CEDARS ASSISTED LIVING, THE

Official classification

Type A

Official code

87611(a)

Regulation authority

CCR

What the official deficiency says

87611 General Requirements for Allowable Health Conditions (a) Prior to accepting or retaining a resident with an allowable health condition licensees … shall obtain Department approval: This requirement is not met as evidenced by. The Licensee allow R1, who was not receive home health or hospice services to receive dialysis in the facility, without seeking prior approval from the Licensing Agency. This poses an imminent health and safety hazard to residents in care.

Official plan of correction

Administrator contacted Spectrum Dialysis, CEO and cancelled Dialysis services for R1 at the facility. Spectrum was asked to pick up all Dialysis equipment from R1's room. POC was cleared during today's visit.

Deadline recorded: May 21, 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

(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 the observation the licensee did not comply with the section cited above in the kitchen area did not have proper lightening which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/20/2026 Plan of Correction The licensee/administrator shall send a picture/repair paperwork to the LPA of repairs conducted. POC due date: 01/20/26.

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 the observation the licensee did not comply with the section cited above in one (1) resident's room window screen needed repair which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/20/2026 Plan of Correction The licensee/administrator shall send a picture/repair paperwork to the LPA of repairs conducted. POC due date: 01/20/26.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation (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 by: Based on the LPA's observations the licensee/administrator failed to ensure that the facility was clean, safe, sanitary and in good repair at all times. This posed an potential health and safety risk to residents in care.

Official plan of correction

The licensee/administrator shall send a picture/repair paperwork to the LPA of repairs conducted. POC due date: 01/12/26.

Deadline recorded: Jan 12, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(5)(A)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows:(5)Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors.(A)All slip-resistant mats, strips, or flooring shall be in good repair and maintain slip-resistant properties. This requirement is not met by: Based on the LPA's observations the licensee/administrator failed to ensure that the facility was free of hazards. This posed an potential health and safety risk to residents in care.

Official plan of correction

The licensee/administrator shall send a picture/repair paperwork to the LPA of repairs conducted. POC due date: 01/12/26.

Deadline recorded: Jan 12, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities (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 by: Based on the LPA's observations the licensee/administrator failed to ensure that the facility was accorded safe, healthful and comfortable accommodations, furnishings and equipment. This posed an potential health and safety risk to residents in care.

Official plan of correction

The licensee/administrator shall send the Pest Control paperwork to the LPA showing that Pest Control has been providing services. POC due date: 01/12/26.

Deadline recorded: Jan 12, 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(a) Maintenance and Operation (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 by: Based on the LPA's observations the licensee/administrator failed to ensure that there was an electrical outlet missing in a common are and in one (1) of the residents room there was a huge hole behind their room door. This posed a potential health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator shall send a picture of the both repairs to LPA

Deadline recorded: Oct 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(f)

Regulation authority

CCR

What the official deficiency says

87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This Based on the LPA's observations and resident interviews the licensee/administrator failed to ensure that there was basic cable provided to residents which states in their admission agreement that is included for free. This posed a potential health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator shall replace the basic cable for all residents which is included in their admission agreement and send a notice to LPA that basic cable has been restored.

Deadline recorded: Oct 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(d)(3)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (d)All personnel shall be given on the job training or have related experience in the job assigned to them...(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement was not met by: Based on the LPA's observations and resident interviews the licensee/administrator failed to ensure that appropriate care and supervision was given to other residents because two (2) caregivers were observed in the dining hall providing meals. This posed a potential health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator shall make sure that proper care and supervision is given to all residents by proper personnel and a new hiree needs to be hired in the kitchen area and all paperwork shall be sent to LPA upon hire and proper training given to other personnel providing food services.

Deadline recorded: Oct 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87413(a)(1)

Regulation authority

CCR

What the official deficiency says

87413 Personnel - Operations (a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement is not met by; Based on the LPA's observations and resident interviews the licensee/administrator failed to ensure that proper coverage is provided by personel with qualifications. This posed a potential health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator shall make sure that in the absence of any employee there shall be a personnel providing adequate services that is trained to perform tasks.

Deadline recorded: Oct 29, 2025. A deadline is not proof that correction was completed.

