SAN DIMAS RETIREMENT CENTER

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Based on physical plant observations during the visit on 06/10/2025, three(3) out of six (6) smoke detector were not working. This posed an immediate health and safety risk to persons in care.

Official plan of correction

Administrator agreed to: 1. Fix or replace smoke detectors that were not working and submit video to LPA by POC due date. 2. Administrator will check all rooms occupied by residents to ensure all smoke detectors are working and send LPA a signed log stating they were checked.

Deadline recorded: Jun 11, 2025. 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) 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) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/25/2025 Plan of Correction Cited in error.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

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 assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self- administered medications as needed. This standard is not met at evidence by: Per medication log, R-1 was provided with both PRN medications in less than (8) hours (ordered for TID/every (8) hours) and the log does not include the “reason” nor “result” of the administered medication.

Official plan of correction

Administrator to submit a written statement which includes a plan on staff training pertaining to PRN medication administration to LPA Irra by POC date 01/08/25. Administrator to ensure staff training in this subject is completed within (2) weeks.

Deadline recorded: Jan 8, 2025. 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

Additional Personal Rights of Residents in Privately Operated Facilities (a) 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: (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 interviews and records review, the findings indicate care staff did not conduct at the very least 2 hours checks after returning to the facility on 7/17/24, which resulted in R1 falling and laying on the floor unassisted for hours. This posed an immediate health and safety risk to the resident.

Official plan of correction

Administrator agreed to submit a plan of correction that states staff responsibilities after residents return from higher level of care discharges, protocols in place, and proof of staff-in service training, which includes staff signatures. Submit written plan by tomorrow and proof of staff training by 10/4/2024.

Deadline recorded: Oct 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(i)(1)(C)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation. Facilities shall have signal systems .... All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: Identify the specific resident living unit. Based on physical plant observations during the visit on 7/23/24, R1's signal wrist bracelet was not working. The resident relied on the wrist alert system, which was inoperable on 7/17/24. This posed an immediate health and safety risk to persons in care.

Official plan of correction

Administrator agreed to: 1. Submit a written POC stating how the deficiency will be corrected by tomorrow. 2. Proof of staff in-service due 10/4/24. 3. Proof that the entire building's signal system, wrist/neck pendants were tested and are operational is due 10/4/24. ***NOTE: LPA observed: 1.The Memory Care Unit has a separate signal system in place, with staff having to run to the signal system room when rooms cannot be identified. 2. Facility staff do not use signal system pagers.

Deadline recorded: Oct 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(8)

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 have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met evidenced by: This requirement was not met evidenced by: Based on record review and interviews conducted staff did not notify R1's responsible party of R1's fall incident (7/17/24), until late afternoon 7/18/24, after Kaiser PT staff notified LVNs of injuries observed, which posed a potential health and safety risk to R1.

Official plan of correction

Administrator agreed to provide in-service training regarding 87468.1 and provide written statement of how the facility will document responsible party contact when incidents occur, and/or there is a change in condition.

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

Official classification

Type B

Official code

87507(f)

Regulation authority

CCR

What the official deficiency says

Admission Agreements. The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met evidenced by: Based on record review, on 7/17/24 R1's authorized representative met with staff and signed an Addendum to the Rental Agreement, that stated the resident would be receiving personal care services, and more frequent checks after return from a higher level of care facility.

Official plan of correction

Administrator agrees to submit proof of: 1. Staff training addressing protocols after residents return to the facility. 2. Change of condition procedures/documentation.

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

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical...and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. Based on interviews, photographs, and record review, the findings indicate that R1 dislocated the hip after falling on 7/17/24, and did not receive medical attention until late 7/18/2024, because staff did not perform a thorough body check, which posed an immediate health and safety risk.

Official plan of correction

Administration staff agrees to submit a written plan that states how the deficiency was corrected by tomorrow, and proof of staff training by 10/4/2024.

Deadline recorded: Oct 2, 2024. 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

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....for sixteen or more... This requirement is not met as evidenced by: Based on interviews conducted, staff and residents stated that facility did not ensure there is adequate staffing to tend to residents' needs in a reasonable amount of time which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee to submit a written plan to LPA detailing how the current staffing level is able to meet the needs and support each resident's physical, social and emotional safety and healthcare needs and determine if additional staffing is required to ensure the facility is meeting Title 22 Regulation by POC due date. Administrator to submit an LIC500 and a breakdown of staff for each department by POC.

Deadline recorded: Sep 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(1)(B)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care. Medications shall be centrally stored under the following circumstances: Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. This requirement was not met evidenced by: Based on observation during interview with resident (R1), 3 medications were observed on the resident's table next to the recliner. Resident stated they are confused and need help with medication management; resident could not recall the names or dosage times; which poses an immediate health and safety risk to the resident.

