GLEN PARK AT VALLEY VILLAGE

Official classification

Type A

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

(a) In addition to the rights listed in Section 87468.1… (8) To be free from neglect… and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by: Based on interviews and record review the Licensee did not comply with the above cited section as R1 was not free from sexual abuse which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee will schedule staff training on sexual abuse and staff conduct with a third party vendor and provide CCLD proof by POC due date.

Deadline recorded: Jul 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(c)

Regulation authority

CCR

What the official deficiency says

(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported… within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the above cited section as the Department did not receive notification of R1’s sexual abuse within 24 hours which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee will review reporting requirements and submit a statement of understanding to CCLD by POC due date.

Deadline recorded: Aug 4, 2026. 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

(a) Each licensee shall furnish to the licensing agency... (1) A written report shall be submitted to the licensing agency... within seven days of the occurrence … (D) Any incident which threatens the welfare, safety or health of any resident, …, or unexplained absence of any resident. This requirement was not met as evidenced by: Based on interview and record review, the Licensee did not comply with the section cited above as the Licensee did not provide CCL notification of the incident which posed/poses a potential health, safety, and/or personal rights risk to residents in care.

Official plan of correction

The Licensee will update staff training on reporting requirements and provide documentation and submit a statement of understanding by POC due date.

Deadline recorded: Oct 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on interview and record review, the Licensee did not comply with the section cited above as the Licensee did not meet R1’s care and supervision needs that resulted in an elopement which posed/poses an immediate health, safety, and/or personal rights risk to residents in care.

Official plan of correction

The Licensee will provide staff training on care and supervision needs as well as elopement protocols and submit proof along with a statement of understanding by POC due date.

Deadline recorded: Oct 16, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident ... pre-admission appraisal, with those activities of daily living such as ... bathing ... This requirement was not met as evidenced by: Based on interviews and record review, the Licensee did not comply with the section cited above as the licensee did not assist residents with showers which posed/poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

The Executive Director (ED) will have Staff ensure shower logs are being completed at the end of each shift as well as update Staff training. The ED will submit a statement of understanding to CCLD by POC due date.

Deadline recorded: Jul 18, 2025. 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

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 be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Staff #4 responded back to Resident #1 when they requested their medication by cursing at them and this poses a possible risk to the rights of the resident

Official plan of correction

Licensee will provide the Department with evidence of current personal rights training or conduct personal rights training and provide evidence of the training by 11/21/24

Deadline recorded: Nov 21, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465(c)(2) Incidental and Medical Care: ....Once ordered by the physician the medication is given according to the physician's directions. This requirement has not been met as evidenced by: The facility was short staffed and the residents were not being given their medications in a timely manner and this poses an immediate risk to the health of the residents.

Official plan of correction

Licensee will provide a written plan of action to ensure that the facility always has sufficient staff and medications available to ensure the medications are dispensed in a timely manner by 11/21/24.

Deadline recorded: Nov 21, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87609(b)(3)

Regulation authority

CCR

What the official deficiency says

87609(b)(3) Allowable Health Conditions and the Use of Home Health Agencies (b) Incidental medical care... (3) The licensee informs the home health agency of any duties the regulations prohibit facility staff from performing...This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff performed wound care treatment to R1’s pressure injury, which posed an immediate health and safety risk to residents in care.

Official plan of correction

The licensee will submit planon how facility will ensure staff do not perform treatment which requires an appropriately skilled professional. Submit proof to CCL by POC due date

Deadline recorded: Oct 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87631(a)(3)(B)

Regulation authority

CCR

What the official deficiency says

87631Healing Wounds(a) Except... the licensee shall be permitted... a resident who has a healing wound...(3) Residents with a stage 1 or 2 pressure injury...an appropriately skilled... (B) All aspects... documented in the resident's file.This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. There were no home health logs or staff notes available for R1 at the facility, which posed an immediate health and safety risk to residents in care.

Official plan of correction

The licensee will plan how facility will ensure all aspects of care by home health and staff are documented. Submit proof to CCL by POC due date

Deadline recorded: Oct 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(5)

Regulation authority

CCR

What the official deficiency says

87615Prohibited Health Conditions (a) Persons who require health services for or have a health condition...shall not be admitted or retained in a residential care facility for the elderly: (5) Residents who depend on others to perform...This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. Facility admitted and retained R1 who had no capacity for self-care, without submitting an exception request for the prohibited health condition, which posed an immediate health and safety risk to residents in care.