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 by: Based on the LPA's record review of the inspection by the Los Angeles Fire Department (LAFD) the licensee/administrator failed to ensure that the above facility is in violation of the Los Angeles Municipal Code of certain sections. This posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator has been conducting fire watch logs since 07/17/25 and has conducted a generator test that has been working. An In service attendance record was also conducted on 07/17/25 with staff. The POC was cleared at time of visit. POC Cleared 07/22/25

Deadline recorded: Jul 23, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(b)(B)

Regulation authority

CCR

What the official deficiency says

87705(b)(B) Care of Persons with Dementia (b)Licensees shall be responsible for the following: (B) Recognizing symptoms that may create or aggravate behavioral expression, as defined in Section 87101, Definitions, including, but not limited to, dehydration, urinary tract infections, and problems with swallowing; and This requirement is not met by: Based on the LPAs Interviews the licensee/administrator failed to ensure the behavioral expressions of resident #1 (R1) having severe dehydration while at the facility. This posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator will provide a statement of understanding regarding the title 22 regulation of 87705 Care of Persons with Dementia: POC Cleared 07/15/25

Deadline recorded: Jul 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87623(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain a resident who requires the use of an indwelling catheter under the following circumstances: (1) If the resident is physically and mentally capable of caring for all aspects of the condition except insertion and irrigation. This requirement is not met by: Based on the LPA's Interviews the licensee/administrator failed to ensure that resident #1 (R1) was under the care of a skilled professional to help with their catheter. This posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator will seek skilled professional help for Resident #1 (R1). The POC was cleared at time of visit. R1 is now under American Home care Health Services. POC Cleared 06/30/25

Deadline recorded: Jul 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269(a)(6)

Regulation authority

HSC

What the official deficiency says

§1569.269 Enumerated rights; severability(a) Residents of residential care facilities for the elderly shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met by: Based on the LPA's Interviews the licensee/administrator failed to ensure the care, supervision and services of resident #1 (R1) while in the facility. This posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator will provide dementia training to all staff on the care, supervision and services to all residents. POC Cleared 05/22/25

Deadline recorded: May 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

87303 (a)(1)-Maintenance:(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall...for the safety and well-being of residents, employees and visitors (1)Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not comply with the section cited above in one area/room that needs to be safe and repaired which poses a Potential Health, Safety or Personal Rights risks to persons in care.

Official plan of correction

The licensee/administrator shall send a picture/repair paperwork to the LPA of repairs conducted. POC due date: 04/30/25.

Deadline recorded: Apr 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269(a)(6)

Regulation authority

HSC

What the official deficiency says

§1569.269 Enumerated rights; severability(a) Residents of residential care facilities for the elderly shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met by: Based on the Investigator's Interviews the licensee/administrator failed to ensure the care, supervision and services of resident #1 (R1) while in the facility. This posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator will provide training to all staff on mandatory reporting and the care, supervision and services to all residents. POC Cleared 03/27/25

Deadline recorded: Mar 27, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(3) Personal Rights of Residents in All Facilities.(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature..This requirement is not met as evidenced by: Based on the LPA's Interviews the licensee/administrator did not ensure that staff provide an environment free of punishment/intimidation/abuse of residents in care which poses an potential Health, Safety or Personal Rights risks to persons in care.

Official plan of correction

The licensee/admnistrator shall immediately place the staff on administrative leave or/and discharge them from their work duties. POC Cleared 02/25/25

Deadline recorded: Mar 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(5)

Regulation authority

CCR

What the official deficiency says

Postural Support-87608(a)(5) (a)Based on the individual's preadmission appraisal, and subsequent changes...the facility shall provide assistance...to a resident who unable to do for himself/herself. Postural supports may be used under the following conditions.(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. This requirement is not met by: Based on the observation, the licensee/administrator did not ensure a resident was free of postural support that deprived resident of movement limitations at the above facility which poses a potential Health, Safety or Personal Rights risks to person in care.

