Fire safety and emergency preparednessType A
- Official classification
- Type A
- Official code
- 87202(a)
- Regulation authority
- CCR
What the official deficiency says
(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. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate 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: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above as a bedridden resident resided in a non-bedridden approved room which poses an immediate safety risk to persons in care.
Official plan of correction
POC Due Date: 06/30/2026 Plan of Correction Administrator agreed to move the identified resident into the bedridden approved room and to send proof of the completed move to CCLD no later than POC due date.
Hazardous items and storageType A
- 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 as cleaning chemicals, pesticides, and gardening shears were left outside of locked storage unsupervised which poses an immediate health and safety risk to persons in care.
Official plan of correction
POC Due Date: 06/30/2026 Plan of Correction Administrator agreed to conduct a training with all facility staff on the importance of securing dangerous items. Administrator agreed to send proof of the completed training to CCLD no later than POC due date.
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(e)(4)
- Regulation authority
- CCR
What the official deficiency says
(4) Grab bars shall be maintained for each toilet, bathtub and shower used by 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 one resident toilet was observed to be missing appropriate grab bars which poses a potential safety risk to persons in care.
Official plan of correction
POC Due Date: 07/13/2026 Plan of Correction Administrator agreed to install appropriate grab bars for the identified resident toilet and to send proof of the installed bars to CCLD no later than POC due date.
Hazardous items and storageType B
- Official classification
- Type B
- Official code
- 87309(a)(2)
- 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. (2) Any items in subsection (a)(1) that are transferred from their original container to another container shall have a legible label that indicates: 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 bleach was stored in an unmarked clear spray bottle left unattended in a resident bathroom which poses a potential health and safety risk to persons in care.
Official plan of correction
POC Due Date: 07/13/2026 Plan of Correction Administrator agreed to appropriately label any and all chemicals stored in the facility that are not in their original container and to send proof of the appropriately labeled containers to CCLD no later than POC due date.
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(a)(4)
- Regulation authority
- CCR
What the official deficiency says
(4) The licensee shall assist residents with self-administered medications as needed. 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 two medications contained errors in the pill count and half of a pill was left imbedded in the packaging and was not administered to the resident which poses a potential health risk to persons in care.
Official plan of correction
POC Due Date: 07/13/2026 Plan of Correction Administrator agreed to write a statement of understanding confirming that they are aware of the importance of accurately logging and administering medications and confirming that they will adhere to all requirements when logging/administering medications in the future. Administrator agreed to submit the statement to CCLD no later than POC due date.
Fire safety and emergency preparednessType B
- 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 as the emergency disaster plan contained inaccurate information pertaining to the emergencty supplies the faciltiy had on hand which poses a potential safety risk to persons in care.
Official plan of correction
POC Due Date: 07/13/2026 Plan of Correction Administrator agreed to revise the facility's emergency disaster plan and to send the updated plan to CCLD no later than POC due date.
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87608(a)(5)(B)
- Regulation authority
- CCR
What the official deficiency says
(B) 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 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 one resident who was not receiving hospice care had full bed rails installed which poses a potential personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/13/2026 Plan of Correction Administrator agreed to remove the rails and to send proof to CCLD no later than POC due date.
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87307(a)(2)(C)
- Regulation authority
- CCR
What the official deficiency says
87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above as bedroom #2 was being utilized as a passageway to a staff only bathroom which poses a potential personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/13/2026 Plan of Correction Administrator agreed to utilize the attached bathroom to bedroom #2 as a private resident bathroom. Administrator agreed to remove all stored items and signage indicating that this is a staff bathroom and to send proof of the removed items to CCLD no later than POC due date.