PASADENA VILLA SENIOR LIVING

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on staff interview and record review, it was revealed that on 08/14/2026, between 2:30pm to 10:30pm residents at the facility did not receive their prescribed medications as Staff #1 (S1) failed to arrive to their scheduled shift. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will ensure that there is sufficient staff in numbers, and competent to provide the services necessary to meet residents needs. Administrator to submit a detailed plan to LPA by POC due date that the facility will ensure that there is sufficient coverage and quailed staff at the facility at all times.

Deadline recorded: Aug 18, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(h)(4)

Regulation authority

CCR

What the official deficiency says

(h) The administrator shall have the responsibility to: (4) Recruit, employ and train qualified staff, and terminate employment of staff who perform in an unsatisfactory manner. This requirement is not met as evidenced by: Based on staff interview and record review, the administrator failed to ensure that there were competent, qualified, and trained staff working in the facility 24 hours a day seven days a week to provide the care to meet the needs of the residents. This poses an potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will ensure that the facility recruit, employ, and train qualified staff to meet the needs of the residents at all times. Administrator will ensure that there are staff qualified to handle medications when needed at all times. Administrator to train noc shift staff in handling medication and provide training material and signup sheet to the LPA by POC due date.

Deadline recorded: Aug 31, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(b)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care. 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. Based on record review, evening med-tech staff did not dispense R1's Ibuprofen 400 mg and Trazodone 25 mg on May 9, 2026 & May 10, 2026 per MD order and PRN medication request. Bubble pack shows Trazodone was popped on 5/9/26 and 5/10/26, but staff did not initial MAR, and Ibuprofen was not administered, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agrees to: 1. Submit a written plan by tomorrow. 1. Submit proof of staff training by 5/22/26. 2. Submit a written plan that addresses centrally stored record keeping/inventory protocols, refill procedures, and facility auditing of medications.

Deadline recorded: May 16, 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 as evidenced by: sliding door in room 7B was broken on 2/28/2026 the glass has not been replaced. The door is currently covered with cardboard through the inside and a plywood sheet on the outside which poses a potential health and safety risk for residents in care.

Official plan of correction

Licensee/Administrator will send LPA, photos of the replaced door. Photos will depict the doorway showing the room number and also to capture the sliding door and the outside of the building (front) to ensure the plywood is removed by POC due date.

Deadline recorded: Mar 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) 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, the licensee did not comply with the section cited above in that water temperature readings in Room #s 9 (124.1 deg F), 13 (122.1 deg F), 34 (132.6 deg F), 40 (127.2 deg F), and 46 (129.5 deg F) did not measure within the required 105 - 120 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 02/13/2026 Plan of Correction Administrator shall immediately adjust water temperature. Administrator to check water temperature at various different times throughout the day and maintain and submit a water temperature log to the LPA for the next 3 days to ensure that hot water temperature falls within 105 degree F and 120 degrees F. Administrator will provide a copy of the log to the department once water temperature falls within Title 22 guidelines.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities.. (a) In addition to the rights listed in Section 87468.1,..... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) 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: Based on investigation conducted by Investigation Bureau, it was determined that facility’s neglect/lack of supervision and additional measures, allowed R2 to make unwanted physical advances toward R1 and other female residents which poses an immediate risk to the health, safety, or personal rights to residents in care.

Official plan of correction

Administrator shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 87468.2 and retrain all staff on the same regulation. Proof of staff training and the written plan must be submitted to CCL/LPA by POC due date.

Deadline recorded: Oct 27, 2025. 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 Reporting Requirements..(a) Each licensee shall furnish to the licensing agency such reports..(1) A written report... for the resident within seven days of the occurrence of any of the events specified...report shall include the resident's name, age, sex and date of admission; date and nature of event;....(D) Any incident which threatens the welfare, safety or health of any resident..... This requirement is not met as evidenced by: Based on interviews, records review, the Administrator did not comply with the section cited above in which R1's unwitnessed fall incidents that happened on 08/10/2025, 08/11/2025 and 08/28/2025, resulting in injuries and hospitalization were not submitted and faxed to CCL which poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

Administrator agreed to comply with Title 22 Regs. Reporting requirements and will fax the incident reports for R1 on 08/10/2025, 08/11/2025 and 08/28/2025 to CCL/LPA today, 09/15/2025. ****DEFICIENCY CLEARED DURING THE VISIT.*****

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

Official classification

Type B

Official code

87463(b)(1)

Regulation authority

HSC

What the official deficiency says

87463 Reappraisals...(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition.... (1) Significant changes in condition, as defined in Section 87101, Definitions, include, but are not limited, to:.. This requirement is not met as evidenced by: Based on interviews, records review, the Administrator did not comply with the section cited above in which a re-appraisal to assess R1’s condition was not completed which poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

Administrator will ensure to comply with Title 22 reg 87463 regulation requirement to conduct reappraisals when there has been a change in residents' mental, medical or social condition. Administrator to submit self-certification that she read, reviewed and understood the regulation and submit it to LPA/CCL by POC due date.

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

Official classification

Type B

Official code

87218(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure an adequate theft and loss program.....(2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property ....The licensee shall.... made reasonable efforts to safeguard resident property ...... to meet each requirement specified in Section 1569.153. This requirement is not met as evidenced by: Based on interviews, Licensee failed to safeguard residents property during the relocation due to fire which poses a potential Health, Safety, and Personal Risk to residents in care.

Official plan of correction

Licensee/Administrator agreed to establish a plan to address how the facility can properly safeguard residents personal belongings during relocations and renovations. Administrator to send statement stating that they have read, reviewed and understood Title 22 Regs 87218 and submit to CCL/LPA by POC due date.