Official plan of correction

The licensee will submit a plan how facility will ensure that exception requests will be submitted for residents with a prohibited health condition. Submit proof to CCL by POC due date

Deadline recorded: Oct 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1

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 be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interviews and observation, the facility did not provide residents a safe, healthful and comfortable accommodations, as bed bugs were observed and interviews confirmed bed bugs. This posed a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Current Administrator stated that they have the pest control company assess the facility and all resident rooms for pest control. Ongoing service is provided. Administrator will provide invoice copies from 8/2023 to present. Also submit what steps have been taken to rectify the facility pest issues and what actions will be taken to ensure facility is maintained free of pests.

Deadline recorded: May 28, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(b)

Regulation authority

CCR

What the official deficiency says

Safeguards for Resident Cash, Personal Property, and Valuables Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above as it related to former administrator storing/leaving resident's belongings outside in the parking lot to get rid of bed bugs. This posed a potential personal rights risk to residents in care.

Official plan of correction

The current Administrator has agreed to do the following: 1. Submit a Plan of Action, detailing how the facility will ensure that resident personal property is safeguarded. Submit plan to CCLD by 05/24/2024.

Deadline recorded: May 28, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year... This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as the licensee failed to keep medication records for R1, which posed a potential health and safety risk to residents in care.

Official plan of correction

Licensee will submit a Plan of Action, documenting how the facility will maintain medication records. Submit plan to CCL on or before 5/22/2024.

Deadline recorded: May 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(h)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (h) All personnel records shall be retained for at least three (3) years following termination of employment. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as the licensee failed to keep personnel records for S1 and S2, which posed a potential health and safety risk to residents in care.

Official plan of correction

Licensee will submit a Plan of Action, documenting how the facility will maintain personnel records of ex-employees. Submit plan to CCL on or before 5/22/2024.

Deadline recorded: May 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.312(a)

Regulation authority

HSC

What the official deficiency says

§1569.312(a)Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as the licensee failed to provide adequate supervision to R1 who signed out of the facility and never returned, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee will submit a Plan of Action, documenting how the facility will follow-up with residents who do not sign back in after an outing to ensure residents are provided appropriate care and supervision. Submit plan to CCL on or before 5/22/2024.

Deadline recorded: May 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2

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: (1) To have a reasonable level of personal privacy in accommodations …This requirement is not met as evidence by: Based on information obtained through interviews, the administrator searched R1’s dresser and nightstand drawers without prior permission, which poses a potential health, safety and personal rights risk to resident in care.

Official plan of correction

The ED will review the regulations on Residents’ Rights and will email the CCL department a statement of understanding and review of the regulation 87468.2- Additional Personal Rights of Residents in Privately Operated Facilities.

Deadline recorded: May 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(d)

Regulation authority

CCR

What the official deficiency says

Eviction Procedures. (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement is not met as evidenced by: Based on interviews, and record review, licensee did not meet with the section above by not including date, place, witnesses, and circumstances surrounding the concerns of the eviction, which causes a potential personal rights violation to residents in care.

Official plan of correction

Administrator agreed to do the following: 1.Rescind the eviction notice within the next 24 hours. This must be done in writing. Submit proof to CCL by 05/03/2024 2.Create a valid eviction notice for R1 and submit the eviction notice to CCL for prior approval.

Deadline recorded: May 3, 2024. 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

Storage Space: Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on observations, licensee did not comply with section above by not ensuring detergents, cleaning solutions and scissors are kept inaccessible to residents. This poses an immediate risk to residents in care.

Official plan of correction

Administrators agreed to provide in service training to staff and discuss with residents the importance of keeping personal items, which pose a dangerous to clients when accessible before POC due date.

Deadline recorded: Mar 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

80072(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal Rights: Except for children’s..., each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations...and equipment to meet his/her needs.This requirement is not met as evidenced by: Based on record review and interviews, licensee did not comply with section above. R1's prescription order dated on 12/14/2023 and _____ for new wheelchair was not processed in a timely manner. This poses a potential risk to residents in care.