Official plan of correction

Licensee/Administrator shall remove the postural support that deprives the resident of movement limitations and send picture to LPA by POC 10/14/24. POC Cleared 10/14/24 at time of viist

Deadline recorded: Oct 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(3) Personal Rights of Residents in All Facilities.(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature..This requirement is not met as evidenced by: Based on the LPA's Interviews the licensee/administrator did not ensure that staff provide an environment free of punishment/intimidation/abuse of residents in care which poses an Immediate Health, Safety or Personal Rights risks to persons in care.

Official plan of correction

The licensee/admnistrator shall immediately place the staff on administrative leave or/and remove the staff from all care given to the residents.

Deadline recorded: Jul 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

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. 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: Based on the LPA's observations, staff/ resident interviews, the staff did not ensure the residents to have good repair of different areas throughout the facility including rooms and common areas which poses an immediate Health, Safety or Personal Rights risks to persons in care.

Official plan of correction

The licensee/admnistrator shall send pictures of repairs being completed by POC due date: 06/20/24.

Deadline recorded: Jun 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

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. 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: Based on the LPA's observations, staff/ resident interviews, the staff did not ensure the residents to have a clean and sanitary facility including rooms, common areas clean of roaches thus ensuring the facility was clean, which poses an immediate Health, Safety or Personal Rights risks to persons in care.

Official plan of correction

The administrator/Licensee must at all times keep a facility free of roaches. The administrator/licensee is to show proof of pest control service/documentation and send to LPA by POC 06/12/2024

Deadline recorded: Jun 12, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)(1)

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...(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Based on the LPA's observations, the staff did not ensure the residents to have a clean and sanitary bathroom free of mold, surface areas of bathroom need repair and light fixture needs a cover which poses an immediate Health, Safety or Personal Rights risks to persons in care.

Official plan of correction

The administrator/Licensee must at all times keep a facility free of mold. At the time of visit there was a maintenance crew of three (3) individuals repairing/cleaning the bathroom and light fixture of resident #1(R1). POC CLEARED at time of visit-06/03/24

Deadline recorded: Jun 4, 2024. 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 was not met as evidenced by: Based on interviews, one (01) staff and three (03) residents stated they've encountered cockroaches at the facility. This poses an immediate health and safety risk to the residents in care.

Official plan of correction

Although the facility hired a pest control company to service the facility for insects periodically, as a POC, the Administrator will schedule an appointment with pest control company and submit documentation as proof of service. The Administrator will also submit a written letter stating that they have reviewed Title 22 Div. 6 Ch. 8 of the CA Code of Regulations 87303(a) and, going forward, will adhere to the regulation.

Deadline recorded: Feb 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidence by: Based on interview and review of licensing report summary and Guardian, S1 is not associated to the facility and no documentation to associate staff was on record which poses an immediate risk to residents in care.

Official plan of correction

S1 was removed from the facility immediately. Licensee agreed to provide a copy of association once it is complete by POC due date and not allow S1 to return to the facility until association is made.

Deadline recorded: Sep 7, 2023. A deadline is not proof that correction was completed.

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. The licensee did not ensure that the facility manintains conformity with Regulations enforced by Fire Department. The violations of the fire codes noted by Fire inspector were not completed. This possesses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator has agreed to provide daily update via-email to Fire Dapartment and Community Care Licensing. Administrator also agreed to submit Fire Watch logs every Friday afternoon until Regulation 4 test is conducted.

Deadline recorded: Aug 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87608(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by using a strap to restrict resident's movement such as falling out a chair which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Staff immediately removed restraint from resident. The Resident Care Director will have an in-service meeting with staff about regulation cited. POC cleared on todays visit.

Deadline recorded: Jun 22, 2023. 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(a) The facility shall be clean, safe, sanitary... 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: Based on inspection, and observation the Licensee did not ensure that the facility is safe and sanitary for wellbeing of residents and others. LPA observed rodent droppings in residents’ bedrooms. This poses a potential health, safety risk and personal rights violation to residents in care.

Official plan of correction

The Administrator will take all measures to maintain the facility free from rodents. Administrator will submit updated documentation of Pest Control service agreement to LPA via fax. On 4/17/23 all measures to prevent rodents from entering resident’s bedroom where taken. LPA observed residents bedroom clean and holes on walls were covered. LPA received Pest Control Invoice indicating aggressive steps for fumigation. POC cleared during this visit.