Deadline recorded: Aug 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) 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, the licensee did not comply with the section cited above in that (3) of the rooms (#4, #37 & #39) tested for hot water measured 122.8-123 deg F. The other rooms readings vary between 84 deg F to 122 deg F which poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 05/09/2025 Plan of Correction Licensee shall ensure that hot water temperature used by residents are within 105-120 deg F as stated in Title 22 Regs. Assistant Administrator will submit a 7-day log of water temperature of the various rooms including the 3 rooms mentioned to CCL/LPA by POC due date.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 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. The licensee did not met this requirement as evidenced by: the licensee did not ensure staff was sufficicient in numbers to prevent residents from accessing the facility while the facility is under renovations and repairs. This poses a potiential risk to the health, safety or personal rights of persons in care.

Official plan of correction

Administrator Solorio agreed to certify plan to address how the facility will address residents gaining entry into the facility while renovations are being conducted.

Deadline recorded: Apr 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(b)

Regulation authority

CCR

What the official deficiency says

87217 Safeguards for Resident Cash, Personal Property, and Valuables- (b)Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. This requirement was not met as evidenced by: Staff did not properly cover and safeguard residents personal belongings during renovations and repairs. This poses a potiential risk to the health, safety or personal rights of persons in care.

Official plan of correction

Administrator Solorio agreed to certify plan to address how the facility plans to properly safeguard residents personal belongings during renovations and repairs.

Deadline recorded: Apr 18, 2025. 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

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may

Official plan of correction

require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. The licensee did not met this requirement as evidenced by: the licensee did not ensure the facility was inaccessible to residents while renovations are taking place.Administrator Solorio agreed to certify plan to address how the facility will address residents gaining entry into the facility while renovations are being conducted.

Deadline recorded: Apr 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(b)

Regulation authority

CCR

What the official deficiency says

Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement was not met as evidenced by: Staff did not properly cover residents personal belongings during renovations and repairs.

Official plan of correction

Administrator Solorio agreed to certify plan to address how the facility plans to properly safeguard residents personal belongings during renovations and repairs.

Deadline recorded: Apr 18, 2025. 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 ... 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 observation and interviews, the Administrator did not comply with the section cited above in which LPAs observed the dining room's air conditioning is inoperable and the ice machine is broken which poses potential health, safety or personal rights risks to residents in care.

Official plan of correction

Administrator agreed to submit a service report/invoice from Air Conditioning/Heating company to prove that the A/C in the dining room has been fixed. And submit receipt/photos of new ice machine to CCL/LPA by POC due date.

Deadline recorded: Sep 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows:(2) Faucets used by residents for personal care.... shall deliver hot water. Hot water temperature controls shall be maintained... to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Based on interviews and observation, the hot water temperature readings during the visit on 5/21/2024 were 90.8 deg F in stall #1, 98.6 deg F in stall #2 and 89.2 deg F in stall #3, all stalls were in the large community shower room which poses an immediate health and safety risk to residents in care.

Official plan of correction

Asst. Administrator shall ensure that the hot water temperature in the community shower rooms meets Title 22 regulation. Asst Administrator shall immediately repair water pump and submit service report/invoice to CCL/LPA by POC due date.

Deadline recorded: Jul 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87207

Regulation authority

CCR

What the official deficiency says

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirment is not met evidence by: Based on IB's investigation it was determined that there were inconsistent/false statements from staff about R1's injuries and who arranged medical transportation for R1, the SIR states staff arranged transportation, however, records reveal that R1 911 for help and to be transported to hospital for further treatment.

Official plan of correction

Licensee/Administrator to submit an addendum to their SIR and provide this updated information. A copy of this addendum/revision to be emailed to LPA by POC Due date.

Deadline recorded: May 17, 2024. 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 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, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirment is not met evidence by: During IB interview with R2 it was stated that R2 had been without a room for 2-3 days. This was confirmed by S4 who found R1 sleeping on the floor and S1 also confirmed that the two residents were having issues, and S1 was working on getting R2 a new room. IB also observed R2 with a few bags in the facility hallway.

Official plan of correction

Licensee/Administrator to submit an SIR detailing incident and what was done to correct this situation, new room/roomate switch and what the facility is doing moving forward to avoid incidents between the two individuals. SIR to be submitted to LPA by POC due date.

Deadline recorded: May 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)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 in (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. This requirment is not met evidence by: IB discovered there was an incident that occurred where S1 was involved in a physical altercation with R1's family member and sustained injuries to their eye during the altercation, an incident report was not filed for this incident and police was called.

Official plan of correction

Licensee/Administrator to submit an SIR detailing incident and report must also have police report number. SIR to be emailed to LPA by POC due date.

Deadline recorded: May 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) 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, the licensee did not comply with the section cited above in that water temperature readings in Room #s 11 (124.5 deg F), 33 (134.9 deg F) and 34 (131.3 deg F) did not measure within the required 105 - 120 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to residents in care. LPAs observed that the faucet in Room #19 was broken, no water coming out on cold water side, and the bathroom sink in Room #18 was clogged which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2024 Plan of Correction Assistant Administrator will submit a 7-day log of water temperature of the 3 rooms mentioned to CCL/LPA by POC due date.

Official classification

Type B

Official code

87303(e)(6)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. 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 that LPAs observed that the faucet in Room #19 was broken, no water coming out on cold water side, and the bathroom sink in Room #18 was clogged which poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 04/12/2024 Plan of Correction Assistant Administrator will submit proof by sending photos and receipts of the fixed bathroom faucet and sink to CCL/LPA by POC due date.

Official classification

Type B

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, record review, the licensee did not comply with the section cited above in that there is no current and valid Administrator certificate on file which poses/posed a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 04/12/2024 Plan of Correction Assistant Administrator will submit proof that Administrator courses had been completed and renewal for Administrator certificate has been submitted. Documents shall be sent to CCL/LPA by POC due date.