Official plan of correction

Administrators agreed to follow up with medical supply company by upcoming Friday and have proof of outcome or resolution to R1 needs before POC due date

Deadline recorded: Mar 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or Per record review, Virginia Sumulong, aslo known as Virginia De Los Reyes, hired on 9/18/23, has been employed and present at the facility and has not been associated to the facility until it was brought to the Admnistrator's attention today-10/5/23. CIVIL PENALTIES of $500 were assessed

Official plan of correction

The Licensee will ensure that all staff, volunteers or individuals who are subject to a criminal record clearance have received a criminal record clearance and are associated to the facility prior to being present at the facility at all times. Virginia Sumulong was associated to the facility under the name of Virginia De Los Reyes through Guardian during the visit today. ***corrected at the time of the visit****

Deadline recorded: Oct 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(g)(1)

Regulation authority

CCR

What the official deficiency says

87217 (g)(1) Safeguards for Resident Cash, Personal Property, and Valuables. Each licensee shall maintain adequate safeguards and accurate records of cash resources and valuables entrusted to his care, including, but not limited to the following...the resident's signature or mark, or responsible party's full signature...This requirement was not met. Based on record review, no residents’ signatures were observed on the LIC 405 ledgers, which is inconsistent with the facility's policies and procedures. The licensee failed to maintain adequate safeguards and accurate records of cash resources and valuables entrusted to their care, which poses a potential health and safety danger to persons in care.

Official plan of correction

Effective immeadiatly as 09/29/2023: Licensee must maintain a current and accurate account of resident's cash resource by using a ledger (LIC405) for each resident with income, disbursement, and balance with date of transaction, description and signature of the resident and the office representative involved with the transaction. The “petty cash” slips used need to be replaced with a “cash receipt”.

Deadline recorded: Oct 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87216(1)

Regulation authority

CCR

What the official deficiency says

Section 87216 (1) Bonding- Each licensee, other..., shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. The amount of the bond shall be in accordance with the …schedule. This reuirement was not met. Based on record review, the facility failed to maintain sufficient surety bond coverage to safeguard the residents’ resources. The current $11,000 surety bond coverage is not sufficient and needs to be increased for the amount that is being safeguarded. which poses a potential health and safety danger to persons in care.

Official plan of correction

Licensee will submit proof of the amount increase of surety bond per the set schedule to CCLD office by 10/16/2023.

Deadline recorded: Oct 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

387217(c)(1)

Regulation authority

CCR

What the official deficiency says

387217 (c) (1) Safeguards for Resident Cash, Personal Property, and Valuables-Every facility shall account for any cash resources entrusted to the care or control of the licensee or facility staff, (1) Cash resources include … and personal and incidental need allowances from funding sources such as SSI/SSP. This requirement was not met. Based on record review, the withdrawals are not supported, and the facility is to refund the residents accordingly. The documentation submitted and reviewed disclosed that the facility mishandled some of the residents’ funds.

Official plan of correction

Licensee is to refund the residents’ accounts for the amount as listed for each of the sixteen (16) residents. Proof of the refund (copies of cashed checks by residents) must be submitted to the CCLD office by 10/16/2023.

Deadline recorded: Oct 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a)(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. Based on evidence gathered through a medication audit, the licensee did not comply with the section cited above as R1 did not have their medication centrally stored which poses a potential health, safety and personal rights risk to person in care.

Official plan of correction

Administrator will conduct a medication audit for all resident medication which should be accurate and centrally stored. Admininstrator will come up with a plan to check medication is accurate and centrally stored.

Deadline recorded: Jul 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1

Regulation authority

CCR

What the official deficiency says

87468.1 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 be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interviews and observation, the facility did not provide R1 a safe, healthful and comfortable accommodations, as bed bugs were observed and interviews confirmed bed bugs which poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Administrator will have a pest control company assess all resident room for pest control. Additionally, Administrator will come up with a plan to keep the facility free of pest and a plan to offer R1 additional help.

Deadline recorded: Jun 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465

Regulation authority

CCR

What the official deficiency says

87465(h)(2)Incidental Medical and Dental CareThe following requirements shall apply to medications which are centrally stored: ...shall be kept in a safe and locked place that is not accessible to persons other than employees …centrally stored medication. This requirement is not met as evidenced by: Based on interviews and observation the licensee did not comply with the section cited above, as R2’s medication was mixed with R1’s medication, which poses a potential health and safety risk for residents in care.

