RESIDENCES AT ROYAL BELLINGHAM, THE

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning 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. 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' medication refusal notifications were not properly documented which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/22/2026 Plan of Correction The Licensee will provide staff training on resident observations, notifications of physicians and reponsible parties, and maintaining documentations and provide proof to CCLD by POC due date.

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 above cited section in R1 developed 2 Stage II pressure injuries which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee will provide staff training regarding documentation, reporting, and pressure injuries and will provide proof to CCLD by POC due date.

Deadline recorded: Apr 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87631(a)(3)

Regulation authority

CCR

What the official deficiency says

(a)Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances: (3) Residents with a stage one or two pressure injury must have the condition diagnosed by a physician or an appropriately skilled professional. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section in R1 developed 2 Stage II pressure injuries that were not treated which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee will provide staff training on identifying pressure injuries and reporting to facility management and will provide proof to CCLD by POC due date

Deadline recorded: Apr 16, 2026. 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... Hot water temperature controls shall be maintained to... 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: Based on observation, the licensee did not comply with the section cited above in 6 resident restroom sinks measured above the required range which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The Licensee will lower the boiler and re-test the 6 resident restroom sinks and provide proof to CCLD by POC due date.

Deadline recorded: Mar 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(20)

Regulation authority

CCR

What the official deficiency says

(a) In addition to the rights listed in Section 87468.1... residents... shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions... This requirement was not met as evidenced by: Based on interview and record review the Licensee did not comply with the section cited above in the facility refused R1's readmission upon hospital discharge which poses/posed an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee will re-admit R1 to the facility from the hospital and send proof to CCLD by POC due date.

Deadline recorded: Mar 11, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(d)

Regulation authority

CCR

What the official deficiency says

(d) …if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident’s needs as identified in the pre-admission appraisal… and providing the other basic services specified below, either directly or through outside resources. This requirement was not met as evidenced by: Based on interview and record review, the Licensee did not comply with the above cited section as the facility did not follow R1's care plan which poses/posed a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee consulted with a physical therapist on 01/13/2026 and provided CCLD clinical notes. POC Cleared.

Deadline recorded: Jan 13, 2026. 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

(a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met as evidence by: Based on interview and observation, the Licensee did not comply with the above cited section in R1 had cockroaches in their room which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The facility removed the dresser during the visit and will send proof of complete pest control treatment by POC due date.

Deadline recorded: Jan 26, 2026. 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

Deficiency rescinded - intentionally left blank.

Official plan of correction

Deficiency rescinded - intentionally left blank.

Deadline recorded: Jan 13, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(a)

Regulation authority

CCR

What the official deficiency says

(a) The services provided by the facility shall be conducted… to continue and promote, to the extent possible, independence and self-direction.... Such persons shall be encouraged to participate… as their conditions permit in daily living activities both in the facility and in the community. This requirement was not met as evidence by: Based on interview and record review, the Licensee did not comply with the above cited section as R1 was not assisted with daily living activities in the community which poses/posed a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee hired a Resident Care Coordinator to oversee residents' needs and has since assisted R1 into the community. The Licensee will provide CCLD proof of the Care Coordinator's employment by POC due date.

Deadline recorded: Jan 6, 2026. 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

(a) Each licensee shall furnish to the licensing agency such reports…including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency… within seven days of the occurrence of any of the events specified in (A) through (D) … This requirement was not met as evidenced by: Based on interview and record review the Licensee did not comply with the above cited section as CCL did not receive a report/notification of an unwitnessed fall which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

The Licensee plans to continue utilizing Genuis App in addition to emailing CCL incident reports. An in-service staff training will also be conducted on CCL reporting requirements and will be provided to CCLD by the POC due date.

Deadline recorded: Dec 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.153(d)

Regulation authority

HSC

What the official deficiency says

(d) A written resident personal property inventory is established upon admission and retained during the resident's stay in the residential care facility for the elderly. Inventories shall be written in ink, witnessed by the facility and the resident or resident's representative, and dated. … This requirement was not met as evidenced by: Based on interview and record review the Licensee did not comply with above cited section in the facility did not complete a personal property inventory written in ink upon admission which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

The Licensee removed the disclaimer from LIC 621 and will inventory resident belongings upon admission. An in-service staff training will also be conducted on admisison precedures and will be provided to CCLD by the POC due date.

Deadline recorded: Dec 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition ...(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on interviews, facility video footage, and records review, the licensee did not comply with the section cited above. S1 sexually abused R1 and R2, which posed an immediate health and safety risk to residents in care.