Official classification

Type B

Official code

87465(a)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement is not met as evidenced by: R1 needing medical attention after sustaining injuries to the right hand and index finger that had redness, swelling, and drainage as a result of an unwitnessed slip and fall, R1 called emergency transportation for treatment themselves on 12/26/23.

Official plan of correction

The administrator will review the Title 22 Regulations and ensure that and all staff will provide the necessary attention to residents who require medical attention and provide assistance in providing transportation to the nearest available medical facility. The administrator will send a copy of the in-service training and log with participants signature by POC due date to LPA via email.

Deadline recorded: Apr 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records...(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff... This requirement is not met as evidenced by: Based on interviews and review of documentation, R1's Medication Administration Record (MAR) for March 2024 is inaccurate. MAR for March 2024 shows that 2 staff initialed the medication log from 3/12/2024-3/16/2024 even after R1’s passing which posed an immediate health and safety risk to residents in care.

Official plan of correction

The Assistant Administrator shall ensure that the Medication Administration Records (MARs) are accurate for all residents. The Assistant Administrator agreed to submit a plan of correction to avoid improper documentation of Medication Administration Record (MAR) and prevent medication errors. Additionally, all facility staff in charge of medication management shall be re-trained on Medication Management & proper documentation. A copy of the in-service training form along with topics discussed and signatures of staff present will be submitted to CCL/LPA by the POC due date.

Deadline recorded: Mar 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ...care facilities ... shall... (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are ...to meet their needs. This requirement is not met as evidence by: Based on documents review licensee did not ensure R1 did not leave the facility unassisted which resulted on a fall which poses an immediate risk to the health,safety, or personal rights of the person in care. *Immediate civil penalities assess for $500.00*

Official plan of correction

Administrator will certify in writing that will ensure that residents do not leave unassisted unless assisted by a staff or responsible party and will provide in-service training to staff to inform staff of which residents are able to leave the facility unassited and which are not and will submit a copy of in-service to the department by POC due date 1/17/23.

Deadline recorded: Jan 17, 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

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. The soda machine dispenser spout has an unknown residue stuck and needs either deep cleaning or replacement.

Official plan of correction

Facility is to ensure that Title 22 Section 87303 regulations are met at all times. Additionally, facility will either deep clean the dispenser spout or replace it and submit proof by 01/19/2024

Deadline recorded: Jan 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Based on observation, interviews, and record review, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. There is sufficient evidence to support that the facility has a cockroach issue.

Official plan of correction

Facility is to ensure that Title 22 Section 87555 regulations are met at all times. Additionally, facility will submit a plan on how they will address the cockroach issue by 01/13/2024.

Deadline recorded: Jan 13, 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

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by: Based on observation and interviews, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. LPA observed floor tile lifting in the dining room and and damaged floor tile in room #23, and damaged furniture in room #40 and #46.

Official plan of correction

Facility is to ensure that Title 22 Section 87303 regulations are met at all times. Additionally, facility will repair the damaged floor tile in the dining room and room #23 and repair or replace the furniture in room #40 and #46, and will submit proof by 01/19/2024.

Deadline recorded: Jan 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87415(a)

Regulation authority

CCR

What the official deficiency says

Night Supervision(a)The following persons providing night supervision from l0:00 p.m. to 6:00 a.m. shall be familiar with....planned emergency procedures, shall be trained in first aid..., Incidental Medical and Dental Care Services and shall be available as indicated below to assist in caring for residents in the event of an emergency. The requirement was not met as evidenced by: LPA reviewed R1, R2, R4 R5 in-service alongside with Staff #1(S1) and there were no identifier's showing nocturnal shift provided care and supervision to resident(s). Interviews with (3) out of (5) staff stated residents were being aware of issues with noc shift caring for residents. Interviews with residents (4) of (5) informed LPA night shift staff were not assisting/ responding to residents to provide care and supervision .

Official plan of correction

Administrator will have a training to refresh staff on care and supervision with night shift staff and review Regulations : 87415 Night Supervision, Health and Safety Reg on Basic Services Requirement 1569.312 and Care and Supervision 1569.2. and go over in-service log and how to properly check on resident's through the night especially incontinent residents. Admin. will provide LPA with in-service sign in sheet and materials used during training.

Deadline recorded: Jan 26, 2024. 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 Reporting Requirements: (1)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 in (A) through (D) below.(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. The requiement was not met as evidenced: LPA tried to request R1's incident reports for the month of Dec 2023, but staff reported they do not have any access on it and LPA was not able to obtain any incident reports during the complaint visit.

Official plan of correction

Administrator to submit incident reports to licensing for the period 12/1/23 through 12/21/23 regarding resident #1 and send a plan to licensing regarding how Licensee will ensure that the facility is reporting incident as required by Title 22 regulation by POC due date.

Deadline recorded: Jan 4, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87618(b)(3)(H)

Regulation authority

CCR

What the official deficiency says

87618 Oxygen Administration-Gas and Liquid (b) 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: (H) Equipment shall be operable. The requirement was not met as evidenced by a witness observed R1 oxygen tanks were not filled and R1 had oxygen which posed a immediate risk to residents in care.

Official plan of correction

Licensee agreed to review Title 22 Regulations, 87618(b)(5) and submit a written plan detailing how administrator would ensure staff understand how to operate the oxygen equipment. Licensee would provide proper training to staff how to operate the oxygen machine. POC due on 12/22/23

Deadline recorded: Dec 22, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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 standard is not met at evidence by: " staff admitted that there was a history prior to the incident that showed R-2 may have needed a higher level of care. Interviews of staff, residents and Investigator observations revealed that there was a lack of available staff and staff response when requested. There is sufficient evidence to support the allegation of lack of supervision resulted in R-2 sustaining injury”.