Official plan of correction

LVN staff removed medications from R1's room, and will begin managing R1's medications. Administrator shall: 1. Submit written proof of correction and conduct staff training by tomorrow. 2. Notify responsible party of care plan changes 3. Follow-up with Primary Care Physician for change in condition

Deadline recorded: Jul 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(2)

Regulation authority

CCR

What the official deficiency says

87468.1 (2) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement is not met as evidenced by: Facility staff failed to properly observe R14 that resulted in fall with injury and failed to properly assess R14 after fall.

Official plan of correction

Administrator to self certify that there is proper observation of Resident's when assistance is needed. Administrator to submit to Licensing a Staff Training in dealing with observation of residents and any changes physically, emotionally, and mentally. Plan to be submitted by 12/19/2022.

Deadline recorded: Dec 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(8)

Regulation authority

CCR

What the official deficiency says

Personal Rights (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. The requirement is not met as evidenced by: Facility failed to communicate with family/responsible party promptly and appropriately after incident on 09/25/2023. Family was not notified about incident until the following day.

Official plan of correction

Administrator shall ensure that family and responsible party of residents are informed in a timely manner. The licensee will write a letter to CCL explaining how this will be remedied and read section Title 22 section 87468.1(a)(8).

Deadline recorded: Dec 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(d)

Regulation authority

CCR

What the official deficiency says

87211(a)(1)(d) Reporting Requirements. (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. (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 requirement is not met as evidenced by: During the course of the investigation, LPA discovered that a special incident report was not submitted by the facility for incident for Resident #14 on 09/26/2022 according to Title 22 Reporting Requirements. Incident reports dated 09/25/2022 and 09/26/2022 were not provided to Ombudsman until 10/25/2022

Official plan of correction

The administrator will review Title 22 Regulations, Section 87211 on Reporting Requirements, and submit a written plan detailing how facility will ensure that incidents are reported to the CCL office as required according by the Regulation. The administrator must also conduct in-service training to all staff in reference to Reporting Requirements and provide a copy of names and signatures of all staff in attendance of training. POC is due to CCL by 12/19/2022

Deadline recorded: Dec 19, 2023. 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

87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. The requirement was not met as evidenced by LPA's observation, LPA toured R1's room ( room#19 from Memory Care Unit) and when LPA opened the door, LPA smelled the urine in the room which posed a potential risk to residnets in care.

Official plan of correction

The administraor will ensure the incontinent residents are kept clean and dry that facility remains free of odors from incontinence. The administaror will send the update care plan about R1 regarding about R1 refused to change and the plan how to keep R1's room free of odor from incontinence.

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

Official classification

Type B

Official code

87412(c)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and records review, the licensee did not comply with the section cited above in 5 of out of 7 staff files missing proof of required annual training certification, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/03/2023 Plan of Correction Assistant Administrator will provide proof of required annual training certification to LPA via email by POC due date.

Official classification

Type B

Official code

87224(a)(4)

Regulation authority

CCR

What the official deficiency says

87224 Eviction Procedures (a) The licensee may evict a resident...Thirty (30) days written notice to the resident is required...(4)If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted... and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement was not met as evidenced by: Based on interview, records review, and observation, the licensee failed to give R1 a 30 day eviction notice due to change in condition, for which a reassessment was not completed or issued. This poses a potential Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

The facility will reassess the resident as appropriate and determine if the resident is able to return to the facility. If unable to, a proper 30 day written notice will be issued. In either case, the licensee will provide a copy of the determination and supporting documents via email by the POC due date.

Deadline recorded: Nov 4, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(k)(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (k)...Initial and continuing requirements must be met for the licensee to utilize... perimeter fence gates:(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 was not met as evidenced by: Based on interviews, records review, and observation, the licensee failed to supervise R1 outside of the facility due R1's desire to leave the facility on several occasions, following redirection. This poses a potential Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

All staff who provide direct care and supervision to residents will complete in-service training regarding Care of Persons with Dementia. A copy of the training material and the sign-in sheet will be provided to LPA via email by the POC due date.

Deadline recorded: Nov 4, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents... shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. Thie requirement was not met as evidenced by: Based on interviews conducted, (4) of (11) residents in care stated they were not being treated with respect by staff in the facility, which poses a potential Health, Saftey, or Personal Rights risk to persons in care.

Official plan of correction

Administrator to conduct Personal Rights training and provide a copy of the sign in sheet with material to the LPA by POC due date.

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

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 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 Based on observation, the elevators did not detect any moving objects when the door was closing more than half way which poses a potential health and safety issue to residents in care.

Official plan of correction

The Administrator shall ensure the elevators are working properly and detect any objects as it is closing. The Administrator will send over the elevator service invoice by POC due date 9/30/22.