Official plan of correction

Licensee agrees to conduct staff training to ensure that residents medications are not missmanaged. Proof of training, sign in sheets, and supportive documentaion must be sent to LPA by 04/07/2023.

Deadline recorded: Apr 7, 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 written report shall be submitted … within seven days of the occurrence of any of the events specified ... (D) Any incident which threatens the welfare, safety or health of any resident ... This requirement is not met as evidenced by: Based on record review, and interviews, the licensee did not comply with the section cited above, as R1’s POA and CCLD were not informed of R1’s hospitalization, which poses a potential health and safety risk for residents in care.

Official plan of correction

The licensee has agreed to do the following:1) Inform the CCLD that the Licensee has reviewed the regulation related to reporting requirements and self certify via a letter that they have completed the review, and submit proof via a self-certification letter to CCLD by 03/17/2023.

Deadline recorded: Mar 17, 2023. 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

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following....: (4)To care, supervision, and services that meet their individual needs...and are delivered by staff that are sufficient in numbers,. This requirement is not met as evidenced by: Based on the investigation, licensee did not comply with the section cited above, as staff did not provide adequate supervision, resulting in a resident falling, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Submit a Plan of Action, detailing how staff are trained to respond to resident falls (witnessed and unwitnessed). In addition, detail the facility's protocol surrounding fall prevention. Submit to CCL by 2/24/2023

Deadline recorded: Feb 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211(a)(1)(D) Reporting Requirements. A written report shall be submitted … within seven days of the occurrence of any of the events specified ... (D) Any incident which threatens the welfare, safety or health of any resident ... This requirement is not met as evidenced by: Based on record review, and interviews, the licensee did not comply with the section cited above, as family members and CCLD were not informed of R1’s hospitalization, which poses a potential health and safety risk for residents in care.

Official plan of correction

The licensee has agreed to do the following:1) Inform the CCLD that the Licensee has reviewed the regulation related to reporting requirements and self certify via a letter that they have completed the review, and submit proof via a self-certification letter to CCLD by 01/17/2023.

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

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on interviews, the licensee did not comply with the section cited above as the facility abandoned R1 for 2 days at the hospital which poses an immediate health, safety and personal rights risk to resident in care.

Official plan of correction

Administrator will conduct all staff training on Personal Rights to all staff and submit documentation and attendees to CCL by 02/15/2023.

Deadline recorded: Feb 8, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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 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 in two (2) out of five (5) restrooms where the hot water temperature measured above 120 degree F, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 01/04/2023 Plan of Correction The Administrator agreed to do the following: 1. Staff will adjust the water tank by the end of the day. 2. Keep a water temperature for four (4) rooms (two upstairs, two downstairs) for three days. Submit the water temperature log no later than 1/11/2023.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above, as the laundry rooms on the 1st and 2nd floor were unlocked and there were cleaning supplies and laundry detergent accessible to clients in care, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/04/2023 Plan of Correction The Administrator agreed to do the following: 1. Items were locked during today's visit. Plan of Correction met at this time.

Official classification

Type B

Official code

87303(a)(1)

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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above, as the laundry room flooring on the 2nd floor was unclean, which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 01/09/2023 Plan of Correction The Administrator agreed to do the following: 1. Clean the flooring on the second floor of the laundry room. Submit photographc proof of completion by 1/9/2023

Official classification

Type B

Official code

87211

Regulation authority

CCR

What the official deficiency says

87211(a)(1)(D) Reporting Requirements. A written report shall be submitted … within seven days of the occurrence of any of the events specified ... (D) Any incident which threatens the welfare, safety or health of any resident ... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, as reports were not submitted for incidents to both CCL and Regional Center, which poses a potential health and safety risk for residents in care.

Official plan of correction

The licensee has agreed to do the following: 1) Conduct staff training on incident reporting and submit proof to CCLD by 01/13/2023.

Deadline recorded: Jan 13, 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 written report shall be submitted … within seven days of the occurrence of any of the events specified ... (D) Any incident which threatens the welfare, safety or health of any resident ... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, as reports were not submitted for all of R1’s incidents to both CCL and Regional Center, which poses a potential health and safety risk for residents in care.