Official plan of correction

Facility Administrator to submit a statement indicating that the facility will update residents’ needs when there is a change in condition. Immediate Civil Penalties will be issued today, in the amount of $500.00.

Deadline recorded: Dec 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 (e) (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water (...) to attain a temperature of not less than 105 degree F and not more than 120 degree F. This requirement is not met as evidenced by: Based on interviews and observation, LPA determined that the hot water temperature in the facility fell below the 105 degree threshold in Rooms 3, 7, and 18, which poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator shall ensure that the hot water temperature will remain within the required range at all times. Administrator will maintain a log of water temperature for the above resident rooms by the POC due date.

Deadline recorded: Nov 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care...(c) ...resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2)..the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on interviews and review of documentation, R1's Medication Administration Record (MAR) for Sep. 2020, no medication was given to R1 to help alleviate his severe pain and fever except on 9/20/2020 and 9/21/2020 only which posed an immediate health and safety risk to residents in care.

Official plan of correction

Administrator will submit an effective and written plan to ensure residents receive their medication as prescribed by their Physicians. The written plan will be submitted to CCL/LPA by POC due date.

Deadline recorded: Oct 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(i)(1)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation: (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more ... buildings shall have a signal system which shall: This requirement is not met as evidence by: Based on observation and interviews licensee failed to ensure residents had a signal system in place which poses a potential risk to the health, safety, or personal rights to the persons in care.

Official plan of correction

Administrator will provide a working call button to each resident and will submit plan to replace or maintain call buttons to the department by POC due date 9/19/23.

Deadline recorded: Sep 19, 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

Personnel Requirements – General. 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 being met as evidenced by: Interviews conducted confirmed that during the month of October 2022, Staff 2 (S2) was a “no-show” multiple times, leaving only one caregiver on duty during the overnight shift, between the hours of 10:30pm – 6:30am. Statements obtained confirmed that overnight staff were observed in the office area most of the time, sitting or sleeping and not doing rounds every two hours and checking on the residents. It was reported that overnight staff would at times ignore the residents call for help and when staff did respond, residents waited 2 or more hours before receiving assistance. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will review Title 22 Regulations Section 87411 on Personnel Requirements – General and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.

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

Official classification

Type B

Official code

87625(b)(2-3)

Regulation authority

CCR

What the official deficiency says

Managed Incontinence. In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not being met as evidenced by: Statements obtained from residents and staff corroborated that caregivers were not doing diaper changes during the overnight shift and/or changing soiled resident beddings and morning staff would often times find incontinent residents laying in bed, wet and soiled for hours. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will review Title 22 Regulations Section 87625 on Managed Incontinence and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.

Deadline recorded: Aug 24, 2023. 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

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 be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not being met as evidenced by: On 9/7/22, at approximately 12:40pm, S1 was overheard by witnesses yelling at R1 in a humiliating and intimidating manner. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will review Title 22 Regulations, Section 87468.1 on Personal Rights, and conduct an in-service training with all staff on the importance of resident personal rights. Administrator will submit a copy of the sign in sheet of all attendees along with the topics covered during the in-service training to CCL, by the POC due date.

Deadline recorded: Aug 8, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements – General All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement is not being met as evidenced by: Statements obtained from staff and residents stated that S4, who works in the kitchen, will often times assist residents with care. After reviewing the file of S4, LPA observed that S4 does not have the required training to provide resident care, such as assisting with showers, changing and providing incontinence care. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Administrator will provide training to S1 with the required training and submit proof of training record; training topic, date, time, training duration, along with signature of S1 to CCL, by the POC due date.

Deadline recorded: Aug 8, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements – General Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not being met as evidenced by: During the visit conducted on 10/20/22, LPA reviewed the file of S1 and observed that the CPR/First Aid Certificate for S1 expired on April 30, 2022. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Administrator will ensure that S1 has a current First Aid Certificate and submit current documentation to CCL by POC due date.

Deadline recorded: Aug 8, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(i)(1)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. (C) Identify the specific resident living unit. This requirement is not being met as evidenced by: During today's visit, LPA and AGPA toured the facility and observed that the facility did not have a functional signal system in all resident rooms, for all residents. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will ensure that the facility has a functional signal system installed in each resident's living unit and submit proof of correction to CCL by the POC due date.

Deadline recorded: Jul 1, 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. 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 being met as evidenced by: During the tour, the LPA and AGPA also observed Room #16 to be unsanitary. The room was dirty, the floors had stains and were sticky and there was debris/trash on the floor of the living area and also the bathroom. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Administrator shall develop a written Plan of Correction (POC) to ensure compliance with California Code of Regulations Title 22, Section 87303. POC is due to CCL by the POC due date of 7/1/23.

Deadline recorded: Jul 1, 2023. A deadline is not proof that correction was completed.

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 in observation of medication for resident was observed on top of the bed frame in shared bedroom #4 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/29/2023 Plan of Correction Licensee will submit LIC 9098 certifying that medication will be maintain centrally store and schedule in-service training regarding the importance of ensuring medication is not left unattended for staff by POC due 5/29/23. In-service training with time duration, topic, and sign-in log is to be submitted by 6/6/23.

Official classification

Type A

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 in medication for R4 was observed outside original labeled package which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/29/2023 Plan of Correction Licensee will certify in LIC 9098 that medication will be properly stored in original label prescribe package at all times and schedule in-service training by POC due date 5/29/23. In-service training will be provided on section 87465 and a copy of sign-in log, topic, and duration of training should be submitted by 6/6/23.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. 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 in 3 out of 5 resident's medication reviewed were missing 1 or more medications and medication sheet was initialed and provided to residents in care; R1,R2,R4 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/29/2023 Plan of Correction Licensee will certify on LIC 9098 that medication is order and provided as prescribed to residents by POC due date5/29/23. In-service training to be provided on section 87465 and a copy of sign-in log, topic, and duration of training is to be submitted by 6/6/23.