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

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above. Six out of the ten residents interviewed confirmed that a specific resident is not getting timely assistance which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator is to submit an in-service training to LPA by 05/19/2022 to ensure that Section 87468.2(a)(4) will be complied with at all times.

Deadline recorded: May 19, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)(3)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (c)(3)(B) importance and techniques of personal care services, including but not limited to, bathing, grooming, dressing, feeding, toileting, and infection control, as specified in Section 87470, Infection Control Requirements. This requirement is not met as evidence by: 6 Residents either witnessed or was in need of toileting assistance corroborated that there were incidents of long wait times. Wait time for Staff to arrive and assist with toileting needs can be from 45 minutes to an hour.

Official plan of correction

Licensee shall provide additional training to Staff ensuring Resident's toileting needs are met in a timely manner and Licensee shall provide proof of training to the department by the POC date.

Deadline recorded: Mar 17, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a)(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidence by: 5 Residents has witnessed incidents of Staff not treating Resident with respect. Incidents include Staff not knocking on the door before entering Resident's bedroom, provoking Resident and speaking to Resident in an inappropriate manner.

Official plan of correction

Licensee shall provide additional training to Staff ensuring Resident's personal rights to be accorded dignity is met and Licensee shall provide proof of training to the department by the POC date.

Deadline recorded: Mar 17, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(19)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(19)(19) To have prompt access to review all of their records and to purchase photocopies of their records. The requirement is not met as evidenced by LPA's interviewed with the residents. Residents reported it took a long time and very difficult o obtain their trust account balance information from staff which posed potential risk of the residents in care.

Official plan of correction

The administrator will ensure the residents have prompt access to review of their records. The administrator will retrain the staff for residents' personal right and send the staff training log to LPA by POC due date.

Deadline recorded: Dec 15, 2021. 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) (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. The requirement is not met as evidenced by LPA's interviews with the residents and reported they never got informed or notified about positive COVID results in facility.

Official plan of correction

The administrator will ensure the residents have the right to be informed the licensee policy of other communications with residents. The administrator will retrain the staff for residents' personal right and send the staff training log to LPA by POC due date

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

Official classification

Type A

Official code

1569.69(a)(1)

Regulation authority

HSC

What the official deficiency says

Employees assisting residents with self-administration of medication; training requirements: In facilities licensed to provide care for 16 or more persons, the employee shall complete 16 hours of initial training. This training shall consist of eight hours of hands-on shadowing training, which shall be completed prior to assisting with medication. Deficiency was evidenced by the following: Staff confirmed S1 passed medication and S1 does not have the required medication training. S1 was asked to pass medications on 10/25/21 due to three med techs calling off sick.

Official plan of correction

Facility will submit a plan explaining that all staff will be properly trained in medication assistance. Administrator will train additional staff in case med techs continue to call off sick. Plan will be submitted by 11/18/21.

Deadline recorded: Nov 18, 2021. 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. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required.... Deficiency was evidenced by the following: Nine out of the sixteen staff interviewed agreed the facility is short staff. Fourteen out of the twenty two residents interviewed agreed facility is short staff. Residents are receiving medications and treatments late. Staff are not respond in a timely manner when residents call for assistance.

Official plan of correction

Administrator is in the process of interviewing staff. The registry cannot be used as Med Techs because they are not trained on medications. Facility must hire additional staff to meet the needs of the residents. Staffing plan will be submitted by 10/1/21.

Deadline recorded: Oct 1, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

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:(5) The licensee shall assist residents with self-administered medications as needed. Deficiency was evidenced by the following: staff confirmed residents are receiving medications and treatments late. Treatments include ointments, eye drops, and breathing treatments. Residents confirmed they have received medications and treatments late.

Official plan of correction

Staffing will be updated to meet the needs of the residents. Administrator will submit staffing plan to describe how facility will mee the needs of the residents. Plan sill be submitted by 10/1/21.

Deadline recorded: Oct 1, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and ....... Deficiency was evidenced by the following: Fourteen out of the twenty two residents interviewed agreed their dietary needs are not being met because the food is bad. Residents reported the meats are dry and sometimes undercooked. They report too much pork is being served and there are not enough options. Food is also served cold.

Official plan of correction

Administrator will ensure kitchen staff have been trained in meal preparation to meet the needs of the residents. Plan detailing training will be submitted by 10/14/21.

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

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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. Deficiency was evidenced by the following: LPA toured the facility and noticed there were several stains on the second floor carpet in the hallway. According to staff, maintenance is responsible for deep cleaning the carpets. However, there has been a shortage of maintenance staff and therefore, the carpets have been neglected.

Official plan of correction

Facility has since hired an additional maintenance staff. Facility will provide proof that carpets have been deep cleaned on the second floor.

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