Deadline recorded: Mar 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

80076(a)(17)

Regulation authority

CCR

What the official deficiency says

80076(a)(17) Food Service. Kitchens, food preparation, and storage areas shall be kept clean... free of rodents, and other vermin. This requirement is not met as evidenced by: Based on inspection, and observation the Licensee did not ensure that the kitchen was free from rodents. LPA observed rodent droppings inside the kitchen. This poses a potential health, safety risk and personal rights violation to residents in care.

Official plan of correction

The Administrator will instruct staff to cover holes on the wall to maintain the kitchen free from rodents. Adminstrator will submit updated documentation of Pest Control service agreement to LPA via fax. On 4/17/23 LPA Alvizar observed holes on wall covered with aluminum sheets underneath the kitchen sinks. LPA received Pet Control Invoice indicating five (5) more Inspection and Treatment services added per month. POC cleared during this visit.

Deadline recorded: Mar 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87470(c)(1)(F)

Regulation authority

CCR

What the official deficiency says

87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and... This requirement is not met as evidenced by: Based on LPAs observation during a previous visit conducted on 11/23/21, Licensee did not comply with the section cited above by having three (3) staff members at the facility not wearing COVID masks appropriately, which poses/posed a potential Health and Safety and Personal Rights risk to persons in care.

Official plan of correction

Licensee/Administrator agreed to provide in house training with all staff regarding Infection Control Requirements and COVID Protocol. A written statement signed by all staff regarding such training shall be emailed to LPA by POC date.

Deadline recorded: Mar 24, 2023. 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. 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: Based on interviews, record review and observations, the licensee did not comply with the section cited above as the closet doors, bathroom vanity and the wall in three (3) rantom residnet rooms were left in disrepair while the rooms were occupied by a residents which poses/posed a potential Health, Safety, or Personal Rights risk to residents in care.

Official plan of correction

Licensee/adminsitrator shall review California Code of Regulations Title 22 section 87303 and submit a written plan to ensure that the facility is in good repair at all times.

Deadline recorded: Mar 24, 2023. 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

Maintenance and Operation (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 was not met as evidenced by Based on observation, the facility did not clean R1's room during their stay at the skilled nursing facility. This poses an potential health and safety risk or personal rights to residents in care.

Official plan of correction

Licensee agreed to clear out R1's room and return items to R1. Proof of schedule date will be emailed to LPA.

Deadline recorded: Jan 27, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities(a) (9)To have communications to the licensee from their representatives answered promptly and appropriately. This requirement was not met as evidenced by Based on interviews facility did not communicate with R1's representative to provide a date to schedule a pick up for R1's belongings. This poses an potential health and safety risk or personal rights to residents in care.

Official plan of correction

Licensee has agreed to communicate with R1 and arrange a date of scheduling for R1's item to be returned. Proof of schedule date will be emailed to LPA.

Deadline recorded: Jan 27, 2023. 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(a) Maintenance and Operation-The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: During R1's room tour LPA observed numerous gnats inside the room. LPA observed a lunch bag with spoiled items that was not thrown out by staff when R1 was admitted to the hospital on 12/23/22. This poses a potential health and safety risk to residents in care.

Official plan of correction

Lunch bag was removed from the room during the visit. Administrator agreed to conduct a check inside residents room who are currently in the hospital or SNF to ensure residents did not leave unattended food that could spoil and attract pests. Facilty will remove gnats from the room.Documentation of this walk through is to be provided to LPA.

Deadline recorded: Jan 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(2) Personal Rights of Residents in All Facilities to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interview, observation, and document review, R1 is under the ALW program in where residents have the right to request a refrigerator and microwave to be placed in their room. Facility did not provide requested items. This poses an potential health and safety risk or personal rights to residents in care.

Official plan of correction

Facility is to prove a refrigerator and microwave to R1 under the ALW program. Administrator will send proof of purchase/placement of items for R1 to LPA via email.

Deadline recorded: Jan 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

8741 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interviews, residents are left waiting a long period of times to receive food trays delivered to their rooms, which poses a potential healthy and safety risk to residents in care.

Official plan of correction

Administrator will develop a plan on how residents will receive their room meal tray delivered once the dining room starts serving food. Administrator will submit plan to LPA via email by 09/21/22.