Official classification

Type A

Official code

87608(a)(3)

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: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. 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 in 3 residents have full bed or half bed rails and a physician's request is not on file which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/29/2023 Plan of Correction Administrator will obtain physician's request for R3,R4, and R5 and submit a copy to the department y POC due date 5/29/23.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in last fire drill conducted for each shift was conducted on 12/20/22, 2/22/23, and 2/23/23 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/02/2023 Plan of Correction Adminsitrator will conduct an emergency drill at facility for each shift and submit a copy to the department by POC due date 6/2/23.

Official classification

Type B

Official code

1569.695(d)

Regulation authority

HSC

What the official deficiency says

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. 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 in emergency disaster plan LIC 610D reviewed did not have date of last update or review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/02/2023 Plan of Correction Administrator will review and update LIC 610D emergency disaster plan and submit a copy to the department by POC due date 6/2/23.

Official classification

Type B

Official code

87217(g)(1)

Regulation authority

CCR

What the official deficiency says

Safeguard of Residents (g) Each licensee shall maintain adequate safeguards and accurate records of cash resources and valuables entrusted to his care, including, but not limited to the following: (1) Records of residents' cash resources maintained as a drawing account shall include a ledger accounting (columns for income, disbursements and balance) for each resident, and supporting receipts filed in chronological order. Each accounting shall be kept current. 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 in review of P & I money showed R2 should have a balance of $70 per log and there was no money on envelope and R8's balance was not tracked on log which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/02/2023 Plan of Correction Administrator willreview and properly log P & I money for R2 and R8 , will submit a copy of log and pictures of money to the department, and will provide trainig on section 87217 to Assistant administrator and business office director P & I by POC due date 6/2/23.

Official classification

Type B

Official code

87216(a)

Regulation authority

CCR

What the official deficiency says

87216 Bonding (a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. 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 in during visit LPA was not provided a copy of surety bond which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/02/2023 Plan of Correction Administrator will provide a copy of surety bond to the department by POC due date 6/2/23.

Official classification

Type B

Official code

87224(a)

Regulation authority

CCR

What the official deficiency says

Eviction Procedures. The licensee may, upon thirty (30) days written notice to the resident, evict the resident for nonpayment of the rate for basic services, failure to comply with state or local law, failure to comply with the general policies of the facility, development of a need not previously identified, and/or a change of use of the facility. The requirement is not met as evidenced by: Based on interviews conducted, LPA discovered that R1 was unlawfully evicted from the facility and an eviction notice was never issued to R1. Statements obtained from the Assistant Administrator and R1 corroborated that R1 was not allowed back at the facility after being hospitalized on 5/2/23. R1 is no longer residing at Pasadena Villa Senior Living.

Official plan of correction

The Administrator shall develop a written Plan of Correction (POC) to ensure compliance with California Code of Regulations Title 22, Section 87224. POC is due to CCL by the POC due date of 5/23/23.

Deadline recorded: May 23, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) 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, the licensee did not comply with the section cited above in water temperature tested in resident's room #28 tested at 121.6 degrees F., #40 tested at 120.7 degrees F., and #14 tested at 97.1 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/24/2023 Plan of Correction Licensee will ensure water temperature is within the required 105-120 degrees F. at all times and certify in LIC 9098 which will be submitted to the department by POC due date 4/24/23. Licensee will maintain a log of water temperature for the above resident rooms.

Official classification

Type A

Official code

87555(b)(28)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirement (b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. 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 moldy and rotten produce (cabbage, brussel sprouts, and apples) were observed in the walking refrigerator which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/24/2023 Plan of Correction Licensee will ensure all moldy/rotten food produce is disposed and will provide in-service training to kitchen staff on section 87555. Administrator will submit pictures of refrigerator and training to the department by POC due date 4/24/23.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 in Administrator and Med-Tech do not have a TB test results on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/28/2023 Plan of Correction Licensee will submit a copy of TB test results for Administrator and Med-Tech to the department by POC due date 4/28/23.

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 observation, the licensee did not comply with the section cited above in kitchen/dining/library floors were observed dirty with crumbs, laundry room has water damage, restroom by room #23 has mold in cabinet which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/28/2023 Plan of Correction Administrator will ensure facility is clean at all times, will provide in-service training to staff, and will contact proper agency to provide mold evaluation and repairs submit pictures of areas and training to the department by POC due date 4/28/23.

Official classification

Type B

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. 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 2 shower rooms observed by room #23 and across room #12 did not have skid mats which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/28/2023 Plan of Correction Administrator will provide skid mats in each shower and submit a picture of correction to the department by POC due date 4/28/23.

Official classification

Type B

Official code

87303(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) Solid waste shall be stored and disposed of as follows: (1) Solid waste shall be stored, located and disposed of in a manner that will not permit the transmission of a communicable disease or of odors, create a nuisance, provide a breeding place or food source for insects or rodents. 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 trash can used to dispose of diapers, liner, and human waste lid was open during tour which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/28/2023 Plan of Correction Administrator will provide in-service training to staff regarding section 87303 and submit training to the department by POC due date 4/28/23.

Official classification

Type B

Official code

1569.69(a)(1)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. 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 in Med-Tech - staff #5 does not have hours of shadowing for medication training and initial training is not signed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/28/2023 Plan of Correction Administrator will provide proper training to staff #5 and will submit training certificate and initial training sign to the department by POC due date 4/28/23.

