Fire safety and emergency preparednessType A
- Official classification
- Type A
- Official code
- 87202(a)
- Regulation authority
- CCR
What the official deficiency says
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in the garage was utilized as a live-in staff room which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/19/2025 Plan of Correction The Licensee will request an updated fire clearance to include the staff room in the garage. The Licensee will submit an LIC 200 and updated floor plan to CCLD by POC due date.
Facility condition and maintenanceType A
- Official classification
- Type A
- Official code
- 87303(e)(4)
- Regulation authority
- CCR
What the official deficiency says
(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 2 restrooms did not have a grab bar in the shower which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/19/2025 Plan of Correction The Licensee will install a grab bar in the hallway restroom/s shower and send CCLD proof by POC due date.
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 in 1 out of 2 restrooms had accessible cleaning supplies under the sink which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/18/2025 Plan of Correction The Administrator installed a lock during the visit. POC cleared.
Records and plan of operationType A
- Official classification
- Type A
- 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 interview and record review, the licensee did not comply with the section cited above in 4 out of 5 residents did not complete or maintained files which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/19/2025 Plan of Correction The Licensee will obtain signatures, complete updated Appraisals, and schedule Physician's assessments and send proof to CCLD by POC due date.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(d)
- Regulation authority
- HSC
What the official deficiency says
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. 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 emergency disaster plan was not reviewed annually which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/25/2025 Plan of Correction The Licensee will review regulations and submit a statement of understanding by 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
(a) Living accommodations and grounds shall be related to the facility's function... (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 interview, the licensee did not comply with the section cited above in the private resident restroom was utilized by all residents and staff which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/02/2025 Plan of Correction The Licensee will review regulations and submit a statement of undertsnaing by POC due date.