ASTORIA PARK SENIOR LIVING

Official classification

Type A

Official code

87465(a)(4)

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. (4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication review, there were discrepancies found in six out of ten residents' medications which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee shall conduct an inservice on medication training and submit a plan to ensure medications are administered as prescribed. This plan is due on 6/24/26.

Deadline recorded: Jun 24, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:..(6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained. This requirement is not met as evidenced by Based on interview, R1's bedtime medication was not administered on 3/24/26 due to R1 being away from the facility during scheduled pass. MAR indicated that R1 received their bedtime medication; however, staff indicated that it was prepared and documented ahead of time and that R1 did not receive their medication. Medication review indicated that R2 has discontinued Furosemide 40 mg tablets no longer administered but still listed on MAR.

Official plan of correction

Licensee will provide LPA with a plan on how to regularly monitor medication and medication logs, ensure medications are current, provide additional medication administration in service training to all staff and provide proof to the department via email by POC due date.

Deadline recorded: Jun 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(10)

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:(10) To be informed of the licensee’s policy concerning visits and other communications with residents, according to Health and Safety Code section 1569.313. This requirement is not met as evidenced by Interviews with (16) out of (17) people stated that they feel safe in the facility or and not received reports of people not feeling safe in the facility. However; interviews indicated that they didn't know and were not informed about the changes in the hours of facility’s concierge service and that the facility should have informed them of the changes. People further indicated that resident responsible parties have not received information from the facility regarding the changes.

Official plan of correction

Licensee will ensure that the concierge hours remain posted in front of the facility on the entrance door for public view. Licensee will monitor the door's posting of the hours. LPA, observed the posting during visit. Citation cleared on 6/8/2026.

Deadline recorded: Jun 8, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(2)

Regulation authority

CCR

What the official deficiency says

(2) Safe and healthful living accommodations and services. This requirement was not met as evidenced by: Per LPA's in person interview with R1, R1 had combative behavior which created an unsafe environment to other residents at the facility. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee agreed to work with R1's physician and family member for an updated care plan, change of medication and possible for a new placement for the level of care that R1 needs. Administrator will provide training for all staff in the facility related to handle resident with combative behavior. Licensee will send the updated care plan and/or possible placement of R1 by POC due date. POC had been cleared prior to the subsequent visit. 5/4/26

Deadline recorded: May 5, 2026. 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

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Staff#2 (S2) did not follow the facility's procedures of having the required two (2) staff for proper use of Hoyer lift when transferring Resident#1 (R1) which cause bruises on leg and knee. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator agrees to submit (1) a staff list for additional in-service training for proper use of Hoyer lift (2) a written statement of how the facility will compliance with section 87411(a) and ensure staff are following the facility policy of using Hoyer lift by 05/05/26. Follow up with proof of training on Hoyer lift by 05/12/2026.

Deadline recorded: May 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

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: (4) The licensee shall assist residents with self-administered medications as needed. This deficiency was evidenced by the following: Based on interview and record review, staff do not dispense all of R1's medications and R1’s medication Gabapentin 300 mg capsule was marked administered, but the medications were still on the bubble pack and the PRN pain medication was not given as prescribed which poses an immediate health and safety risk to residents in care.

Official plan of correction

The licensee shall ensure all medications are administered timely and that residents do not miss any dosage. An in-service training course for medication staff shall be conducted and the log to be submitted to LPA by POC due date.

Deadline recorded: Mar 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored:..(6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained. This requirement is not met as evidenced by: Per medication review, R5 TK has control Rx Pregabalin 150 mg adminsitered twice on 3/14/26 but did not administer on 3/18/26. R6 AT has discontinued Rx-Midodrine HCL 2.5 MG still given to R6 on 3/26/26. R7 SS, has discontinued Rx-Furosemide 40 mg no longer administered but still listed on MAR. Licensee did not have an explanation about Rx discrepancy/ record.Based on observation 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.

Official plan of correction

Licensee agreed to (1) review all residents' medication and medication log to ensure residents' medications are current. (2) provide additional medication administration / in service training to all staff and provide proof to the department; (3) review Title 22, Section 87465 and provide a signed statement indicating the review of this section detailing how to prevent future medication errors by the POC date.