Official classification

Type B

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based onrecord review, the licensee did not comply with the section cited above in R5 does not have a 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: 04/28/2023 Plan of Correction Administrator will obtain a TB test for R5 and submit a copy of TB test results to the department by POC due date 4/28/23.

Official classification

Type B

Official code

87507(c)

Regulation authority

CCR

What the official deficiency says

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in R1 adn R2 do not have a signed admision agreement which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/28/2023 Plan of Correction Administrator will obtain signatures for the admission agreement for R1 and R2 and submit a copy to the department by POC due date 4/28/23.

Official classification

Type B

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirement (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. 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 kitchen floors were observed dirty, stove had grease with dust attached to it, trays were observed with grease and burn leftovers, and oatmeal bag was observed open which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/28/2023 Plan of Correction Administrator will ensure a deep cleaning of the kitchen is provided, properly store food items, and provide in-service training to kitchen staff on storage and maintanance of kitchen, will submit pictures and training to the department by POC due date 4/28/23.

Official classification

Type B

Official code

87412(b)(2)

Regulation authority

CCR

What the official deficiency says

Personnel Records (b) Personnel records shall be maintained for all volunteers and shall contain the following: (2) Health screening documents as specified in Section 87411(f). 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 in Med-Tech does not have a health screening on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/28/2023 Plan of Correction Administrator will obtain a copy of Med-Tech (staff #5) health screening and submit a copy to the department by POC due date 4/28/23.

Official classification

Type A

Official code

87459(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

87459 Functional Capabilities ...(a) The facility shall assess ....personal assistance and care ... to perform specified activities of daily living...(5) Continence, including: (B) Whether assistive devices...catheter are used. This requirement is not met as evidenced by: Based on observation, interviews, records review, the Administrator did not comply with the section cited above in that R1's need for personal assistance and care was not met as R1 was observed in by EMS, “urine in the foley to be dark in color and cloudy” which posed a potential health and safety risk to residents in care.

Official plan of correction

The Administrator will implement a Restricted Health Condition Care Plan in place and have a licensed professional provide training to all staff on catheter care and assistance. Proof of staff training including topics covered, duration and the name and signatures of staff and the licensed professional, shall be submitted to LPA Bennette Pena by POC due date.

Deadline recorded: Mar 13, 2023. 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 Observation of the Resident..The licensee shall ensure...observed for changes in physical, mental, ...functioning ....appropriate assistance is provided...physical health condition are observed, the licensee shall ensure that such changes are documented...resident's responsible person, if any. This requirement is not met as evidenced by: Based on observation, interviews, records review, the Administrator did not comply with the section cited above in that the condition that the resident was observed in by EMS, “urine in the foley to be dark in color and cloudy”, “EMS observed rigidity, pain, distension, and tenderness in all four quadrants” and “R1 was weak and in severe discomfort with a pain level 10 out of 10 and nausea level 8 out of 10 " which posed a potential health and safety risk to residents in care.

Official plan of correction

Administrator to provide an in-service training on Observation of the Resident regulations. Administrator will submit a copy of the training sign-in log with staff names and signatures, date, duration of training, name of trainer and curriculum used to LPA Bennette Pena by POC due date.

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

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

87555(b)(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. The requirement is not met as evidenced by: Based on interviews conducted: LPA observed food quality for perishable foods (vegetables and fruits) containing bacteria, fungus and mold. Food in unsanitary conditions for residents in care.

Official plan of correction

Assistant Administrator immediately notified kitchen staff to remove unsanitary food items and develop a plan to maintain good quality, fresh food for residents in care. Administrator will provide in-service food training on food handling will provide LPA with in servicie training. Will obtain Quality food check log. Assistant Administrator will submit proof of correction to CCL by the POC due date.

Deadline recorded: Feb 15, 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 conducted, the back door switch to the smoking area was in disrepair which poses a potential personal rights risk to residents in care.

Official plan of correction

The Administrator shall ensure that the automatic door switch is in good repair at all times. This POC is due on 12/23/22. ***This POC has been cleared as of today.***

Deadline recorded: Dec 23, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87470(c)(1)(F)

Regulation authority

CCR

What the official deficiency says

Infection Control Requirements. Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidenced by: At 9:30am, LPA was greeted by Staff #1 (S1) inside the facility (by the front door) and S1 was observed not wearing a face covering/mask, while working inside the facility. Also, upon entering the facility and walking inside the office area, LPA observed the Assistant Administrator / Alexander Solorio and Staff #2 also not wearing a face covering/mask, while working inside the facility. During today's visit, LPA was not screened for COVID upon entering the facility. This poses an immediate health and safety risk to persons in care.

Official plan of correction

Administrator will ensure that all facility staff are following Pasadena Public Health and CCLD requirements by conducting an in-service training with all staff on the importance of wearing a face covering/mask and also on the importance of COVID screening for all visitors, staff and residents. Administrator will submit a copy of the sign-in sheet of all attendees along with the topics covered during the in-service training to CCL, by the POC due date.

Deadline recorded: Oct 22, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(14)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities... To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility, except when accommodation would endanger the health or safety of the individual resident or other residents. The requirement is not met as evidenced by; Residents and staff interviewed confirmed that the fire doors that exit to the back patio are too heavy for residents in wheelchairs to open. Often times, residents will wait on staff to come and open the doors for them because they are unable to keep the door open and wheel themselves out at the same time. During today's visit, LPA tried opening the fire doors that exit to the back patio and observed the weight of the doors and based on LPA's observation, it would be very difficult for anyone in a wheel chair to hold the door open and wheel themselves out at the same time.

Official plan of correction

Administrator will develop a plan and make corrections to the exit doors making them easily accessible for residents in wheelchairs and submit proof of correction to CCL by the POC due date.

