Staffing, personnel, and trainingType A
- Official classification
- Type A
- Official code
- 87411(a)
- Regulation authority
- CCR
What the official deficiency says
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in the facility did not take measures to ensure R2 was not being administered duplicate medications prescribed by different parties which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/30/2026 Plan of Correction The Licensee will contact the physician and psychiatrist to ensure the correct medications/orders are prescribed/updated for R2 and will provide proof from both parties verifying the updated orders to CCLD by the POC due date.
Incident reportingType B
- Official classification
- Type B
- Official code
- 87211(g)
- Regulation authority
- CCR
What the official deficiency says
(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in the Department did not receive notification of an Administrator change which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2026 Plan of Correction The Licensee will provide CCLD the Administrator's records to process the change by POC due date.
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87307(a)(2)(B)
- Regulation authority
- CCR
What the official deficiency says
(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: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in staff utilized residents' private restroom which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2026 Plan of Correction The Licensee will have the staff shower in an alternate location. The Licensee will review regulations and provide a statement of understanding by POC due date.
Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87506(a)
- Regulation authority
- CCR
What the official deficiency says
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in residents' records were not complete with signatures which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2026 Plan of Correction The Licensee will obtain signatures on all documents and provide them to CCLD by POC due date.
Licensing and administrationType B
- Official classification
- Type B
- Official code
- 87109(b)
- Regulation authority
- CCR
What the official deficiency says
(b) The Licensee shall notify the licensing agency… at least thirty (30) days prior to the transfer of the property or business, or at the time that a bona fide offer is made… 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 by not notifying the Department of the change of ownership which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2026 Plan of Correction The Licensee will review regulations and submit a statement of understanding to CCLD by POC due date.
Background checksType A
- Official classification
- Type A
- Official code
- 87355(e)
- 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: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in the new Administrator was not associated which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/30/2026 Plan of Correction The Licensee will associate the Administrator and provide CCLD proof by POC due date.
Fire safety and emergency preparednessType A
- Official classification
- Type A
- Official code
- 87203
- Regulation authority
- CCR
What the official deficiency says
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. 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 the fire exttinguisher was not serviced or re-purchased annually which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/29/2026 Plan of Correction The Licensee purchased a new fire extinguisher during the visit. POC cleared.