SENIOR MANOR CARE III

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above for the water testing in 2 out of 3 bathrooms tested at between 127.0 – 128.0 degrees F, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2026 Plan of Correction Licensee will adhere to Title 22 Reg 87303 at all times. Licensee will ensure that water supply remain in compliance with hot water temperature of not less than 105 degrees F and not more than 120 degree F. Proof of correction must be sent to LPA Elvira.Gonzalez@dss.ca.gov

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 (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, and interviews conducted, the licensee did not comply with the section cited above because the sinks’ handle in bathroom #1 is in disrepair, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/04/2026 Plan of Correction Licensee will repair above item(s) and submit proof (video) to Elvira.Gonzalez@dss.ca.gov

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,... Prior to accepting or retaining... persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance... This requirement was not met as evidence by Based on record review, bedrooms #1, #2, and #4 are approved for non-ambulatory or bedridden residents. Licensee accepted R3 and R5 (non-ambulatory) into ambulatory rooms (#3 and #5). This poses an immediate safety risk to residents in care.

Official plan of correction

The Licensee agree to obtain a fire safety inspection to increase the number of rooms approved for non-ambulatory residents. The Licensee will create a plan, indicating specific steps to be taken by staff, based on the Fire Marshal’s guidance to ensure the residents’ safety.

Deadline recorded: Jun 25, 2025. A deadline is not proof that correction was completed.

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 and interview, the licensee did not comply with the section cited above for one out of four staff members which poses a potential health rights risk to persons in care. LPA did not observe TB results for Staff #2 (S2). Interview with S2 indicated that S2 has to complete the TB test.

Official plan of correction

POC Due Date: 06/23/2025 Plan of Correction The Licensee will submit a plan of correction to regina.cloyd@dss.ca.gov by the POC due date.

Official classification

Type B

Official code

87204(b)

Regulation authority

CCR

What the official deficiency says

(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents. 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 for two out of five residents which poses a potential safety rights risk to persons in care. During record review of facility sketch, it revealed rooms #3 and #5 as ambulatory. Record review of register of residents revealed two non-ambulatory residents (R3 and R5) in rooms #3 and #5. Record review of medical assessment revealed R3 and R5 as non-ambulatory.

Official plan of correction

POC Due Date: 06/23/2025 Plan of Correction The Licensee will email plan of correction to regina.cloyd@dss.ca.gov by the POC due date.

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care. (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met by evidence by: Based on record review and interviews, Staff #2 (S2) did not immediately call 911 when S2 saw that Resident #1 was unresponsive. This posed an immediate risk to resident's health while in care.

Official plan of correction

The Licensee will provide a plan of correction and email it to regina.cloyd@dss.ca.gov by the POC due date.

Deadline recorded: Jun 6, 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

A plan for incidental medical … and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above for one resident which poses/posed a potential health risk to persons in care. Staff provided Resident # 1 (R1) with two expired medications (Oxybutynin Chloride and Simvastatin). Both medications expired in 2022.

Official plan of correction

POC Due Date: 07/15/2024 Plan of Correction The Licensee will provide medication training to staff and new and/or current medication to R1. Licensee will send evidence of correction by the POC due date to regina.cloyd@dss.ca.gov

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 and interview, the licensee did not comply with the section cited above. LPA Lourdes Montoya observed a smoke detector in the hallway next to resident bedrooms has no cover and no battery. LPA also observed a desk in the office area next to the kitchen has a broken leg. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/19/2022 Plan of Correction Staff Catherine Espino agreed to change the battery of the smoke detector in the hallway and place the cover. Espino stated she will remove and dispose the broken desk and replace it with a desk in good repair. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov