ARARAT BOARD AND CARE

Official classification

Type B

Official code

87412(a)(11)

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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in 1 staff did not have a health screening and TB test on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/24/2025 Plan of Correction The Licensee will have the staff obtain their health screening and TB test and provide CCLD with the documents and results by the POC due date.

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

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: This requirement was not met as evidenced by: Vagan Alikyan, son of the Licensee does not have a clear criminal record clearance as of ths visit. The Associate status reads " invalid " Civil Penalties in the amount of $500 were assessed.

Official plan of correction

The Licensee will ensure that all staff, volunteers or family members who are at the facility regularly will have submitted to a criminal record clearance and is associated to the facility prior to being present at the facility. Evidence that Vagan Alikyan has received a valid and clear criminal record clearance prior to being at the facility by 4/9/25

Deadline recorded: Apr 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. 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 nonperishable foods including peanuts, ketchup and mac and cheese in food pantry area were expired dating 04/03/2024; 01/23/2024 and 01/25/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2024 Plan of Correction Administrator agrees to purchase items to replace the ones that are expired. Adminstrator agrees to check food pantry for lables and send picture proof of items that were pulled from pantry.

Official classification

Type A

Official code

87303(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above as per information provided, the used needles for Resident #5 are tossed in the trash can which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/27/2023 Plan of Correction The Licensee will contact the pharmacy and come up with a plan to properly and safely dispose of all needles used in the facility by 9/27/23

Official classification

Type A

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

Prior to construction or alterations, all facilities shall obtain a building permit. 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 per review of facility sketch and tour of the physical plant that there were 2 additional bathrooms added and without notification to the Department and without permits which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction The Licensee will contact the city to obtain permits or instructions as to how the addition can be brought to code and provide the Department evidence that the addition is now up to code or has been approved by the city by 10/03/23

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

(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. Assistance with self-administered medications shall be limited to the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview , the licensee did not comply with the section cited above per information received, the Licensee is administering insulin injections to Resident #5 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/27/2023 Plan of Correction Licensee will provide the Department with a plan by 9/27/23 as to how the facility will come into compliance with how the resident in care receives the prescribed insulin without staff having to administer injectable medications by 9/27/23

Official classification

Type A

Official code

87465(h)(1)(C)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, the licensee did not comply with the section cited above per tour of the facility, it was observed that the Licensee stored prescribed insulin, Lantus in the butter compartment of the refrigerator without securing the medication from other residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/27/2023 Plan of Correction The licensee will provide the Department with a plan as to how medications that need to be refrigerated will be made inaccessible to the other residents, especially those with dementia by 9/27/23

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above per tour of the facility, LPA observed that the file cabinet used to store the medications were left unlock and in an unlocked office while staff were assisting other residents and while they were outside the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/27/2023 Plan of Correction Licensee will ensure that all centrally stored medications are made inaccessible to residents in care at all times. The licensee locked the cabinet and office door during the visit

Official classification

Type B

Official code

87303(e)(4)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (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 per tour of all 3-1/2 bathrooms inspected, the private bathroom located inside Bedroom #4 did not have grab bars in the bath tub or in the shower stall which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction Licensee will ensure that all bathrooms available for resident use are equipped with grab bars. Provide evidence that grab bars have been installed for resident use by 10/3/23

Official classification

Type B

Official code

87307(a)(3)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above per tour of the 4 resident bedrooms, Bedrooms #2 and Bedroom #3 do not have a chest of drawers that meet Title 22 requirements of 8 cubic feet for 2 of the residents, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction Licensee will ensure that all residents have a chest of drawers meeting Title 22 requirements. LIcensee will provide a chest of drawers for resident in Bedroom #2 and Bedroom #3 by 10/3/23

Official classification

Type B

Official code

87307(a)(3)(C)

Regulation authority

CCR

What the official deficiency says

(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above per tour of the residents' bedrooms, residents beds had a mattress cover, fitted sheet and a comforter. Beds did not have a flat sheet, blanket/comforter. An extra fitted sheet and a flat sheet were stored in the bottom of the dresser drawers. The quantity does not allow for weekly changing or as needed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction Licensee will purchase additional bed linens-fitted sheets, flat sheets, pillow cases, blankets and comforters in quantities that will allow the bed linens to be changed weekly or as needed