Official plan of correction

The licensee has agreed to do the following: 1. Submit incident reports for R1’s incidents and/or hospitalizations for the record. Review the report for exact dates. Submit to CCL no later than 11/11/2022. 2. Conduct staff training on incident reporting and submit proof to CCL by 11/11/2022.

Deadline recorded: Nov 11, 2022. 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

87411(a) Personnel requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on information received, the licensee did not comply with the section cited above, as the facility experienced an incident where there were no staff present in the facility for approximately one-hour, if not longer, which posed an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Submit an updated staffing schedule. Submit a Statement of Understanding, demonstrating how the facility will maintain adequate staffing to meet the needs of the residents and conduct emergency protocol training pertaining to staffing and call offs. Submit proof to CCL by 9/12/2022. An Immediate $500 Civil Penalty was issued during today’s visit.

Deadline recorded: Sep 12, 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. This requirement is not met as evidence by: Based on observation, and interviews: During the physical plant inspection, LPA Urena observed holes in the hallways’ walls and ceilings, as well in residents’ rooms 23 and 20, with some wiring exposed. which poses a potential Health, Safety, and Personal rights risk for persons in care.

Official plan of correction

Licensee will repair the holes in the hallways’ ceiling and walls, and the holes in all residents’ rooms on the first and second floor. Pictures of the hallway and each bedrooms’ walls and ceilings should be submitted as proof correction. This POC has been cleared as of today’s visit.

Deadline recorded: Apr 12, 2022. 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

87411(f) Personnel Requirements - General. 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. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in four out of ten staff (S1, S2, S4, S5), which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator has agreed to do the following: 1. Obtain the health screenings for the four staff, and submit to CCL by 4/22/2022.

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

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411(c)(1) Personnel Requirements - General. Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in three out of ten staff (S2, S3, S5), which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator has agreed to do the following: 1. Obtain the valid first aid certification forms for the three staff, and submit to CCL by 4/22/2022.

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

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465(a)(4) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in one out of nine residents (R5), which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator has agreed to do the following: 1. Locate the medication for Resident #5. Inform CCL when this has happened, but no later than 4/7/2022.

Deadline recorded: Apr 7, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

87463(c) Reappraisals. The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff ... when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first ... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in four out of nine residents (R1, R2, R3, R4), which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator has agreed to do the following: 1. Complete the updated appraisals for the four residents, and submit proof of completion to CCL by 4/22/2022.

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

Official classification

Type A

Official code

87211(c)

Regulation authority

CCR

What the official deficiency says

87211(c) Reporting Requirements. Any suspected physical abuse that does not result in serious bodily injury... shall be reported to the local ombudsman, the licensing agency, and the local law enforcement agency within twenty-four (24) hours. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, as facility staff did not fulfill reporting requirements to appropriate parties, including Mandated Reporter requirements by reporting suspected abuse, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agree to review 87211 Reporting Requirements. Submit memo of understanding regarding reporting requirements, including Mandated Reporting, to CCL via email by 3/4/2022

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

Official classification

Type B

Official code

87468(a)

Regulation authority

CCR

What the official deficiency says

87468(a) 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.. and equipment. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observation, the licensee did not comply with the section cited above, as the facility does not currently have a sufficient 30-Day supply of PPE gear, which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/02/2022 Plan of Correction The Licensee has agreed to do the following: 1.The facility will review their Mitigation Plan submitted to CCLD, and implement all practices adhering to directives given by the Department and the California Department of Public Health as it relates to visitation during COVID-19.

Official classification

Type B

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

87211(a)(2) 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: (2) Occurrences, such as epidemic outbreaks.. which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews, the licensee did not comply with the section cited above, as the facility failed to report between five (5) to six (6) COVID cases within 24 hours to the licensing agency, which poses a potential health and safety risk to residents in care.

Official plan of correction

POC Due Date: 02/02/2022 Plan of Correction The Licensee has agreed to do the following: 1.Submit an incident report pertaining to each COVID case the facility has had for the past month. 2.Submit a statement of understating and reviewal of section 87211(a)(2).

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355(e)(2) Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) 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 S3 and S4 have not been associated to the facility, which poses an immediate health and safety risk to residents in care.

