Facility condition and maintenanceType A
- Official classification
- Type A
- Official code
- 87303(e)(2)
- Regulation authority
- CCR
What the official deficiency says
(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 degrees C) and not more than 120 degree F (49 degrees 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. The hot water temperature was tested at the residents bathrooms and measured at 125.2 and 126.1.9 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/02/2026 Plan of Correction Hot water temperature was adjusted at the time of visit. The hot water temperature retested and it was measured within Title 22 Regulation guidelines. Citation cleared at the time of visit.
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, the licensee did not comply with the section cited above. LPA observed large scissor and knives/sharps accessible to the residents in unlock kitchen drawers, laundry detergent and cleaning solutions in the laundry area accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/02/2026 Plan of Correction Scissor and knives/sharps, laundry detergent and cleaning solutions were removed and locked immediately. Citation cleared at the time of visit.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(h)
- Regulation authority
- CCR
What the official deficiency says
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. 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. LPA observed that R1's and R2's Physician's Reports are dated 9/21/23 and 2/10/25, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/17/2026 Plan of Correction Licensee/ Administrator shall submit copies of updated Physician's Reports for R1 and R2 before POC due date.
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87307(a)(2)(C)
- Regulation authority
- CCR
What the official deficiency says
Personal Accommodations and Services. (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (C)No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above.LPA observed that the garage area was being used as a staff room. Access to the garage required entering through a resident bedroom. LPA also observed that a bathroom used by staff was accessed through the resident’s bedroom. Staff personal belongings were observed in the garage area and in the bathroom. The residents bedrooms was being used as a passageway to access areas used by staff, which did not ensure the resident’s privacy and personal accommodations, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/17/2026 Plan of Correction The licensee shall discontinue using any resident bedroom as a passageway to access staff areas, including the staff room and bathroom. The licensee shall ensure resident bedrooms are used only for resident accommodations and privacy is maintained. The licensee shall submit a written plan describing how the facility will prevent resident rooms from being used as passageways.