Facility condition and maintenanceType B
- 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 the licensee did not comply with the section cited above. LPA the garage was pilled up with old matteress, weelchairs and chairs which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/13/2025 Plan of Correction Administrator stated that she will work on cleaning the garage and provide pictures by the POC
Licensing and administrationType B
- Official classification
- Type B
- Official code
- 1569.618(c)(3)
- Regulation authority
- HSC
What the official deficiency says
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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. LPA observed S1 and S2 did not have CPR certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 10/27/2025 Plan of Correction Administrator will email CPR certificates for S1 and S2 by the POC date.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87458(c)(1)
- 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: 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. R1, R3, and R4 files do not have updated Medical Assessment (LIC 602) which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 10/27/2025 Plan of Correction Administrator will provide updated LIC 602 for R1,R3, R4 by the POC date
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(a)
- Regulation authority
- CCR
What the official deficiency says
(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. LPA observed that R1-R5 files do not have an updated Appraisal Needs and Services Plan. which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 10/27/2025 Plan of Correction Administrator will provide copies of updated Appraisal Needs and Services Plan for R1-R5 by the POC date