Official classification

Type B

Official code

87468(c)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above per inspection of posters on the facility wall, there were no personal rights posted in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction Licensee will ensure that posters advising resident in care of their personal rights and complaint information by 10/3/23

Official classification

Type B

Official code

87468(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities shall be posted as applicable to the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above per review of posted posters by kitchen, there was no posters advising the residents in care of Additional Personal Rights of Residents in Privately Operated Facilities which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction Licensee will post information regarding Additional Personal Rights of Residents in Privately Operated Facilities in a conspicuous area for viewing by residents in care and families.

Official classification

Type B

Official code

87468(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above per review of facility posting by the kitchen that the facility does not provide information on the appropriated reporting agency in case of a complaint, with contact information which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction Licensee will ensure that information for the Department and contact information is posted.

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above per review of posting, that the facility does not have the required complaint poster meeting the above requirements posted in the main entry way of the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction Licensee will download PUB475 and print the poster in the required size of 20 " x 26 " and post in the main entryway for viewing by residents, representatives and the public by 10/3/23

Official classification

Type B

Official code

87468.1(a)(4)

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (4) To be informed by the licensee of the provisions of law regarding complaints and of procedures for confidentially registering complaints, including, but not limited to, the address and telephone number for the complaint receiving unit of the Department, and how to contact the Community Care Licensing Division of the California Department of Social Services, and the long-term care ombudsman regarding grievances in regard to the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above that there is no poster or information posted for contacting Community Care Licensing which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction Licensee will post information for contacting Community Care Licensing and procedures for registering complaints and the Long Term Care Ombudsman regarding grievances in regard to the facility

Official classification

Type B

Official code

1569.267(d)

Regulation authority

HSC

What the official deficiency says

(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented. 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 per request to review facility training logs and Licensee was not able to provide evidence of ongoing taff training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction Licensee will locate records of staff training provided and make it available for Licensing review by 10/3/23

Official classification

Type B

Official code

1569.157(f)(3)

Regulation authority

HSC

What the official deficiency says

(3) If a facility does not have a resident council, upon admission, the facility shall provide written information on the resident’s right to form a resident council to the resident and the resident representative, as indicated in the admissions agreement. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and observation, the licensee did not comply with the section cited above per review of the Admission Agreement and postings, there is no information provided by the facility regarding the formation of a resident council provided in the Admission Agreement or posted in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction LIcensee will post information regarding the resident's right to form a resident council

Official classification

Type B

Official code

1569.157(h)

Regulation authority

HSC

What the official deficiency says

(h) The text of this section with the heading “Rights of Resident Councils” shall be posted in a prominent place at the facility accessible to residents, family members, and resident representatives. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above per review of posting, there is no Rights of Resident Council posted in a prominant place at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction

Official classification

Type B

Official code

1569.158(d)

Regulation authority

HSC

What the official deficiency says

(d) Family councils shall be provided adequate space on a prominent bulletin board or other posting area for the display of meeting notices, minutes, information, and newsletters. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above per inspection of the facility postings that there is no information posted regarding the right to create a family council which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction Licensee will post information regarding the formation of a family council by 10/3/23

Official classification

Type B

Official code

1569.158(g)(2)

Regulation authority

HSC

What the official deficiency says

(2) If a facility does not have a family council, the facility shall provide, upon admission of a new resident, written information to the resident’s family or resident representative of their right to form a family council. 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 per review of resident records and Admission Agreement that there is no written information provided to the families regarding the right to form a family council which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction Licensee will ensure that all new residents, their families and representatives are proviided with written information of their right to form a family council by 10/3/23

Official classification

Type B

Official code

1569.319(a)

