FOUR DIAMONDS

Official classification

Type B

Official code

1569.626(b)

Regulation authority

CCR

What the official deficiency says

Advertising for special care, special programming, or a special environment for elderly with dementia; training requirements. All residential care facilities for the elderly that advertise or promote special care, special programming, or a special environment for persons with dementia, in addition to complying with the training requirements described in Section 1569.625, shall meet the following training requirements for all direct care staff: (b) Eight hours of in-service training per year on the subject of serving residents with dementia. 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 that proof of staff training was not available for review, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/04/2025 Plan of Correction Licensee shall submit proof that all staff have received 8 hours of in-service training on the subject of serving residents with dementia.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section above; resident (R6's) Tamsulosin .4mg & Tylenol have not been refilled, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/21/2025 Plan of Correction Administrator shall: 1. Submit proof that R1’s medications will be obtained by tomorrow. 2. Submit by tomorrow a written plan that addresses centrally stored record keeping/inventory protocols, refill procedures, and facility auditing of medications. 3. Submit proof of staff training by 11/21/2025.

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 that residents (R1- R5) are missing file documents i.e., Pre-Admission Appraisal, ID and Emergency Information, Safeguards for property/valuables, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/04/2025 Plan of Correction Administrator shall submit copies of residents (R1- R5's) required file documents listed on LIC 811 provided.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. 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 because resident's R1, R2, & R3 do not have Pre-Admission Appraisals on file, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/04/2025 Plan of Correction Administrator shall submit copies of R1, R2, and R3's Resident Appraisals.

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 record review, the licensee did not comply with the section cited above in that R1's Medical Assessment dated 9/29/2025 is missing TB exam/ results, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/04/2025 Plan of Correction Administrator shall submit proof that R1 received a TB exam/results.

Official classification

Type B

Official code

87463(h)

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. 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 that R3's Physician's Report is dated 1/17/2024, R4's Physician's Report is dated 8/30/2024, R5's Physician Report is dated 5/10/2023 & R6's Physician's Report is dated 2/5/2024, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/04/2025 Plan of Correction Administrator shall submit copies of R3, R4, R5, and R6's updated Medical Assessments.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

Fire Safety 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 that the front door has a slip latch lock on the top of the door above the auditory alarm that was turned off, as well as a locking mechanism latch by the door handle, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/10/2024 Plan of Correction Licensee/Administrator shall remove the door lock immediately as it poses a Fire Safety hazard. During the visit, staff arrived and removed the locking mechanisms. Licensee shall train all caregiver staff. Submit proof by TOMORROW.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

(a) Each facility shall have and maintain a current, written definitive plan of operation. 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: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, all resident admission agreements have an Addendum that was not approved by CCL that states the refund policy as " No refund shall be given ...any and all payments made are considered monthly and never daily " , which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/23/2024 Plan of Correction Licensee/Administrator shall submit a written plan of correction that addresses the non-approved Addendum to the Admission Agreement. Additionally, all resident's responsible parties must be issued written notification that the Addendum that was originally issued is void.

Official classification

Type B

Official code

87506(b)(13)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or the services he needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the facility is using and ARF Physician's Report form for R1 instead of an RCFE form and hospice resident (R4's) file is missing MD report and needs and services plan, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/23/2024 Plan of Correction Administrator shall submit a copy of R1's updated Physician's Report, and Physician's Report and Service Plan for R4.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. 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 that all resident files did not have pre-admission appraisals, only R5 has a resident appraisal, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/23/2024 Plan of Correction Administrator shall ensure all resident files have Resident Appraisals. Submit copies of R1- R4's Resident appraisals.

Official classification

Type B

Official code

87407

Regulation authority

CCR

What the official deficiency says

Administrator Recertification Requirements (d) To apply for recertification prior to the expiration date of the certificate, the certificate holder shall submit to the Department’s Administrator Certification Section, post-marked on, or up to ninety (90) days before, the certificate expiration date: 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 that Administrator certificate expired 4/23/2024 and recertification documents were sent until 9/3/24,which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/09/2024 Plan of Correction Administrator showed LPA Guardian proof that shows recertification is pending. Cleared during the visit.

