later than POC due date.

Deadline recorded: Apr 23, 2026. 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.... This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as the closet doors in bedroom #1 and the shared tub were in disrepair which poses a potential safety or personal rights risk to clients in care.

Official plan of correction

Administrator agreed to complete repairs to the identified items and to send proof of the completed repairs to CCLD no later than POC due date.

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

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) ... by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation, record review and interview the licensee did not comply with the section cited above as twenty three medications across six residents had errors in the medication count which poses an immediate health risk to persons in care.

Official plan of correction

Administrator agreed to conduct an immediate training with all staff handling resident medications covering best practices for medication administration and to submit proof of the completed training to CCLD no later than POC due date.

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

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(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 record review, the licensee did not comply with the section cited above as four staff members files contained expired first aid certifications which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/01/2026 Plan of Correction Administrator agreed to submit updated first aid certifications for the identified staff members to CCLD no later than POC due date.

Official classification

Type B

Official code

87465(h)(6)

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: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above as R1 and R2's CSMDRs contained inaccurate records of their prescribed medications which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 04/01/2026 Plan of Correction Administrator agreed to submit updated CSMDRs for the identified individuals to CCLD no later than POC due date.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above as three residents files contained appraisal needs and services plans that were created more than 12 months prior which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/01/2026 Plan of Correction Administrator agreed to submit updated Appraisal needs and services plans for the identified individuals to CCLD no later than POC due date.

Official classification

Type B

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

(g) All personnel records shall be maintained at the facility. 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 as one employee file was not maintained at the facility for review which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/01/2026 Plan of Correction Administrator agreed to place the identified employee file in the facility's records and to submit a copy of the file to CCLD no later than POC due date.

Official classification

Type B

Official code

87507(g)(3)(A)

Regulation authority

CCR

What the official deficiency says

87507 Admission Agreements (g) Admission agreements shall specify the following: (3) Payment provisions, including the following: (A) Rate for all basic services which the facility is required to provide in order to obtain and maintain a license. Basic services rate(s), including: 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 as two resident admission agreements did not contain the amount charged for basic services which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/01/2026 Plan of Correction Administrator agreed to submit updated admission agreements including initials acknowledging the changes to the agreement for the identified individuals to CCLD no later than POC due date

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal... This requirement is not met as evidenced by: Based on observation and file review the Licensee did not comply with the section cited above as one resident was observed to be non-ambulatory for which the facility does not have an approved fire clearance which poses an immediate safety risk to clients in care.

Official plan of correction

The Administrator stated that they will contact the local fire department and notify them that they have a Non-Ambulatory resident. Additionally, the Administrator confirmed that the resident would be issued an eviction notice and be relocated to an appropriate facility. Licensee will submit their plan on how they will evacuate the identified resident safely from the facility in the event of a fire or emergency. Licensee will submit proof of corrections no later than POC due date.

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

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating...all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by: Based on file review the Licensee did not comply with the section cited above as one resident file was observed to be missing proof of a negative TB test which poses an potential health risk to clients in care.

Official plan of correction

The Licensee will obtain an updated physician report for R2 confirming a negative TB test. The Licensee may also satisfy this POC via the eviction of R2 due to the fire clearance violation mentioned above. Licensee will submit proof of corrections no later than POC due date.

Deadline recorded: Jun 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

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency... (1) A written report shall be submitted to the licensing agency... within seven days of the occurrence... This requirement is not met as evidenced by: Based on file review and interview the Licensee did not comply with the section cited above as incident reports for R1's hospitalization and R2's change of condition were not submitted to CCLD which poses a potential health, safety, or personal rights risk to clients in care.

Official plan of correction

Administrator submitted R1's incident report at the time of the visit. Licensee will submit an incident report for R2 and will submit a statement of understanding confirming that they understand the importance of submitting reports in a timely manner. Licensee will submit these items no later than POC due date.

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

Official classification

Type B

Official code

87463(b)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition... This requirement is not met as evidenced by: Based on file review and observation the Licensee did not comply with the section cited above as R2 had a change of condition that was not reflected on their physician report which poses a potential health and safety risk to clients in care.

Official plan of correction

The Licensee will obtain an updated physician report for R2. The Licensee may also satisfy this POC via the eviction of R2 due to the fire clearance violation. Licensee will submit proof of corrections no later than POC due date.

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

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by: Based on observation the Licensee did not comply with the section cited above as the flooring in the kitchen near the exit, the closet door in room # 2, and the light switch cover in the shared resident bathroom were in disrepair which poses a potential health and safety risk to clients in care.

Official plan of correction

Licensee will submit proof of completed repairs for the identified items. Licensee will submit proof no later than POC due date.

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

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following... shall apply... (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained... This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as one medication prescribed to R1 was not logged on R1's CSMDR which poses a potential health risk to clients in care.

Official plan of correction

The Administrator agreed to conduct a medication audit and submit an accurate CSMDR for R1 to CCLD no later than POC due date.

Deadline recorded: Jun 13, 2025. 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 as the facility's carbon monoxide detector was non-functional at the time of the visit which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 02/21/2025 Plan of Correction Licensee will submit proof of a functioning carbon monoxide detector to CCLD no later than 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 as the water temparature was measured between 138.2 and 140.4 degrees F which poses an immediate health risk to persons in care.

