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 there was an unsecured hand saw located in the back yard which posed an immediate safety risk to persons in care.
Official plan of correction
POC Due Date: 12/23/2025 Plan of Correction Administrator secured the saw at the time of the visit. POC cleared.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 1569.625(b)(1)
- Regulation authority
- HSC
What the official deficiency says
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. 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 S1 did not have the required 20 hours of trainings logged prior to working directly with residents which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/06/2026 Plan of Correction Administrator agreed to conduct the required 20 hours of training with S1 and to submit proof of the completed trainings to CCLD no later than POC due date.
Food serviceType B
- Official classification
- Type B
- Official code
- 87555(b)(5)
- Regulation authority
- CCR
What the official deficiency says
(b) The following food service requirements shall apply: (5) Meals shall consist of an appropriate variety of foods and shall be planned with consideration for cultural and religious background and food habits of residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews, the licensee did not comply with the section cited above as three of three residents interviewed had complaints about the variety of foods served at the facility which poses a potential personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/06/2026 Plan of Correction Administrator agreed to develop their plan on how they will ensure adequate food variety for resident meals. Administrator agreed to submit their plan and a log of meals served over a two week period to CCLD no later than POC due date.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87507(c)
- Regulation authority
- CCR
What the official deficiency says
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. 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 did not have a completed admission agreement for this facility in their file which poses personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/06/2026 Plan of Correction Administrator agreed to complete the admission agreement for the identified individual and to submit the agreement to CCLD no later than POC due date.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(c)
- Regulation authority
- HSC
What the official deficiency says
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 did not log the last time a disaster drill was completed which poses a potential safety risk to persons in care.
Official plan of correction
POC Due Date: 01/06/2026 Plan of Correction Administrator agreed to conduct and appropriately log a disaster drill. Administrator agreed to submit proof of the completed drill to CCLD no later than POC due date.
Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87208(a)(7)
- Regulation authority
- CCR
What the official deficiency says
87208 Plan of Operation (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility…Any significant …shall be submitted to the licensing agency for approval…shall contain the following: (7) Sketches, showing dimensions, of the following: 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 in May the licensee notified CCLD of construction changes but did not submit an updated facility sketch to the department which poses a potential safety risk to persons in care.
Official plan of correction
POC Due Date: 01/06/2026 Plan of Correction Administrator agreed to submit an updated facility sketch to CCLD no later than POC due date.