Deadline recorded: Sep 21, 2022. 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(a)(1) 87468.1 Personal Rights of Residents in All Facilities. To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Residents in care stated they do not feel that staff are treating them with dignity, which poses a potential healthy and safety risk to residents in care.

Official plan of correction

Administrator is to conduct training with all staff on personal rights for residents in care. Administrator is to email proof of training to LPA via email no later than 09/28/22.

Deadline recorded: Sep 28, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(16)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities:Residents in all residential care facilities for the elderly shall have all of the following personal rights-To receive or reject medical care or other services. This requirement was not met as evidenced by: Based on interviews conducted facility failed to let R1 speak to their medical provider when they called on three different occasions. This posed a potential health and safety risk to R1.

Official plan of correction

Administrator shall have an in-service with staff regarding protocol when medical providers call to speak with residents and how to proceed to get the residents on the phone with their medical provider. Copy of in-service sign in sheet to be sent to LPA by poc due date.

Deadline recorded: Sep 13, 2022. 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

The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on interviews and observation room #273 was not clean, trash was all over the room along with expired food, and foul odor was observed in the room. This posed a potential health and safety risk to resident's in care.

Official plan of correction

Facility will have room #273 deep cleaned and submit pictures. Staff will go to each room and see if any other rooms need to be deep cleaned.

Deadline recorded: Sep 14, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. This requirement has not been met as evidenced by: interviews with 10 residents made on 02/10/22. Nine (9) out of these ten residents confirmed of experiencing or observing roaches in their room or common areas of the facility. This is an immediate health and safety risk to the residents in care.

Official plan of correction

Copies of invoice and statments from pest control company as proof of service for roacheds and rodents was obtained during the visit. No further corrections needed at this time.

Deadline recorded: Aug 16, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

87464(f)(4) Basic Services. Personal assistance and care as needed by the resident...with those activities of daily living such as dressing, eating, bathing... This requirement is not met as evidenced by: Based on interviews, staff failed to respond to pull cords in a timely manner. This poses an immediate healthy and safety risk to residents in care.

Official plan of correction

The Administrator has agreed to the following: 1. Submit a comprehensive plan on how facilty staff will respond to pull cords in a timely manner by POC due date.

Deadline recorded: May 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

87625(b)(3) Managed Incontinence Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Based on interviews, residents were left in soild diapers for an extended period of time and will have to wait when requsted assistance for changing. This poses an immediate healthy and safety risk to residents in care.

Official plan of correction

The Administrator has agreed to the following: 1. Submit a comprehensive plan on how facilty staff will ensure residents are changed when soiled and in a timely manner.

Deadline recorded: May 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468. (a)(4) Additional Personal Rights of Residents in Privately Operated Facilities to care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Residents are not receiving adequate care and are left waiting a long period to receive care by staff. This poses a potential healthy and safety risk to residents in care.

Official plan of correction

The Administrator has agreed to the following: 1. Submit a comprehensive plan on how facilty staff will ensure residents are obtaining adequate care in a timely manner.

Deadline recorded: May 20, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

Prohibited Health Conditions-Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly.Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on interviews and documentation obtained R1 developed multiple stage 3 pressure injuries while in the facility. This posed an immediate health and safety risk to residents in care.

Official plan of correction

Administrator will provide proof of all direct care staff undergoing training from an approved vendor on the topic of prohibited health conditions.

Deadline recorded: Apr 25, 2022. 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(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times This requirement is not met as evidenced by: Based on interviews, the Administrator did not comply with this section cited above in ensuring resident's room were properly clean which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC was already cleared during the time of the visit. Administrator will train staff on how to properly dispose of the trash cans in resident’s room. Administrator will email proof of training to LPA Martinez no later than 04/06/22.

Deadline recorded: Apr 6, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(2)

Regulation authority

CCR

What the official deficiency says

(2) Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Service This requirement is not met as evidenced by: Based on records reviewed, the faciity did not ensure that it was kept free from rodents which poses a potential risk to residents in care.

Official plan of correction

All staff members will be provided with training on pest prevention measures and rodent dropping sanitization procedures. A log will be created to document weekly checks of rodent traps from now through the POC due date and submitted to LPA along with training records.