Official classification

Type B

Official code

87618(b)(3)(I)

Regulation authority

CCR

What the official deficiency says

Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (I) Equipment shall be removed from the facility when no longer in use by the resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, licensee has 3 oxygen tanks that are no longer being used in the garage, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/10/2024 Plan of Correction Administrator agreed to contact company for removal of oxygen tanks. Submit proof by tomorrow.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, resident room #3 has a toilet leak and walls are in disrepair, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/23/2024 Plan of Correction Submit picture proof of correction.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 that Staff (S2's) medications pills and R3's Cholestyramine Light Powder were unlocked in a kitchen cabinet, and R2's Betamethasone Dipropionate Lotion & Hydrocortizone Cream were unlocked in the living room recliner, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/01/2023 Plan of Correction Administrator agrees to submit a written plan of correction that states how the deficiency was corrected. In addition, all staff shall receive Title 22 Incidental Medical and Dental Care Services regulation training. Submit proof of training by tomorrow.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. 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 that R1's Quetiapine Fumarate 25 mg is a PRN med, but is being given as a routine noon medication, and the physician order for Vitamin C is 500 mg, but 1000 mg is being given, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/01/2023 Plan of Correction Administrator agrees to: 1. Submit proof of staff training. 2. Submit a written plan that addresses centrally stored record keeping/inventory protocols.

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section above in that R1 OTC Calcium 1200 mg, B-12 (5000 mg), and Vitamin K do not have a physician order and it is not documented on Centrally Stored Records, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/01/2023 Plan of Correction Administrator agrees to: 1. Obtain a physician order for R1's OTC medications 2. Update Centrally Stored Records 3. Conduct staff training and submit proof to LPA by tomorrow.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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 that residents (R1, R2, & R4) have full bed rails without a physician order. R1 is receiving palliative care and R2 & R4 are not enrolled in hospice care, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/01/2023 Plan of Correction Administrator agrees to: 1. Remove the full rails from residents beds and obtain by tomorrow a physician order for half bed rails for residents R1, R2, & R4.

Official classification

Type B

Official code

1569.695(a)

Regulation authority

HSC

What the official deficiency says

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in that LIC 610D Emergency Disaster Plan was not posted, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/07/2023 Plan of Correction Administrator agrees to submit a copy of LIC 610D Emergency Disaster Plan.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

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 observation, the licensee did not comply with the section cited above in that the kitchen sink water temperature was 126.7 DF, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/24/2023 Plan of Correction Administrator agrees to conduct staff training and submit: 1. Hot water temperature log tested 3 times today and each shift tomorrow 2. Written plan and proof of staff training

Official classification

Type B

Official code

87412(c)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement was not met as evidenced by: Based on interviews, observations, and records review, it was determined the licensee failed to maintain personnel records verification of required staff training and updated COVID-19 training for all staff currently employed.

Official plan of correction

Licensee will provide in-service training for COVID-19 infection control practices and other required training for current staff. Copies of training certificates, training material, and sign in sheet for in-service training on COVID-19 prevention will be faxed to LPA by the POC due date.

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

Official classification

Type B

Official code

87470(c)(1)(C)(3)

Regulation authority

CCR

What the official deficiency says

87470 Infection Control Requirements (c) An Infection Control Plan shall be developed by the licensee...(1) The Infection Control Plan shall include all of the following:(C)An Infection Control Training Plan. (3.)The description of initial and ongoing training... This requirement was not met as evidenced by: Based on interviews, observations, and records, review, it was determined that the licensee who is also the infection preventionist has failed to provide ongoing training to staff regarding infection prevention of communicable diseases, including COVID-19.

Official plan of correction

Licensee will provide in-service training for COVID-19 infection control practices and other required training for current staff. Copies of training certificates, training material, and sign in sheet for in-service training on COVID-19 prevention will be faxed to LPA by the POC due date.

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

Official classification

Type A

Official code

87355(c)(1)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance. A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department.A signed Criminal Background Clearance Transfer Request, LIC 9182 (Rev. 4/02). This requirement is not met as evidenced by: Based on records reviews Staff (S3) is not associated to the facility. S1 began working at the facility yesterday June 14, 2022.This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee shall ensure that all staff complete a criminal background transfer request and are associated to the facility prior to employment. Staff cannot return to work until they are associated to the facility. Submit form LIC9182 by tomorrow's POC due date.

Deadline recorded: Jun 16, 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

87705(f)(1) Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This poses and immediate health and safety risk to residents in care. Based on observation 2 knives were observed on top of the counter, 1 on the dish rack, and the sharps/knives drawer was unlocked. Pictures were taken. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee shall ensure all sharps are locked and inaccessible to residents in care at all times. Staff locked knives immediately. ****Cleared during the visit.

Deadline recorded: Jun 15, 2022. A deadline is not proof that correction was completed.