Official plan of correction

S1 no longer works at the facility has been removed from roster as of 10/13/2025. The Licensee will send LPA a statement of understanding by POC of the cited regulation, Conduct abuse prevention training for all employees, with a specific focus on sexual abuse. The Licensee must submit proof to LPA of the completed training, including materials provided to staff. All staff shall sign an acknowledgment form confirming participation, and the signed forms must be maintained in each staff member's file by 11/11/2025.

Deadline recorded: Oct 28, 2025. 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 Reporting Requirements (c) Any suspected physical abuse... shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours ... This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above. Administrator submitted the incident report late and with incorrect information, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Administrator agrees to review 87211 Reporting Requirements. Submit memo of understanding regarding reporting requirements, including Mandated Reporting, to CCL, LPA Mosley via email by 07/02/2025.

Deadline recorded: Jul 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(d)(2)(5)

Regulation authority

CCR

What the official deficiency says

87405(d)(2)(5) Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(5) Good character and a continuing reputation of personal integrity.This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above. Administrator did not follow the reporting requirements for suspected abuse which posed an immediate health and safety risk to residents in care.

Official plan of correction

Administrator agrees to review Reg.87405(d)(2)(5) Submit memo of understanding regarding regulation by 07/02/2025 and train staff on 87405(d)(2)(5) and submit proof to CCLD , LPA Mosley by 07/16/2025.

Deadline recorded: Jul 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

87307(a) Personal Accommodations and Services (a)Living accommodations and grounds shall ...comfortable living accommodations and privacy for the residents, staff... (1) There shall be ...prevent such activities from interfering with other functions. This requirement is not met as evidenced by: Based on interviews and observation, the licensee did not comply with the section cited above. Staff are sleeping in the basement room which also serves as a lounge for employees, which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator agreed to not allow staff sleeping in this area and clear out all furniture (bed) and submit photos to LPA Mosley by 07/16/2025. Licensee/Administrator agreed to submit 24hr staffing schedule (LIC500) by POC date.

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

Official classification

Type A

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities (a) (a) In addition ...(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on interviews, facility video footage, and records review, the licensee did not comply with the section cited above. S2 sexually assaulted R1, which posed an immediate health and safety risk to residents in care.

Official plan of correction

The Licensee has suspended S2 and removed them from the facility roster as of 06/05/2025. The Licensee will conduct abuse prevention training for all employees, with a specific focus on sexual abuse.The Licensee must submit proof to LPA ... of the completed training, including materials provided to staff. All staff shall sign an acknowledgment form confirming participation, and the signed forms must be maintained in each staff member's file by POC date 07/16/2025

Deadline recorded: Jul 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in two (2) out of six (6) staff did not have a completed health screening signed by a physician, and one (1) out of six (6) staff did not have a TB test which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2025 Plan of Correction The Executive Director will have staff visit their health care providers within the next 48 hours to complete their health screening and TB test. The executive Director will send the health screening and TB test result to CCLD by the POC due date.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in one (1) out of five (5) residents did not have a TB which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/06/2025 Plan of Correction The Executive Director will have a health care provider come to the facility within the next few days to administer the TB test to the resident and will send CCLD the results by the POC due date.

Official classification

Type B

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements (b)The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Based on LPA and witness observation, interviews, file review and pictures obtained, the licensee did not comply with the section cited above as roaches were observed in kitchen areas. This poses a potentail health and safety risk to persons in care.

Official plan of correction

Licensee will ensure kitchen will be thoroughly cleaned and sanitized, will submit a plan for the next 3 months to ensure all regular and preventive professional treatments are taken. Administrator will submit proof to CCL by 03/28/2024.

Deadline recorded: Mar 28, 2025. 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 interviews, 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

The licensee will schedule training on Mandated Reporting Requirements for all staff. Training must be conducted by an outside vendor. Submit training date to CCL by Training must be conducted within the next 14 days. Submit confirmation of training, sign in sheet and training materials.

Deadline recorded: Jan 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)(3)

Regulation authority

CCR

What the official deficiency says

87463(a)(3) Reappraisals(a)The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a… This requirement is not met as evidenced by: Based on record review, R1’s Reappraisal was not updated when R1 began drinking alcohol, smoking marijuana and had a change of mental condition, which posed a potential health and safety risk to residents in care.