Deadline recorded: Mar 7, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c This requirement is not met as evidenced by: Based on the records reviewed, the facility did not ensure that R1 was provided with adequate care and suprvision to prevent R1 from leaving the facility without any supervision which poses an immediate risk to the residents in care.

Official plan of correction

Administrator will conduct a review of all resident appraisals to ensure that they are current and accurate. Staff training will be provided on the topics of preventing resident AWOLs.

Deadline recorded: Feb 14, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement is not met as evidenced by: Based on records reviewed, the facility did not ensure that adequate personal assistance and care was provided to prevent the development of a UTI which poses a potential risk to residents in care.

Official plan of correction

Administrator will provide proof of staff training being provided on the topic of incontinence care and preventing UTIs.

Deadline recorded: Feb 21, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based on the records reviewed and interviews conducted, the facility did not report that R1 was hospitalized on 4/3/21 for a Fall and UTI which poses a potential risk to residents in care.

Official plan of correction

Administrator, Wellness Director, and Resident Care Director will all sign a statement of understanding and intent to abide by the cited regulation.

Deadline recorded: Feb 21, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(a)(4)

Regulation authority

CCR

What the official deficiency says

87224(a)(4) Eviction Procedures: The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5) This requirement is not met as evidenced by: Based on the interviews and record review, the Administrator did not comply with the section cited above by not providing an eviction notice for an approval with supporting documents (SIRs,Resident Appraisal) to Community Care Licensing Department, which poses a potential health and safety risk to persons in care.

Official plan of correction

The Administrator agreed to the following: -Update the appraisal needs and services plan, submit all SIRs to Department of Social Services -Submit a new eviction notice to CCLD for approval before delivering it to the resident or resident’s responsible party.

Deadline recorded: Dec 14, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211(a)(1)(D) Reporting Requirements: The licensee shall send a written report, within seven days, to the licensing agency and the person responsible for the resident when any incident occurs which threatens the welfare, safety or health of any resident. This requirement is met as evidenced by: Baed on the documents provided, on 9/11/21 R1 had a knife in possession and threatened someone with it, this incident was not reported to CCLD. R1 had eight (8) more incidents of aggressive behavior on 10/28/21- 10/30/21 and 08/22/21-08/23/21 that were not reported to CCLD. This poses a potential health and safety risk to persons in care.

Official plan of correction

The Administrator agreed to the following: -Provide the training for incident reporting requirement for CCL. -Submit the training log and material to LPA by 12/14/21.

Deadline recorded: Dec 14, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(a)(4)

Regulation authority

CCR

What the official deficiency says

87224 Eviction Procedures. (a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required…If, after admission, it is determined that the resident has a need not previously identified, a reappraisal has been conducted … and the licensee… believe that the facility is not appropriate for the resident. This requirement is not met as evidenced by. Prior to refusal to accept R1 back to the facility, the Administrator did not conduct a reappraisal and serve a 30-day written eviction notice.

Official plan of correction

The Administrator states that he will submit a signed written statement that regulation 87224 has been read and understood and that the Administrator will comply with eviction procedures in the future. Submit to LPA by 12/09/21

Deadline recorded: Dec 9, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on recrods reviewed and interviews conducted, the facility did not ensure that sufficient care and supervision was provided to R1 to prevent a series of falls which poses an immediate risk to residents in care.

Official plan of correction

Administrator will provide proof of having obtained training from an approved vendor for all direct care staff on the topic of fall prevention.

Deadline recorded: Nov 12, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability... This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, the facility did not ensure that R1's deteriorating condition was documented and responded to in a timely fashion which posed an immediate risk to residents in care.

Official plan of correction

Administrator will provide proof of having obtained training from an approved vendor for all direct care staff on the topic of observing residents in changes of condition.

Deadline recorded: Nov 12, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615

Regulation authority

CCR

What the official deficiency says

87615(a)(1) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. This requirement is not met as evicenced by: Based on record review the licensee did not ensure that Resident 1 did not contract a prohibited health condition while at the facility which posed an immediate risk to residents in care.

Official plan of correction

Administrator will provide proof of all direct care staff undergoing training from an approved vendor on the topic of prohibited health conditions.