Regulation authority

HSC

What the official deficiency says

(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above per information provided during the interview that the Administrator did not know that a dedicated computer, tablet or any internet access device that can support real time interactive application, equipped with videoconferencing was to be provided for resident use and no one asked which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction Licensee will provide the residents with a computer, tablet o any internet access device capable of supporting real time interactive application, equipped with videoconferencing technology, dedicated for their use by 10/3/23

Official classification

Type B

Official code

1569.319(b)(1)

Regulation authority

HSC

What the official deficiency says

(b) A licensee shall ensure the following requirements are met in providing any internet access device for resident use: (1) The device shall be available in a manner that allows a resident to access it for discussion of personal or confidential information with a reasonable level of personal privacy. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above per information provided during the interview that the facility does not have a plan in place that will allow residents to access the device for discussion of personal or confidential information with a reasonable level of personal privacy which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction Licensee will provide the Department with a plan that will address how the internet access device will be made available in a manner that will allow residents to access the device with personal privacy by 10/3/23

Official classification

Type B

Official code

1569.319(b)(2)

Regulation authority

HSC

What the official deficiency says

(b) A licensee shall ensure the following requirements are met in providing any internet access device for resident use: (2) The device shall be made available to residents in a manner that permits shared access among all residents in the facility during reasonable hours. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the Licensee did not comply with the section cited above per information provided that the facility does not have a plan in place to ensure that the device is available to residents in a manner that permits shared access among the residentsi in the facility during reasonable hours, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction Licensee will put together a plan that will permit all facility residents shared access to the internet access device during reasonable hours by 10/3/23

Official classification

Type B

Official code

87465(a)(8)(A)

Regulation authority

CCR

What the official deficiency says

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above since the Licensee could not provide a copy of the First Aid Manual to LPA for review, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction Licensee will purchase a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal agency and maintain in the facility by 10/3/23

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above per review of medications for Resident #****, medications were prepared and stored in 2 pill boxes labeled Monday through Sunday which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction Licensee will review Title 22, Section 87465 - Incidental Medical and Dental Care and submit a written statement that the section was read and understood and will be adhered to at all times by 10/3/23

Official classification

Type B

Official code

87465(b)

Regulation authority

CCR

What the official deficiency says

(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. 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 per review or of Resident #6 file, it was observed that there is no PRN Authorization letter on file to establish that the physician has determined that Resident #6, who is diagnosed with Alzheimer, is able to to determine his/her need for the PRN Medication - Acetominophen, SM Stool Softener and Vitamin B-1 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction Licensee will contact the prescribing physician and obtain a completed PRN Authorization Letter to confirm whether Resident #6 can or cannot determine his/her need for the PRN medication and maintain in the resident's file.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 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 or This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview, the licensee did not comply with the section cited above per information obtained, Ashkhik Kebabjian, present at the facility for her first day of work today-9/25/23, was not cleared and associated to the facility prior to being present at the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/27/2023 Plan of Correction Licensee will ensure that all staff, volunteers and persons who are required to obtain a criminal record clearance have obtained the required clearance and is associated to the facility before being present at the facility. Licensee will provide a plan of action that will be adhered to, to ensure all person are cleared and associated prior to being at the facility by 9/27/23. CIVIL PENALTIES WERE ASSESSED.

Official classification

Type B

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above per tour of the physical plant, all fiive doors exiting to the outside were not equipped with auditory devices and the facility retains residents with dementia which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2023 Plan of Correction Licensee will install auditory devices or other staff allert features on all doors that exit to the outside by 10/3/23

Official classification

Type B

Official code

87465(e)(1-4)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (e) 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. (1) The specific symptoms which indicate the need for the use of the medication.(2) The exact dosage. (3) The minimum number of hours between doses.(4) The maximum number of doses allowed in each 24-hour period This requirement is not met as evidenced by: Deficient Practice Statement Based on record reivew, the licensee did not comply with the section cited above per information reviewed revealed that the facility does not have any physician's orders on file for any of the centrally stored medications] which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/10/2023 Plan of Correction The Licensee will contact the prescribing physician or dispensing pharmacy to obtain a copy of the physician's order for all centrally stored medications and maintain in the residents files by 10/10/23. Licensee will self certify that all physicians orders have been obtained.

