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) (interview) (record review)], the licensee did not comply with the section cited above in that one of the resident's room in the new dwelling unit from the newly constructed garage conversion does not have a fire clearance which poses an immediate health, safety or personal rights risk to residents in care.
Official plan of correction
POC Due Date: 05/20/2026 Plan of Correction Licensee/administrator to submit a completed STD850 and LIC 200 to CCLD by POC due date.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(h)(1)
- Regulation authority
- CCR
What the official deficiency says
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation. interview, record review, the licensee did not comply with the section cited above in that a resident diagnosed with dementia did not have a current medical assessment on file, last medical assessment on file was 08/02/2024 which poses/posed a potential health, safety or personal rights risk to residents in care.
Official plan of correction
POC Due Date: 05/29/2026 Plan of Correction Licensee/administrator to submit an updated physician's report to CCL/LPA by POC due date.
Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87208(a)(7)(A)
- Regulation authority
- CCR
What the official deficiency says
87208 Plan of Operation (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (7) Sketches, showing dimensions, of the following: (A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents and for bedridden residents, other than for a temporary illness or recovery from surgery as specified in Sections 87606(d) and (e) This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above in that the facility sketch on the plan of operation and submitted to CCLD did not match the actual lay out of the facility due to a recent construction of garage conversion which poses/posed a potential health, safety or personal rights risk to residents in care.
Official plan of correction
POC Due Date: 05/29/2026 Plan of Correction Licensee/administrator shall update the plan of operation, submit the necessary requirements such as building permits, along with the updated sketch. In addition, administrator shall submit a signed self certification acknowledging understanding of Title 22 Regs, 87208 to CCLD by POC due date.