Official plan of correction

The licensee will submit a plan, detailing how the facility will maintain compliance of 87463(a)(3). Submit to CCL by due date

Deadline recorded: Jan 19, 2024. 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

A written report shall be submitted to licensing agency and to the person reponsible for the resident within seven days of the occurrence of any of the events ...if any; and disposition of the case. This requirement is not met as evidenced by: Based on interviews and record review, license did not comply with the section cited above as R1’s responsible party was not notified about an unwitnessed fall, which poses a potential health and safety risk to residents in care.

Official plan of correction

The Licensee agree to submit a statement of understanding, detailing how the facility will maintain compliance of 87211(a)(1) and submit to LPA via email by EOD 03/31/2023.

Deadline recorded: Mar 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(d)(1)(B)

Regulation authority

CCR

What the official deficiency says

87224 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. (1) The notice to quit shall include the following information: (B) Resources available to assist in identifying alternative housing and care options which include, but are not limited to, the following: 1. Referral services that will aid in finding alternative housing. 2. Case management organizations which help manage individual care and service needs.

Official plan of correction

Licensee will review 87224 Eviction Procedures and submit a written statement of understanding the requirements to CCL on or before 3/15/2023. This requirement is not met as evidenced by: Based on documents obtained and interviews with staff and R1, R1 was served an unlawful eviction notice on 1/7/2022, which poses a potential health and safety risk to residents in care.

Deadline recorded: Mar 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)(3)

Regulation authority

CCR

What the official deficiency says

87463(a)(3) Reappraisals. (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes...(3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition... This requirement is not met as evidenced by: Based on interviews and record review, licensee did not comply with the section cited above as R1's reappraisal was not updated to reflect change of condition after being discharged from the hospital, which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to submit a Statement of understanding, detailing how the facility will maintain compliance of 87463(a)(3) and submit to LPA via email by EOD 3/10/2023.

Deadline recorded: Mar 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights (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, furnishings and equipment. This requirement is not met as evidenced by: Based on interviews with staff and R1, R1 was not bathed for at least a week and did not have a change of socks in at least a week, which poses a potential health and safety risk to residents in care.

Official plan of correction

The ED will train staff regarding bathing and clothing changes. If a resident refuses, staff must notify management so they can make other attempts and/or notify responsible parties and physicians. A copy of the training will be provided to CCL by 07/20/2022.

Deadline recorded: Jul 20, 2022. A deadline is not proof that correction was completed.

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 in the section cited above due to accessible tools and sharps in the courtyard, which poses an immediate health and safety risk to residents in care.

Official plan of correction

POC Due Date: 04/22/2022 Plan of Correction The Administrator agreed to do the following: 1. Secure the items. Inform the LPA as to when this takes place, no later than 4/22/2022 (end of day).

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

(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, furnishings and equipment. 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 staff were observed without the appropriate face covering, which poses a potential personal rights risk to residents in care.

Official plan of correction

POC Due Date: 04/29/2022 Plan of Correction The Administrator agreed to do the following: 1. Hold an in-service training with all staff, reviewing masking guidelines. Submit sign in sheet to CCL no later than 4/29/2022.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

87615(a)(1) Prohibited Health Conditions. (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained...: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as R1 was retained with an unstageable pressure injury and was hospitalized with multiple deep tissue pressure injuries, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Schedule a training regarding Pressure Injuries and Healing Wounds. Verification of scheduled training with the trainer’s credentials will need to be submitted by 4/25/2022 and completion of training must be submitted no later than 5/13/2022. An immediate civil penalty of $500 is also assessed.

Deadline recorded: Apr 25, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

8735(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 was not associated to the facility until 12/23/21, however S1 has been working at the facility since approximately 11/16/21, which which poses an immediate health and safety risk to residents in care.

Official plan of correction

S1 was associated to the facility by the facility management during LPAs visit.

Deadline recorded: Dec 23, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

87411(f) Personnel Requirements - General. 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...This requirement is not met as evidenced by: S1 was missing a health screening, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator will remove S1 from the schedule until a health screening is obtained. Administrator will provide a copy of S1's health screening to CCL on or before 12/30/21.

Deadline recorded: Dec 30, 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

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 was not met as evidenced by: Licensee failed to keep the carpet in the unit of R1 clean and well kept. During the investigation LPA observed the carpet to have multiple stains in various areas. This poses as a potential health and safety riske to the residents in care.

Official plan of correction

LIcensee agreed to either have carpet cleaned or replaced by the POC date. Licensee will send pictures of cleaned or newly installed floor to LPA via email by POC date.

Deadline recorded: Sep 17, 2021. A deadline is not proof that correction was completed.