Official classification

Type B

Official code

87211(a)(1)(A-D)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Licensee did not report Resident #1's hospitalization on 5/202/3

Official plan of correction

Licensee will complete an LIC624-Special Incident report for the hospitalization of Resident #1 on 5/20/23 and submit it to licensing by 7/18/23

Deadline recorded: Jul 18, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(a)(1-2)

Regulation authority

CCR

What the official deficiency says

a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. 1) The text of the admission agreement, including any attachments and modifications, shall be (A) Printed in black type of not less than 12- -point type size, on plain white paper. The print shall appear on one side of the paper only.(B) Written in clear, understandable, coherent, and unambiguous language, using words with common and everyday meanings, and shall be appropriately divided with each section appropriately titled. Resident #1 does not have an admission agreenmer

Official plan of correction

The Licensee will ensure that all residents have a completed and signed copy of an Admission Agreement on file for every resident. LIcensee will review all residents files and complete an Admission agreement. Provide evidence that all residents have a Signed Admission Agreement by 7/24/23

Deadline recorded: Jul 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(b)(1-17)

Regulation authority

CCR

What the official deficiency says

Resident Record- Each resident’s record shall contain at least the following information:(1) Resident's legal name and preferred name, as indicated by the resident. (2) Social Security number. (3) Gender identity and preferred pronoun, as indicated by the resident. (4) Dates of admission and discharge. (5) Last known address.. (6) Birthdate. (7) Religious preference, if any, and name and address of clergyman or religious advisor, if any (8) Names, address, and telephone numbers of the resident’s representative, as defined in Section 87101(r), to be notified in case of accident, death, or other emergency. (9) Name, address and telephone number of physician and dentist to be called in an emergency. (10) Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions. (11) The documentation required by Section 87611 for residents with an allowable health condition. (12) Ambulatory status. (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services. (14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services. (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables. (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal; (B) Section 87459, Functional Capabilities; (C) Section 87461, Mental Condition; (D) Section 87462, Social Factors; (E) Section 87463, Reappraisals; and (F) Section 87505, Documentation and Support.

Official plan of correction

Licensee will review all resident files to ensure that their file includes all the required documents. Provide evidence that the file review has been completed and that all files are availale for review by 7/24/23

Deadline recorded: Jul 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(f)(1)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements:Failure to comply with Section 87211(d), or Section 87211(e), or both, may result in a civil penalty of one hundred dollars ($100) for each day of the failure to provide the required notification, not to exceed two thousand dollars ($2,000)1) If a resident is relocated without the specified notification, and the resident suffers transfer trauma as defined in Section 87101, or other harm to their health or safety, the Department may suspend or revoke the license or other specified actions pursuant to Health and Safety Code section 1569.686(c) Licensee did not notify Resident #1's Conservator of relocation

Official plan of correction

The Licensee will review Title 22, Section 87211 and provide a signed written statement indicating that the section was read and understood and that the facilty will adhere to the regulations by 7/24/23

Deadline recorded: Jul 24, 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

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. 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 accessible chemicals were observed in the cabinet under the sink, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/26/2022 Plan of Correction The Administrator agreed to do the following: 1. Remove the cleaning supplies and lock them away. This was done during today's visit. Plan of Correction met.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. 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 exterior gate and latched gate were locked, which did not allow residents to egress the facility without a key, which poses an immediate safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/27/2022 Plan of Correction 1. Locking mechanism needs to be removed from the single-latch gate, and the lock on the exterior gate will need to be changed to a single latch lock within the next 24 hours. Civil penalty assessed in the amount of $500 for the zero tolerance violation.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. 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 staff were observed not wearing appropriate face coverings and did not ask COVID-19 screening questions upon the LPA's arrival, which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/31/2022 Plan of Correction 1. The Administrator agreed to do the following: Conduct a staff training, communicating the protocol around face coverings and screening for COVID-19. Submit sign-in sheet to the Department no later than 8/31/2022.