Hazardous items and storageType A
- Official classification
- Type A
- Official code
- 87309(a)
- Regulation authority
- CCR
What the official deficiency says
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in having all cleaning solutions, sharp objects unlocked and accessible to a resident in care which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/22/2026 Plan of Correction The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87309 Storage Space; The written letter must be sent to the LPA by the POC due date.
Licensing and administrationType B
- Official classification
- Type B
- Official code
- 1569.618(c)(3)
- Regulation authority
- HSC
What the official deficiency says
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in having one staff without CPR/first aid training which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/27/2026 Plan of Correction The Administrator agreed to provide one (1) staff CPR/first aid training by POC due date.
Licensing and administrationType B
- Official classification
- Type B
- Official code
- 1569.618(a)
- Regulation authority
- HSC
What the official deficiency says
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in not being available themselves or a designee at the facility during normal business hours which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/27/2026 Plan of Correction The Administrator will submit an updated LIC 500 with their working hours at the facility and have a designee for the facility during their absence with their contact information to LPA by the POC due date.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(a)
- Regulation authority
- CCR
What the official deficiency says
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in not maintaining one (1) staff records/file at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/27/2026 Plan of Correction The Administrator agreed to have all staff complete files/records available at the facility at all the times for audit and review. The Administrator will submit staff files via e-mail to LPA by POC due date.
Not classified in the sourceType B
- Official classification
- Type B
- Official code
- 1569.267(d)
- Regulation authority
- HSC
What the official deficiency says
(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation during today's visit, the licensee did not comply with the section cited above in not properly training the staff who got verbally involved with one (1) resident in an argument which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/27/2026 Plan of Correction The Administrator agreed to provide training to all staff on residents' personal rights and submit the training log to the LPA by POC due date.
Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87506(b)
- Regulation authority
- CCR
What the official deficiency says
(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in not having one (1) resident records/file in the facility for review which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/27/2026 Plan of Correction The Administrator agreed to provide one (1) resident complete file to LPA by POC due date.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(d)(3)
- Regulation authority
- CCR
What the official deficiency says
87411-Personnel Requirements - General(d) All personnel shall be given on the job training or have........effective job performance:(3) Skill and knowledge required to..care and supervision, including the ability to communicate with residents. This was not met as evidence by: Deficient Practice Statement Based on the interview, the administrator did not have staff available to communicate in English with residents in care which poses a potential risk to the residents in care.
Official plan of correction
POC Due Date: 01/27/2026 Plan of Correction Administrator agrees to put in writing their plan for hiring or ensuring English Speaking staff are always on shift and submit the plan by the POC date. Additionally, Administrator shall submit an updated LIC500 to reflect all staff.