Deadline recorded: Mar 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

Managed Incontinence.... the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met evidenced by: Based on interviews and observation during the 10/30/25 physical plant inspection, the findings indicate R1 requires incontinence care at least every 2 hours and feces were observed on the floor, bedding, and mattress of a Memory Care Unit resident room. This posed a potential health and safety risk to the resident in care.

Official plan of correction

Executive Director agrees to conduct staff training in incontinence care, responsibilities, and Memory Care Unit facility protocols. Submit proof of staff training.

Deadline recorded: Apr 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87413(a)(1)

Regulation authority

CCR

What the official deficiency says

Personnel - Operations. In each facility: When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement was not met evidenced by: Based on interviews and record review, it was revealed that in October 2025, 2 Memory Care Unit (MCU) staff were suspended, of which 1 was terminated, but both were listed in the MCU weekly staff schedule and administration staff did not ensure adequate staff coverage. This posed a potential health, safety, and personal rights risks to persons in care.

Official plan of correction

Executive Director agreed to ensure staff schedules are updated, posted, and in instances of staff shortages shift coverage shall be implemented. Please submit a written plan of correction.

Deadline recorded: Apr 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(2)

Regulation authority

CCR

What the official deficiency says

(2) Safe and healthful living accommodations and services. This requirement was not met as evidenced by: Per LPA's in person interview with R1, R1 had combative behavior which created an unsafe environment to other residents at the facility. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee agreed to work with R1's physician and family member for an updated care plan, change of medication and possible for a new placement for the level of care that R1 needs. Administrator will provide training for all staff in the facility related to handle resident with combative behavior. Licensee will send the updated care plan and/or possible placement of R1 by POC due date.

Deadline recorded: Apr 3, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

Personal assistance and care as needed by the resident .. such as … bathing… This requirement was not met as evidenced by: Per staff and residents’ interviews, staff were not bathing residents and missed at least once last week for providing their bathing needs. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee agreed to provide bathing care to residents who were not provided from last week and keep up with the bathing assistance as scheduled. Showing log will be provided for POC by due date.

Deadline recorded: Mar 17, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.2(c)(4)

Regulation authority

HSC

What the official deficiency says

Personal assistance and care as needed by the resident .. such as … bathing… This requirement was not met as evidenced by: Per staff and residents interviews, staff were not bathing residents and missed at least once last week for providing their bathing needs. This poses a potential health and safety risk to residents in care.

Official plan of correction

Liscensee agreed to provide bathing care to residents who were not provided from last week and keep up with the bathing assistance as scheduled. Showing log will be provided for POC by due date.

Deadline recorded: Feb 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(a) (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 was not met as evidenced by: Per interviews of residents and call button test, it showed that staff would take 15 min or did not respond to residents at all due to the call button was not working. This poses a potential health and safety risk to residents in care

Official plan of correction

Licensee agree to hire more quailified staff to provide adequate assistance and care to residents. Also to ensure staff would respond to calls within 10 minutes. Proof of hiring additional staff will provide to licensing by the POC due date.

Deadline recorded: Feb 27, 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

The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Per call button tests, mulitple of call buttons were not working properly at the facility. This poses a potential health and safety risk to residents in care

Official plan of correction

Licensee agree to fix the call button to ensure it is in good repair at all times. Proof of repair will provide to licensing by the POC due date.

Deadline recorded: Feb 27, 2026. 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. 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 was not met as evidenced by: Based on interviews conducted staff stated there is not enough staff and at times residents aren't assisted in a timely manner This poses a potential health and safety risk to residents in care

Official plan of correction

Licensee will conduct an in-service training regarding timely response to assist residents and also submit a staff schedule which includes additional staffing to meet the needs of over 100 residents and submit POC to LPA by 2/19/2026.

Deadline recorded: Feb 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by: Based on record review, S1 had been working at the facility from February of 2025 - 10/16/2025 while not being associated to the facility, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator is to ensure that all staff are associated to the facility prior to working at all times. Administrator is to submit a written plan explaining how the facility will ensure all staff are associated to the facility prior to beginning work, and submit the place to the licensing agency for review by the POC due date.

Deadline recorded: Feb 10, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(6)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (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 was not met as evidence by: During facility tour LPA observed Room #116's toilet to be completely off and in the shower. It was explained to LPA by facility's Maintenance Director that there is a plumber arriving to repair toilet today 12/12/25 as the toilet is clogged. LPA toured room once again prior to concluding visit (around 3:20pm) and toilet was still not repaired and taken apart.