Official plan of correction

POC Due Date: 02/21/2025 Plan of Correction Licensee will submit proof of appropriate water temparature to CCLD no later than POC due date.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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 as the facility was unable to provide a copy of un-expired liability insurance at the time of the inspection which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2025 Plan of Correction Licensee will submit proof of valid liability insurance to CCLD no later than POC due date.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as three windows were observed to have screens missing or not properly installed which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2025 Plan of Correction Licensee will submit proof of appropriate window screen repairs for the three identified windows to CCLD no later than POC due date.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above as one employees file was observed to be missing their LIC 508 and one additional employee's file was observed to be missing their LIC 503 and a negative TB test which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2025 Plan of Correction Licensee will submit the missing documentation for the identified employees to CCLD no later than POC due date.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. 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 as one resident's file was observed to be missing a negative TB test which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2025 Plan of Correction Licensee will submit proof of a negative TB test for the identified resident to CCLD no later than POC due date.

Official classification

Type B

Official code

1569.695(d)

Regulation authority

HSC

What the official deficiency says

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. 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 as the facility's emergency disaster plan was not reviewed annually which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2025 Plan of Correction Licensee will submit a reviewed emergency disaster plan to CCLD no later than POC due date.

Official classification

Type A

Official code

1569.725(a)

Regulation authority

HSC

What the official deficiency says

(a) A residential care facility for the elderly may permit incidental medical services to be provided through a home health agency, licensed pursuant to Chapter 8 (commencing with Section 1725), when all of the following conditions are met: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review,, the licensee did not comply with the section cited above in 2 out of six persons, did not have on file documenation of services provided by the Home Health/Hospice agency LVN/RN, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/04/2024 Plan of Correction Licensee will submit Plan of Correction with Care plans for two residents to the LPA by 03/04/2024.

Official classification

Type B

Official code

87705(a)(k)(4)(5)(6)

Regulation authority

CCR

What the official deficiency says

(4)Without violating ... Personal Rights, facility staff shall attempt to redirect a resident who attempts to leave the facility.(5)Residents who continue to indicate a desire to leave the facility following redirection shall be permitted to do so with staff supervision. Personal Rights, facility ... the continued safety of residents if they wander... facility. This requirement was not met as evidence by: Based on interviews, the licensee did not comply, R1 was able forcefully restrained while trying to leave the facility, which poses a potential safety risk to residents in care.

Official plan of correction

Administrator agrees to review the regulations with staff as they pertain to caring to persons with dementia. Submit staff training sig in sheet, training agenda and materials/handouts used for training by 04/14/2023.

Deadline recorded: Apr 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

The following should be strored inaccesible to residents with dementia... toxic substances. 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 as two out of two bottles of charcoal fluid were observed by the barbecue grill outdoors, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/06/2023 Plan of Correction Licensee agrees to provide training to staff about locking and making all toxic substances inaccessible to residents. Send proof of training to CCLD by 02/06/2023.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

Licensee shall have an auditory device to monitor exits, if it presents a hazard to any residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the section cited above as two out of two signal devices were not installed correctly for front door and outdoor gate, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/06/2023 Plan of Correction Licensee agrees to install correctly the auditory devices and send pictures ti CCLD by 02/06/2023.

Official classification

Type B

Official code

80020(a)

Regulation authority

CCR

What the official deficiency says

All facilities shall secure and maintain a fire clearance approved by the city or county fire department... This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the section cited above as one out of one fire extinguishers were found to have been serviced on 02/26/2021, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/06/2023 Plan of Correction Licensee agrees to purchase a new fire extinguisher , and send to CCLD pictures of the receipt for the new fire extinguisher by 02/06/2023.

Official classification

Type B

Official code

1569.695(a)(2)

Regulation authority

CCR

What the official deficiency says

Plans for the facilityto be self-reliant for a period of not less than 72 hoursduring an emergency... This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as canned food was found to have expired on 2021 and 2022, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/06/2023 Plan of Correction Licensee agrees to purchase additional canned food for emergency supplies, and send a picture of the receipt and pictures to CCLD of can goods for the emergency supply.

Official classification

Type B

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

87458(b)(1) Medical AssessmentThe medical assessment, at a minimum, shall include: A physical exam of the resident containing a primary and secondary diagnosis, if any, results of a test for tuberculosis and any medical conditions which would preclude care of the person in an RCFE.

Official plan of correction

Licensee agreed to have a TB test result from the Physician office by POC date. Licensee agrees to submit a written plan of correction outlining how the Licensee will prevent this from occurring in the future

Deadline recorded: Sep 20, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Licensee did not comply with the above citation, as three out of four residents' records were not available at facility upon request for review, which poses a potential health and safety risk to residents. Deficient Practice Statement All residents’ records shall be maintained at the facility and shall be available to the licensing agency for review

Official plan of correction

POC Due Date: 09/07/2021 Plan of Correction Licensee to submit proof by 09/07/2021 of residents' files available for review upon inspection.

Official classification

Type A

Official code

87465(c)(3)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Upon review of records, licesee did not comply with the above citation, as four out of four residents' records were missing the medication logs and were not available at facility upon request for review , which poses a potential health and safety risk to residents. Deficient Practice Statement A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

Official plan of correction

POC Due Date: 09/07/2021 Plan of Correction Licensee to submit proof by 09/07/2021 of four residents' medication logs.