Official plan of correction

POC Due Date: 01/27/2022 Plan of Correction The Licensee has agreed to do the following: 1. Ensure that S1 and S2 are associated to the facility prior to allowing S1 and S2 to return to work. S1 and S2 will not work at the facility until proof of association is obtained.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303(e)(2) 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 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 LPAs observation and interviews, the licensee failed to ensure hot water temperature measured within 105 to 120 degrees Fahrenheit to residents in care due to the facility’s water heater being in need of repairs, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/28/2022 Plan of Correction The Licensee has agreed to do the following: 1. Submit proof of repairs to the facility's water heater. 2. Submit a five (5) day log on hot water temperature.

Official classification

Type B

Official code

87468.1(a)(11)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(11) Personal Rights of Residents in All Facilities: (a) Residents in..facilities for the elderly shall have..personal rights:(11)To have their visitors..permitted to visit privately.. This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews and LPAs observation, the Licensee did not comply with the section cited above, as the facility failed to ensure that residents in residential care where allowed to have their visitors with restrictions in accordance with PIN 22-040-ASC, which poses a potential health and safety risk to residents in care.

Official plan of correction

POC Due Date: 01/31/2022 Plan of Correction No visitation signs were removed during today’s visit. The Licensee has agreed to do the following: 1. All staff will review PIN 22-04-ASC issued on 01/18/2022, and submit staff log to CCLD. 2.Facilty will continue to allow visitation following the updated CDSS PIN, and apply updated changes.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355(e)(2) Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, as S1 and S2 have not been associated to the facility, which which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Executive Director Tillman Pink agreed to do the following: 1. Ensure that S1 and S2 are associated to the facility prior to allowing S1 and S2 to return to work. S1 and S2 will not work at the facility until proof of association is obtained.

Deadline recorded: Dec 21, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87406(a)

Regulation authority

CCR

What the official deficiency says

874069A) Administrator Certification Requirements. (a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, as the current Administrator Certificate for the current Administrator on file is expired, which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Identify a current Administrator; submit the required documents to CCL by 12/31/2021

Deadline recorded: Dec 31, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87224(a)

Regulation authority

CCR

What the official deficiency says

87224(a) Eviction Procedures. The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required… This requirement is not met as evidenced: Based on interview and record review, the licensee did not comply with the section cited above, as the issued eviction notice to R1 was invalid, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator agreed to do the following: 1.Rescind the eviction notice within the next 24 hours. This must be done in writing. Submit proof to CCL by 12/22/2021 2.Create a valid eviction notice for R1 and submit the eviction notice to CCL for prior approval. Notice must be completed no later than 12/31/2021.

Deadline recorded: Dec 22, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355(e)(2) Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, as S1 and S2 have not been associated to the facility since 08/04/21 (S1) and 04/10/20 (S2), which which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Executive Director Tillman Pink agreed to do the following: 1. Ensure that S1 and S2 are associated to the facility prior to allowing S1 and S2 to return to work. S1 and S2 will not work at the facility until proof of association is obtained.

Deadline recorded: Dec 17, 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

1569.69(a)(1) Employees assisting residents with self-administration of medication; training requirements. ... The employee shall complete 24 hours of initial training. ...16 hours of hands-on shadowing training... and 8 hours of other training or instruction ... This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as staff failed to complete all required medication training prior to assisting residents with the self-administration of medication for R1, which poses an immediate health and safety risk to residents in care.

Official plan of correction

S1 and S2 are no longer employed with this community. Facility has ensured that staff complete medication training prior to assisting residents with the self-administration of medication. Plan of Correction met.

Deadline recorded: Nov 9, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(19)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities. (19) To have prompt access to review all of their records and... photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies. This requirement was not met as evidenced by: Based on interviews, and record review, the licensee did not meet the above section by failing to produce requested records resulting in a potential risk to the personal rights of residents in care.

Official plan of correction

The Licensee has agreed to do the following: 1. Third party training and acknowledgment in Title 22, Division 6, Chapter 8. 87468.2 Additional Personal Rights of Residents in Privately Operated Facilities by 10/29/2021.

Deadline recorded: Oct 29, 2021. A deadline is not proof that correction was completed.