Deadline recorded: Nov 12, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87219(a)

Regulation authority

CCR

What the official deficiency says

Planned Activities-Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. This requirement was not met as evidenced: Based on interviews conducted facility has not had any planned activities for a few months which poses a personal rights risk to residents in care.

Official plan of correction

Administrator stated an activities calendar and will send a copy of the activities calendar to LPA by poc due date.

Deadline recorded: Oct 29, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87219(f)

Regulation authority

CCR

What the official deficiency says

Planned Activities-In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities. This requirement is not met as evidenced by: Based on interviews conducted the facility has not had an activity director for over a year.

Official plan of correction

Administrator has stated they have hired an activities director. Administrator will send proof of hire to LPA by poc due date.

Deadline recorded: Oct 29, 2021. 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

General Food Service Requirements-All food shall be of good quality. This requirement was not met as evidenced by: Based on interviews conducted it appears the food served is not of good quality which is a potential health and safety risk to residents in care.

Official plan of correction

Administrator stated he will have a meeting with the resident council and with the facility chef to discuss menu and food choices. Self certification will be sent to LPA when this is completed.

Deadline recorded: Oct 29, 2021. 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

Maintenace and Operation-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 was not met as evidenced by: Based on interviews conducted it was found that the facility did have an issue with pest and that some rooms and parts of the facility were not clean and in good repair which posed a potential health and safety risk to residents in care.

Official plan of correction

Administrator submitted copies of pest control invoices to LPA to show the pest control issue has been addressed. Issue with parts of the facility being in good repair has already been addressed previously.

Deadline recorded: Oct 25, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

All facilities shall maintain a fire clearance. Prior to accepting persons over 60 years of age none ambulatory and/or bedridden the licensee shall notify the licensing agency and obtain an appropriate fire clearance. This requirement is not met as evidenced by: This requirement is not met as evidenced by: Deficient Practice Statement Based on Based on observation and interview the licensee did not comply with the cited section by retaining 6 out of 7 bedridden residents in rooms that were do not have bedridden fire clearance which poses an immediate health, safety and personal rights risk to persons in care. (Room 106,136, 208, 221,242, 240, )

Official plan of correction

POC Due Date: 10/06/2021 Plan of Correction This is a zero tolerance violation therefore civil penalty in the amount of $500 has been issued. Civil penalties in the amount of $100 dollars per day will accrue until POC is received.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

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: This requirement is not met as evidenced by: Deficient Practice Statement Based on observations made the licensee did not comply with the section cited above by utilizing full bedrails for 5 residents who are on hospice however licensee does not have hospice care plan which indicates the need for the rails which poses an immediate health, safety and personal rights risk to persons in care..

Official plan of correction

POC Due Date: 10/06/2021 Plan of Correction Licensee/administrator will conduct a tour of the resident rooms. Identify the residents who are utilizing full rails and half rails. Licensee/administrator will submit copy of the hospice care plans for those residents who are on hospice to indicate the need for the rails.

Official classification

Type B

Official code

87633(b)

Regulation authority

CCR

What the official deficiency says

A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by: 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 by not maintaining a hospice care plan for 13 out of 13 residents who are currently on hospice which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/11/2021 Plan of Correction Licensee/Administrator will contact the hospice agencies and obtain current/updated hospice care plans for all residents. The hospice care plans will have to include the frequency of the visits. Copies of the care plans will be submitted as POC.

Official classification

Type B

Official code

87705(c)(5)(A)

Regulation authority

CCR

What the official deficiency says

Licensees who accept & retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment, & a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited by not obtaining an Annual Medical assessment and not completing annual re-appraisals for 5 out of 5 residents diagnosed with dementia. This poses a potential health and safety risk to the residents in care.