Official plan of correction

Licensee/Administrator to have toilet repaired and submit proof of repair via email to LPA by POC due date. A copy of the invoice/work order and photo of toilet back in its proper area is to be emailed as proof. tena.herrera@dss.ca.gov

Deadline recorded: Dec 19, 2025. 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, residents and review of facility alarm event report for 11/07/2025 showed that staff did not respond in timely manner and that resulted in R1 spending 9 minutes 11 seconds or 24 minutes 17 seconds on the floor. Both times are unreasonable call light respond times or for any resident to spend on the floor. This poses a potential health and safety risk to residents in care

Official plan of correction

Licensee will conduct an in-service training regarding call light response and submit POC to LPA by 12/16/2025

Deadline recorded: Dec 16, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Persons who require health services for or have a health condition...shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Record review shows that R1 developed stage 3 and 4 pressure injuries while at the facility and was retained by facility.

Official plan of correction

The licensee shall review the prohibited health conditions regulation 87615 and shall not retain a resident with stage 3 and 4 pressure injuries. Licensee will send written notice that section 87615 has been reviewed and understood. $500 immediate civil penalty

Deadline recorded: Dec 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(16)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(16) 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: (16) To receive or reject medical care or other services. This requirement is not met evidenced by: R1 was not provided timely medical care for pressure injuries.

Official plan of correction

Licensee will read section 87468 and write a statement indicating that licensee read and understand the section. Also, Licensee will provide personal rights training to all staff and have all staff sign the roster as proof that training was provided.

Deadline recorded: Dec 16, 2025. 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

87411(a) Personnel requirements general. Personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: After R1 was admitted to the hospital and was diagnosed with dehydration. Medical documents showed the resident was lacking fluid intake. Medical records show the resident was suffering from diarrhea at facility and interviews with staff indicated that resident was refusing liquids.

Official plan of correction

The facility will provide training to staff on the observation and needs of all the residents and send proof to LPA by POC date.

Deadline recorded: Dec 10, 2025. 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 Based on interviews conducted with other agencies licensee did not ensure staff were following complete and correct record log for medication infection which poses a potential risk to the persons safety, health, or personal rights of the persons in care.

Official plan of correction

Administrator will conduct training with staff on section 87506 and ensure staff does not sign for medication that is not given to residents. Administrator will send training to LPA by POC due date.

Deadline recorded: Nov 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

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: (4) The licensee shall assist residents with self-administered medications as needed. Based on observations and interviews licensee did not ensure, R1 received the medication prescribed due to R1 not being in the facility also R1 was given discontinued medication by staff which poses an immediate risk to the health, safety, and personal rights of the persons in care.

Official plan of correction

Administrator will conduct training with staff on 87465(a)(4) and the importance of medication given to residents correctly and on prescribed time.

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

Official classification

Type A

Official code

87465(a)(4)

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: (4) The licensee shall assist residents with self-administered medications as needed. This standard was not met as evidence by: Based review of R1's MAR on 5/18/25 R1 missed a dose of thier routine Riboflavin medication, when LPA interviewed staff 3 staff confirmed that their was a glitch in the MAR during that time where the medication was listed as discontinued and was reordered the following day.

Official plan of correction

*medication was all accounted for during visit* Administrator confirmed that there has been an in-service training on medication and provided LPA a copy of the training participant log that was on 10/7/25, and a copy of the training materials. POC is cleared

Deadline recorded: Oct 21, 2025. 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

(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, the licensee did not comply with the section above; R1's Acidolphilus Tablet, Calcium 600-Vit D3 500, Clobetasol .05%, Aquaphor 41% ointment medications have not been filled, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/07/2025 Plan of Correction Administrator shall: 1. Submit proof that R1’s medications will be obtained by tomorrow. 2. Submit by tomorrow a written plan that addresses centrally stored record keeping/inventory protocols, refill procedures, and facility auditing of medications. 3. Submit proof of staff training by 10/9/25.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above; MCU patio door is inoperable, room 152's bathtub faucet had a leak, MCU public bathroom door is in disrepair, room 132-bathroom wall drywall is in disrepair/ window is missing blinds, room 133 is missing a medicine cabinet mirror; which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/03/2025 Plan of Correction Executive Director shall submit picture a written statement of how the above items were corrected, and submit picture proof evidence of repair completion.

