CHATEAU OF OAKS

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 staff did not receive the full 20 hours of annual training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction The Licensee will have staff complete the missing hours and provide proof to CCLD by POC due date.

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 interview and record review, the licensee did not comply with the section cited above in staff do not maintain documentation or physician notification of missed dosages or refusals which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction The Licensee will draft a medication log and train staff on maintaining medication documentation and provide proof to CCLD by POC due date.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in residents did not have complete records which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction The Licensee will obtain complete records for the residents and provide proof to CCLD by POC due date.

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 the facility did not have an updated emergency disaster plan which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction The Licensee will update the emergency disaster plan and provide proof to CCLD by POC due date.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal... This requirement was not met as evidenced by: Based on observation, interview, and record review, the Licensee did not comply with the above cited section in the facility's fire clearance was not maintained which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee will provide an updated LIC 200, facility sketch, and confirmation of the scheduled pre-inspection to CCLD by the POC due date.

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

Official classification

Type B

Official code

87208(a)(12)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in the Licensee did not maintain the infection control plan which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/12/2025 Plan of Correction The Licensee will locate or create an infection control plan and send the plan to CCLD by the POC due date.

Official classification

Type B

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 3 residents did not have a PRN Authorization Letter which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/12/2025 Plan of Correction The Licensee will obtain PRN Authorization Letters for 3 residents and send them to CCLD by the POC due date.

Official classification

Type B

Official code

87465(c)

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: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in 1 out 3 residents did not have a current PRN Authorization Letter and 3 out of 3 resident did not have PRN administration logs which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/12/2025 Plan of Correction The Licensee will create a log for 3 residents and document the administration of PRN medications which includes the date, tine, medication, and symptoms/reason for administration. The Licensee will send CCLD a draft of the PRN logs by POC due date.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 six out of six medications containers which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/14/2024 Plan of Correction Licensee agreed to provide training to staff and will submit proof of correction to LPA vai email by POC Due Date

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation,and interview, record review, the licensee did not comply with the section cited above in one out of one floor plans did not match the map on record at CCL, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/08/2024 Plan of Correction Licensee has agreed to contact the LAFD to schedule an insoection visit and will submit a date to LPA via email.

Official classification

Type B

Official code

1569.696(a)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include 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 three out of three staff didnot receive the annual 20 hour training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/31/2024 Plan of Correction Licensee agreed to provide training to staff and submit proof of training to LPA by the POC due Date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

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

Official plan of correction

POC Due Date: 08/09/2024 Plan of Correction Licensee agreed to conduct a a quartely drill by POC Due Date and send proof to LPA via email.

Official classification

Type B

Official code

1569.695(d)

Regulation authority

HSC

What the official deficiency says

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in one out of one floor plans wer not updated and posted which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2024 Plan of Correction Licensee agrre to update the floor plan with emergency exits/meeting place and will submit to LPA by POC Due Date.

Official classification

Type B

Official code

1569.695(e)(1)

Regulation authority

HSC

What the official deficiency says

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (1) A resident roster with the date of birth for each resident. 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 one out of total Resident Roster (LIC 9020) was not available at time of inspection. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2024 Plan of Correction Licensee agreed to submit correction to LPA by POC Due Date.

Official classification

Type B

Official code

87611(d)

Regulation authority

CCR

What the official deficiency says

(d) In addition to Section 87463, Reappraisals and Section 8, Observation of the Resident, the licensee shall monitor the ability of the resident to provide self care for the allowable health condition and document any change in that ability. 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 two out of three reappresials were not completely filled out and signed by responsible partys and administrator, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2024 Plan of Correction Licensee agreed to submit proof of corrections to LPA by POC Due Date.

Official classification

Type B

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary, and in good repair at all times…This requirement is not met as evidenced by: Based on the observation, the licensee did not comply with the section cited above, as the backyard patio area was found to be encumbered with debris, which poses a potential health and safety risk to residents in care.

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

Official classification

Type B

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary, and in good repair at all times…This requirement is not met as evidenced by: Based on the observation, the licensee did not comply with the section cited above, as the wood fence is wobbly, and leaning. The passage from the front to the back of the house is partially blocked with tree branches and clothing line...which poses a potential health and safety risk to residents in care.

Deadline recorded: Aug 26, 2022. A deadline is not proof that correction was completed.