Deadline recorded: Sep 15, 2022. 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. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. The requirement is not met as evidenced by: Based on interviews conducted, the majority of statements obtained were consistent and corroborated with the allegation. Residents confirmed that linens and bed sheets are not changed regularly and often times residents have to request for their linens to be washed/changed because staff will not change them. There have been times where residents linens and bed sheets have not been changed for more than two weeks. During today's visit, LPA toured a random selection of resident rooms and observed the linens in rooms 33, 34B, 38B and 36B were soiled/dirty. Blood stains were observed on the linens in rooms 34B and 38B and on the pillow case in room 33. The pillow case in room 36B was torn and covered in stains.

Official plan of correction

Administrator will develop a plan ensuring all resident beds have required bed linens and are washed regularly and submit plan of correction to CCL by the POC due date.

Deadline recorded: Sep 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements. 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 in (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. This requirement is not met as evidenced by; On 7/17/22, at approximately 5:50pm, there was an incident involving R1. S1 noticed R1 was smoking marijuana and drinking beer in the designated smoking area (back end of the facility). S1 also noticed a bag containing additional marijuana on top of the table, where R1 was sitting. S1 confiscated the bag containing the marijuana and locked it in the front office and reported the incident to facility management. The Pasadena Police Department was involved and conducted a visit on 7/18/22.

Official plan of correction

Assistant Administrator will review Title 22 Regulations, Section 87211 on Reporting Requirements, and submit a written plan detailing how he will ensure that incidents are reported to the CCL office as required according to the Regulation. Also, an Unusual Incident/Injury Report must be submitted to CCL no later than the end of business day on 7/27/22, in reference to the incident involving R1.

Deadline recorded: Jul 27, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87415(a)(2)

Regulation authority

CCR

What the official deficiency says

87415(a)(2) - Night Supervision (a) The following persons providing night supervision from l0:00 p.m. to 6:00 a.m....shall be available... to assist in caring for residents. (2)In facilities caring for sixteen (16) to one hundred (100) residents at least one employee shall be on duty on the premises, and awake.... This requirement was not met as evidenced by: LPA's interviews with staff revealed that there was a staff not responding to the call light. This poses a potential health and safety risk to residents in care

Official plan of correction

Licensee will conduct an in-service training in rgards to the call light and submit POC to LPA by 05/27/2022. It has been confirmed that an in-service training has already been conducted on 03/11/2021 when this allegation was brought up. POC cleared.

Deadline recorded: May 27, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87618(b)(3)(C)

Regulation authority

CCR

What the official deficiency says

Oxygen Administration - Gas and Liquid. Smoking shall be prohibited where oxygen is in use. This requirement is not being met as evidenced by: Residents 1 and 2 require the use of oxygen administration and are able to administer oxygen on their own. On multiple occassions, R1 was observed by multiple staff and residents lighting up cigarettes inside her room, while oxygen is in use. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The Assistant Administrator has developed a Behavior Contract with R1 stating that R1 will follow the house rules of Pasadena Villa, R1 will smoke in the designated smoking area and request assistance from staff to be escorted to the smoking area. According to the Assistant Administrator, R1 has been following the Behavior Contract as of 5/9/22 and is no longer non-compliant. ***Citation was cleared at the time of visit and no further action is needed***

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

Official classification

Type B

Official code

87307(a)(3)(C)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services. Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident... 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... Based on majority of the interviews conducted the statements obtained were consistent and corroborated with the allegation. At 11:35am, LPA toured the facility and inspected the linen closets and laundry room and observed a low supply of bath towels for 53 residents.

Official plan of correction

The Assistant Administrator purchased extra bath towels during the time of this visit and provided a copy of the receipt to the LPA. ***Citation was cleared at the time of visit and no further action is needed***

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

Official classification

Type A

Official code

87101(c)(3)

Regulation authority

CCR

What the official deficiency says

Care and Supervision " means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents. The requirement is not met as evidenced by; On 1/1/22, at approximately 8am, R1 eloped from the facility in her wheelchair. From the interviews conducted, LPA learned that on the weekends, the front desk staff does not begin their work shift until 9am and there is no staff monitoring the front desk area and resident traffic going in and out of the facility between the hours of 6:30am and 9am. Per R1's Physician's Report, R1 is not able to leave the facility unassisted. This poses an immediate health and safety risk to R1.

Official plan of correction

Licensee will submit a plan to CCL ensuring the safety measures the facility will implement ensuring residents are not leaving the facility without informing staff and/or without assistance. POC is due to CCL by 4/8/22.

Deadline recorded: Apr 8, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

Maintenance and Operation. 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 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by; Between the hours of 11am - 1pm, the hot water temperature was tested throughout the facility and not measured within Title 22 Regulation guidelines. In room #43, it was measured at 102.8 degrees F. In room #12, it was measured at 123 degrees F. This poses an immediate health, safety risk to persons in care.

Deadline recorded: Mar 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by; At 1:10pm, LPA discovered medication Trazadone HCL 50MG (Take 1 tablet by mouth once daily at bedtime) was missing from facility for Resident 1. This poses an immediate health, safety risk to persons in care.

Deadline recorded: Mar 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

Maintenance and Operation. Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by; Between the hours of 11am - 1pm, LPA toured the facility and observed missing skid mats in one of the main showers and also in the private shower. This poses a potential health, safety risk to persons in care.

Deadline recorded: Apr 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

Maintenance 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 is not met as evidenced by; Between the hours of 11am - 1pm, LPA toured the facility and observed resident rooms #115, #24, #17 and #43 were unsanitary and in need of cleaning. Urine was observed in the shared bathroom of room #115 and stains, dirt, food particles and dust were observed in rooms #24, #17 and #43. This poses a potential health, safety risk to persons in care.