Official classification

Type B

Official code

87303(f)

Regulation authority

CCR

What the official deficiency says

(f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or 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; room 148 had a soiled incontinence pad on the room entrance, Memory care unit (MCU) public bathroom had feces on toilet, blood on bed/sheets in room 141, and MCU shower room floor had feces on the floor, MCU rooms were not clean, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2025 Plan of Correction Executive Director shall submit proof of staff training and a written statement that discusses caregiver and housekeeper job responsibilities.

Official classification

Type B

Official code

87307(a)(3)(C)

Regulation authority

CCR

What the official deficiency says

(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that the majority of the 26 rooms inspected that were primarily shared rooms did not have mattress pads on resident beds, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2025 Plan of Correction Executive Director shall submit purchase order invoice proof that all rooms inspected and all other resident room beds have mattress pads placed on resident beds. Submit a written plan of correction.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(1) 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 met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above staff (S3, S5, S7, S8) do not have 1st Aid/CPR training on file and/or it is expired which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2025 Plan of Correction Executive Director shall submit proof that S3, S5, S7, S8 completed 1st Aid/CPR training.

Official classification

Type B

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above; rooms 130 and 133 had oxygen tanks but no " No Smoking-Oxygen in Use " sign, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/13/2025 Plan of Correction Executive Director shall submit picture proof that rooms 130 and 133 have posted " No Smoking-Oxygen in Use " outside the room doors.

Official classification

Type A

Official code

87464(f)(6)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services: (f) Basic services shall at a minimum include:v(6) Arrangements to meet health needs, including arranging transportation... This requirement is not met as evidence by: Based on medication review, and document review licensee did not ensure that R2 had routine and as needed medication which poses an immediate risk to the health, safety, and personal rights of the persons in care.

Official plan of correction

Administrator will provided a picture of as needed medications and or a discontinued order for the medication for R2 by POC due date 9/20/25.

Deadline recorded: Sep 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(4)

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... by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidence by: Based on observations and review licensee did not ensure that routine medications were available for R1-R3 which poses a potential risk to the health, safety, and personal rights of the persons in care.

Official plan of correction

Administrator implemented weekly audit since 4/3/25 and training was provided on 3/27/25 deficiency clear as of 4/29/25.

Deadline recorded: May 2, 2025. 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

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... staff shall... ensure provision of personal assistance and care... This requirement is not met as evidence by: Based on observations and interviews licensee did not ensure, R1 received the correct medication provided by S1 which poses an immediate risk to the health, safety, and personal rights of the persons in care.

Official plan of correction

Administrator provided in-service training to S1 on 3/28/25. Administrator will create a plan to have all medications audit and will submit the plan to the department by POC due date 4/4/25.

Deadline recorded: Apr 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87470(b)(2)

Regulation authority

CCR

What the official deficiency says

87470 Infection Control Requirements: (b) In addition... the following shall apply: (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE),,, This requirement is not met as evidence by: Based on observation and interviews licensee failed to ensure staff are wearing PPE supplies when providing care to symptomatic residents and proper use of PPE which poses an immediate risk to the health, safety, or personal rights to the persons in care.

Official plan of correction

Administrator will schedule training to staff regarding proper use of PPE supplies while providing care to residents by POC due date 11/27/24. Will submit all training provided by 12/2/24.

Deadline recorded: Nov 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87470(a)(1)

Regulation authority

CCR

What the official deficiency says

87470 Infection Control Requirements: (a) A licensee shall ensure that infection control practices are maintained as follows: (1) All staff and volunteers shall perform hand hygiene. This requirement is not met as evidence by: Based on interviews conducted with other agencies licensee did not ensure staff were following infection procedures to prevent the spread of the infectious disease which poses a potential risk to the persons safety, health, or personal rights of the persons in care.

Official plan of correction

Administrator provided training on hand hygiene to all staff on 11/22/24. Deficiency cleared as of 11/26/24.

Deadline recorded: Dec 3, 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...:(a) ... facilities for the elderly shall have ... personal rights: (4) To care, supervision, ... meet their individual needs ... by staff that are sufficient in...qualifications, and competency to meet their needs. This requirement is not met as evidence by: Based on interviews and documents reviewed licensee did not ensure R1 was provided with timely medical care during the incident by delaying the care by an hour which poses an immediate personal right, health, or safety risk to the persons in care.