Official plan of correction

POC Due Date: 10/11/2021 Plan of Correction POC: Licensee/Administrator will review files for all residents., Identify the residents whose physician report and the appraisal needs and services/reappraisals are older than 1 year, Contact the residents physicians and obtain a current and complete Medical Assessment for all residents. Contact the residents responsible party to update that appraisal needs and services plan. Licensee/Administrator will submit list of the identified residents by 10/7/2021 and submit a self-certification once all medical assessment and the appraisal needs and services plans have been updated. The certification will need to list the names of the identified residents and the dates updated. All records and Medical Assessments will need to be updated on or before 10/22/2021.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

Postural Supports. A written order from a physician indicating the need for postural support shall be maintained in the resident’s record. The licensing agency is authorized to require additional documentation if needed. This requirement is not met as evidenced by: This requirement is not met as evidenced by: Deficient Practice Statement Based on Records reviewed, observations made the licensee did not comply with the section cited above by not obtaining an order for postural support for 10 residents which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/11/2021 Plan of Correction Licensee/administrator will conduct a tour of the resident rooms. Identify the residents who are utilizing full rails and half rails. Licensee/administrator will contact the residents physicians and obtain a doctors order for the postural supports. Copies will need to be submitted to the LPA as POC.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 observations made during physical plan tour the licensee did not comply with the section cited above by not ensuring that the facility was maintained, sanitary, odor free and in good repair at all times.

Official plan of correction

POC Due Date: 10/11/2021 Plan of Correction Licensee/Administrator will conducted a tour of all residents rooms, bathrooms and other areas of the facility 2. Licensee/administrator will create a maintenance log for each room and identify the areas in need of repair by 10/8/2021. Licensee/Administrator will need to complete all repairs as identified on the maintenance log by October 29,2021. Copy of the maintenance log will need to be submitted to LPA by 10/8/2021. Licensee/administrator will notify the Department once repairs are completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

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 observations made the licensee did not comply with the section cited above by locking designated exit doors with a key inside the residents rooms which poses and immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/06/2021 Plan of Correction Licensee administrator will submit a written statement indicating how this deficiency will be corrected. Licensee will also submit photos of the corrections. This is a zero tolerance violation and civil penalties have been assessed for $500.00. . Additional civil penalties in the amount of $100.00 will continue to accrue daily until complete POC has been received. This is a zero tolerance violation therefore civil penalty in the amount of $500 has been issued. Civil penalties in the amount of $100 dollars per day will accrue until POC is received.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

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 observations made the licensee did not comply with the section cited above by not ensuring smoke detectors are properly working throughout the facility which poses and immediate health, safety or personal rights risk to persons in care..

Official plan of correction

POC Due Date: 10/06/2021 Plan of Correction Administrator agreed to fix or put or replace the smoke detectors all over the facility and will submit proof of correction or or before the POC date. This is a zero tolerance violation therefore civil penalty in the amount of $500 has been issued. Civil penalties in the amount of $100 dollars per day will accrue until POC is received.

Official classification

Type A

Official code

87303(e)(2)(e)

Regulation authority

CCR

What the official deficiency says

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 during physical plant tour, the licensee did not comply with the section cited above by not ensuring water temperature was properly regulated to a maximum of 120 degrees which poses an immediate health, safety and personal rights risk to persons in care

Official plan of correction

POC Due Date: 10/06/2021 Plan of Correction Administrator agreed to adjust the water temperature immediately and will continue to monitor for the next seven (5) days by submitting water temperature log for random residents' bathroom AM/PM and submit this to CCL.

Official classification

Type B

Official code

87618(b)(3)(b)

Regulation authority

CCR

What the official deficiency says

In addition to Section 87611(b), the licensee shall be responsible for the following: (3)Ensuring that the use of oxygen equipment meets the following requirements: (B) " No Smoking-Oxygen in Use " signs shall be posted in the appropriate areas. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations made during physical plan inspections the licensee did not comply with the section cited above by not ensuring " No Smoking-Oxygen in Use " signs are posted near resident rooms.

Official plan of correction

POC Due Date: 10/11/2021 Plan of Correction Administrator has agreed to place appropriate signage in appropriate rooms. Administrator will identify all residents who use oxygen. Once completed licensee will be submit photo to CCL for proof of completion.

Official classification

Type B

Official code

87307(a)(3)(B)

Regulation authority

CCR

What the official deficiency says

Living accommodations and grounds shall be related to the facility's function. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (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 made the licensee did not comply with the section cited above by not ensuring that all residents have the required furnishings on their rooms, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/11/2021 Plan of Correction Licensee has agreed to inspect all of resident’s room, identify required furnishing that are missing. Licensee will then provide required furniture to residents and submit copies of receipt for POC as will as the list of the rooms identified.