Deadline recorded: Apr 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

Maintenance 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 is not met as evidenced by; At 11:15am, LPA observed the table located near the dining room patio area was in disrepair (broken pieces). At 11:30AM, LPA observed the plywood behind the fascia board located near the roof facing the side of the property (near the parking lot) was in disrepair. A large piece was broken and missing. This poses a potential health, safety risk to persons in care.

Deadline recorded: Apr 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

Personal Accommodations and Services. The following space and safety provisions shall apply to all facilities: All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: At 11:25am, LPA observed broken furniture/appliance, wheelchair, wheelbarrow, pieces of wood and a plantoon boat located in the outdoor passageway, near the parking lot. This poses a potential health, safety risk to persons in care.

Deadline recorded: Apr 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87101(c)(3)

Regulation authority

CCR

What the official deficiency says

Care and Supervision " means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents. The requirement is not met as evidenced by; On 3/7/22, R1 is observed (in surveillance video at 4:17pm) leaving the facility through the front door without staff supervision. Facility staff did not witness R1 leaving the facility and it wasn't until later, while conducting room checks when staff discovered R1 had eloped. Per the physician's report dated 3/1/22, R1 is not able to leave the facility unassisted. This poses an immediate health and safety risk to R1.

Official plan of correction

Licensee will submit a plan to CCL ensuring the safety measures the facility will implement (effective 3/11/22) to ensure residents who are listed as not able to leave the facility unassisted, do not elope from the facility. The plan must not violate the personal rights of residents. POC is due to CCL by 3/12/22.

Deadline recorded: Mar 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(14)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1...following personal right (14)To reasonable accommodation of their individual needs and preferences in all aspects of life in the facility. The requirement is not met as evidenced by LPA's observation and interviews by residents and reported the doors are not easy access for the residents use wheelchairs to go through which pose an potential risk for residents in care.

Official plan of correction

The Executive Director will come up a plan for how to make the doors to be easy access for the residents who use the wheelchair to go through. The Executive will send the plan to LPA by POC due date.

Deadline recorded: Mar 2, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

Reappraisals. The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. This requirement is not met as evidenced by; Based on interviews conducted and records reviewed, LPA discovered that R1's health began deteriorating around the end of December 2021 and beginning of January 2022. R1 was observed by staff and R2 (roommate) to be disoriented and paranoid. Due to a decline in health, R1 was often observed to be hallucinating. This poses a potential health and safety risk to R1.

Official plan of correction

Licensee will review Title 22 Regulations, Section 87463 on Reappraisals and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.

Deadline recorded: Feb 8, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87457(c)(1)

Regulation authority

CCR

What the official deficiency says

Pre-Admission Appraisal - General. Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462 Social Factors. This requirement is not met as evidenced by: After reviewing the file of R1, it was observed that at the time of admission, facility staff did not conduct a proper assessment of R1 as the Care Assessment/Evaluation, Functional Assessment, Mental Status Questionnaire and the Resident Appraisal were incomplete. Most of the answers to the questions listed on the forms were left blank. This poses a potential health and safety risk to the residents in care.

Official plan of correction

The Executive Director will review Title 22 Regulations, Section 87457 on Pre-Admission Appraisal and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.

Deadline recorded: Oct 15, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

Reappraisals. The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. This requirement is not met as evidenced by: The Unusual Incident/Injury Reports were reviewed for R1 and it was determined that R1's behaviors changed between period April of 2021 through September of 2021 and facility staff did not update the Appraisal/Needs and Services Plan for R1 addressing the current changes. This poses a potential health and safety risk to the residents in care.

Official plan of correction

The Executive Director shall update R1's Appraisal/Needs and Services Plan to indicate the changes in behaviors which led to the eviction. The Plan shall be submitted to CCL by the POC due date.

Deadline recorded: Oct 15, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

HSC

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: 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: After reviewing the file of S1, LPA discovered that S1 did not have the qualifications and training to administer medications to residents. Interviews conducted corroborated with the information found in the file of S1.

Official plan of correction

Administrator will review Title 22 Regulations Section 87468.2 on Additional Personal Rights of Residents in Privately Operated Facilities and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.

Deadline recorded: Sep 15, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

HSC

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: 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: On 6/27/21, between the hours of 10:35PM - 11:35PM, S1 was the only staff member on duty at the time of the incident and in charge of providing care and supervision to 36 residents. S2 was scheduled to be on duty with S1 but was a " no call, no show " leaving S1 alone at the facility.

Official plan of correction

Administrator will review Title 22 Regulations Section 87468.2 on Additional Personal Rights of Residents in Privately Operated Facilities and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.

Deadline recorded: Sep 15, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

HSC

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 be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by; During the visit conducted on 7/7/21, at 12:15PM, LPA Katrdzhyan toured the facility with the assistance of Assistant Administrator / Alexander Solorio and observed a strong odor of marijuana coming from the hallway, near the dining room area. Based on statements obtained, LPA learned that residents have been observed smoking marijuana in their rooms and the outside, near the courtyard area.

Official plan of correction

Administrator will review Title 22 Regulations Section 87468.1 on Personal Rights of Residents in All Facilities and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.

Deadline recorded: Sep 15, 2021. 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. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interviews conducted, LPA learned that residents are smoking marijuana at the facility and staff admitted that there have been complaints regarding marijuana smell coming from the facility. During the visit conducted on 08/11/21, LPAs toured the facility and observed a strong odor of marijuana coming from room 45B and the nearby hallway area.

Official plan of correction

Administrator will review Title 22 Regulations Section 87468.1 on Personal Rights of Residents in All Facilities and develop a written Plan of Correction (POC) to ensure compliance. Written POC must be submitted to CCL by the POC due date.

Deadline recorded: Sep 15, 2021. A deadline is not proof that correction was completed.