Official plan of correction

Administrator will provide training to facility's staff in timely medical attention, will provide a copy of staff log, description, duration of training, and will submit to the department by POC due date 9/26/24.

Deadline recorded: Oct 26, 2024. 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

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... additional staff whenever... the needs of the particular residents... This requirement is not met as evidence by: Based on documents reviewed and interviews conducted the licensee did not ensure R1 did not elopped from the facility which poses an immediate risk to the health, safety, and personal rights of the persons in care.

Official plan of correction

Administrator provided in-service training to staff on 9/10/24 regarding securing doors, conducting door checks. Facilty has put in place a log to ensure egress system is working each day in the memory care unit, and staff was given a warning. Deficiency cleared as of 9/26/24.

Deadline recorded: Sep 26, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interviews, the licensee did not comply with the section cited above in R3's prescribed medication was observed with labels which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/03/2024 Plan of Correction Administrator will request that prescribed medication has labels prior to accepting if brought to the faciltiy by familiy or will ensure that centralized stored medication has labels once received from pharmacy and will send pictures of the medication with labels to the department by 10/3/24.

Official classification

Type B

Official code

87211(a)(2)

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: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidence by: Based on documents reviewed licensee did not report the epidemic outbreak to licensing within the 24 hour reporting requirement, as multiple residents tested positive for Covid-19 (5) days prior to reporting to licensing, which poses a potential risk to the health, safety, or personal rights of the persons in care.

Official plan of correction

Licensee/Executive Director will review the cited regulation in its entirety and confirm that moving forward the facility will report occurences such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. A copy of the signed Proof of Correction Form LIC9098 must be emailed to LPA by POC due date. This form will serve as an agreement that the regulation has been reviewed and understood. (tena.herrera@dss.ca.gov)

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

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 a cleaning solution was observed under bathroom's sink in room #150 which is located in the memory care unit which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/28/2024 Plan of Correction Administrator will removed cleaning solution from room #150 and will provide in-service training to staff regarding keeping cleaning solution inaccessible to all residents with dementia by POC due date 8/28/24.

Official classification

Type A

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents ...(a)... shall have all of the following personal rights:(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidence by: Based on interviews and documents reviewed licensee did not ensure S1 treated R1 and R2 with dignity and respect which poses an immediate risk to the health, safety, or personal rights of the persons in care.

Official plan of correction

Administrator provided in service training to staff regarding resident personal rights, elder abuse, dignity and respect a copy was provided of training during this visit. Deficiency cleared as of 8/22/24.

Deadline recorded: Aug 23, 2024. 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

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... additional staff whenever... the needs of the particular residents... This requirement is not met as evidence by: Based on documents reviewed and interviews conducted the licensee did not ensure R1 did not prevent R1 from eloping the facility after first incident which poses an immediate risk to the health, safety, and personal rights of the persons in care.

Official plan of correction

Administrator has placed a one-on-one staff to provide care for R1, is activily assisting with placement in a smaller setting, and has provided training to staff on delay egress and memory care on 3/5/24 and 3/19/24. Deficiency cleared as of 3/19/24.

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

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidence by: Based on observation licensee did not ensure that all passageways were free of obstruction which poses a potential risk to the health, safety, or personal rights of the persons in care.

Official plan of correction

Administrator will remove wood planks and will submit a picture to the department by POC due date 3/11/24.

Deadline recorded: Mar 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(a)

Regulation authority

HSC

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. This requirement was not met as evidenced by: Interviews with Administrator and Staff #1 indicate that resident #1 was not given 30 days written eviction notice as required.

Official plan of correction

Administrator will ensure that the facility follows Title 22 eviction procedures, (87224) as required. Administrator will conduct an in service training with staff regarding eviction procedures and will send proof of training to LPA by POC due date.

Deadline recorded: Dec 28, 2023. 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...: (1)A written report shall be submitted...within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement is not met as evidence by: Based on document review licensee did not ensure incident occured on 3/24/23 with R1 was reported to the department within 7 days which poses a potential risk to the health, safety, or personal rights of the persons in care.

Official plan of correction

Administrator will certify that any incident or occurence will be reported to the department within 7 days of it's occurence and will submit a report for the incident on 3/24/23 by POC due date 10/26/23.

Deadline recorded: Oct 26, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia; (c) Licensees who accept and retain residents with dementia shall...: (5) Each resident with dementia shall have an annual medical assessment... and a reappraisal done at least annually. This requirement is not met as evidence by:

Official plan of correction

Administrator will create a plan to ensure physician's reports are obtained at least annually and needs and care plans are updated at least annually or upon a change in condition occurs, plan is to be submitted to the department by POC due date 10/26/23.

Deadline recorded: Oct 26, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(k)(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia: (k) The following... requirements must be met ...(5) Residents who continue to indicate a desire to leave the facility following redirection shall be permitted to do so with staff supervision. This requirement is not met as evidence by: Based on observation, interviews, and documents reviewed licensee did not ensure there is a plan, staff, or assessments for residents in the memory care unit that continued to exit the memory care unit which poses an immediate risk to the health, safety, or personal rights of the persons in care.

Official plan of correction

Administrator is to create and provide a plan, review needs and care plans for residents in memory, and/or ensure there is sufficient staff provided in the memory care unit to assist residents that will potentially attempt to exit by POC due date 10/20/23.

Deadline recorded: Oct 20, 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..., safe,... and in good repair at all times... maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidence by: Based on observation licensee did not ensure that exit door by room #129 egress system was working at all times which poses a potential risk to the health, safety, or personal rights of the persons in care.

Official plan of correction

Administrator fixed the door. LPA observed the door and egress system working, there are no boards blocking the door. Deficiency cleared as of 10/18/23.

Deadline recorded: Oct 26, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in disinfectant sprays were observed in kitchenette's cabinet without a lock in the dementia unit which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/22/2023 Plan of Correction Administrator is to submit LIC 9098 certifying facility staff will be train and all cleaning solutions will be made inaccessible to the residents and a plan for staff training is to be submitted by POC due date 9/22/23. Staff training is to be submitted by 9/28/23.

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 S4 does not have a TB clearance on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/28/2023 Plan of Correction Administrator will submit a copy of TB clearance by POC due date 9/28/23 to the department.

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 dementia bathroom's faucet sink accessible to the resident in dining room was not working, activity's room refrigerator was observed dirty, and ceiling by the family lounge was observed with water damage and crack, screen door was observed in the dementia courtyard on the floor which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/28/2023 Plan of Correction Administrator will ensure the sink's faucet is in working condition, submit a copy of invoice/work order and picture for the following: the faucet's sink functioning, repaired ceiling, and clean refrigerator to the department by POC due date 9/28/23. Screen door was removed by Gina Lopez from the floor at the time of the visit.

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 toilet in room #149 was clogged and overflowed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/28/2023 Plan of Correction Administrator will submit an invoice/work order for repairs in room #149 related to the toilet to the department by POC due date 9/28/23.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 5 out of 5 staff files review did not have a current CPR on file, Brianna Goodlett CPR/first aid expired on 3/23 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/28/2023 Plan of Correction Administrator will submit CPR/first aid cards for 5 staff by POC due date 9/28/23.

Official classification

Type B

Official code

1569.695(a)

Regulation authority

HSC

What the official deficiency says

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in LIC 610E(10/03) was reviewed which does not meet the updated emergency disaster plan LIC 610E(12/21) which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/28/2023 Plan of Correction Administrator will submit LIC 610E(12/21) or a version that meets all requirements to the department by POC due date 9/29/23.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 1 out of 5 files review, R3 does not have an updated physician's report, last report 3/15/22 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/28/2023 Plan of Correction Administrator will obtain a current physician's report and submit a copy to the department by POC due date 9/28/23.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. 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 passageways located in the first floor, to the right of the dementia courtyard and outside room #119 have a bench and chairs obstructing which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/28/2023 Plan of Correction Administrator will clear the passageways and submit a picture to the department by POC due date 9/28/23.

Official classification

Type B

Official code

87211(g)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements: (g)The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in listed administrator Brianna Goodlett does not have a current administrator certificate per administrator Erin Manohey is assuming the role and the department was not notify of this change which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2023 Plan of Correction Administrator will notify the department of change and submit pertinent documents to make the change by POC due date 9/29/23.

Official classification

Type B

Official code

87412(b)(2)

Regulation authority

CCR

What the official deficiency says

87412 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 2 out of 5 staff do 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: 09/28/2023 Plan of Correction Administrator will obtain a health screening for the S4 and S5 and will submit a copy to the department by POC due date 9/28/23.