GREENLEAF COURT SENIOR LIVING, LLC

Official classification

Type B

Official code

1569.157(c)

Regulation authority

HSC

What the official deficiency says

Resident-oriented facility council. If a resident council submits written concerns or recommendations, the facility shall respond in writing regarding any action or inaction taken in response to those concerns or recommendations within 14 calendar days. This requirement was not met evidenced by: Based on record review, the resident council had a meeting on May 20, 2026. On June 4, 2026 LPA obtained copies of the Resident Council Meeting Minutes. No proof of a written response was provided to LPA on that day. The response obtained today is not dated. This poses a potential health, safety, and personal rights risks to persons in care.

Official plan of correction

Executive Director agreed to submit a written plan of correction addressing resident council written responses.

Deadline recorded: Jul 24, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(3)(C)

Regulation authority

CCR

What the official deficiency says

(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. 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 beds in rooms 106, 110, 127, 209, 247 did not have mattress pads, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/05/2026 Plan of Correction Executive Director purchased mattress pads during the visit. Please submit a written plan of correction and proof of housekeeping and caregiver training in regulation 87307.

Official classification

Type B

Official code

87555(b)(28)

Regulation authority

CCR

What the official deficiency says

(28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. 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 refrigerator tray had blood from a ground beef bag that was placed on the tray to thaw on 4/17/26; the ground beef was gray in color in some areas, which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/05/2026 Plan of Correction Executive Director agreed to conduct an in-service for all kitchen personnel iin regulation 87555. Submit proof of training.

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 resident (R5's) last medical assessment on file is dated 1/11/2024, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/05/2026 Plan of Correction Executive Director agreed to submit R5's updated Medical Assessment.

Official classification

Type B

Official code

87303(e)(4)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation. Grab bars shall be in each toilet, bathtub and shower used by residents. This requirement was not met evidenced by: This deficiency was evidenced by the following: A total of 36 resident rooms and public restroom were toured. There were no grab bars near the toilets. There is a non-ambulatory and bedridden fire clearance. This poses a potential health, safety, and personal rights risks to persons in care.

Official plan of correction

Facility shall ensure all toilets used by residents have grab bars installed. Submit proof of correction.

Deadline recorded: Apr 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met evidenced by: During the 2/25/2026 Town Hall meeting, resident (R1) was humiliated by a staff person when they brought up incontinence wipes packs being left out and not put away by staff. This poses a potential health, safety, and personal risk to persons in care.

Official plan of correction

Executive Director agreed to provide Personal Rights and Price Schedule training to Administration and caregiver staff. Submit proof of training.

Deadline recorded: Mar 31, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(b)(2)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation. A comfortable temperature for residents shall be maintained at all times. The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement was not met evidenced by room inspections of 2nd floor rooms conducted on 5/23/25 and today. Room 207's thermostat read 62DF, and the room controls many rooms located in the 2nd floor. This poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

Executive Director stated and agreed to submit proof of completed air conditioning service request.

Deadline recorded: Oct 14, 2025. 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

Maintenance and Operation. 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 evidenced by: Based on observation, the dining room laminate flooring is raised and in disrepair. This poses a potential health, safety, and personal risk to persons in care.

Official plan of correction

Executive Director stated and agreed to submit picture proof evidence and a copy of the completed work order.

Deadline recorded: Oct 14, 2025. 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

Maintenance and Operation. 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 evidenced by: Based on observation, resident (R1's) room is infested with cockroaches. During 5/16/25 visit the room had dead and alive cockroaches, maggots, unswept floors, food on the floor/tables, clutter, and excessive amounts of personal belongings on the floor. This poses a potential health and safety risk to persons in care.

Official plan of correction

Executive Director Harrison agreed to submit a written plan of correction, proof of staff in-service training, pest control service plan for R1's room., and picture proof evidence that R1's room was cleaned. Proof of completed plan of correction was submitted. *Citation is cleared.

Deadline recorded: Jun 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(f)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation. All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. This requirement was not met evidenced by: Based on physical plant observation and interviews conducted on 5/16/25, R1's room had a strong odor of pet feces and urine. Pet feces was observed in the patio area and pet urine was on R1's room and temporary room. This poses a potential health and safety risk to persons in care.

Official plan of correction

Executive Director Harrison agreed to conduct staff training in regulation 87303, and pet services job responsibilities for applicable staff. Proof of completed plan of correction was submitted. *Citation is cleared.

Deadline recorded: Jun 26, 2025. 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

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 standard is not met as evidence by: LPA conducted a tour of the second floor common bathroom and observed the fan above the sink had lint on the lid, the fan inside the shower was non-operational and the tile in the shower needs a deep cleaning (half bottom of shower grout is darker).

Official plan of correction

Administrator to provide proof of the shower fan repairs and cleaning, the cleaning of the shower tile grout and a written statement as to how this facility will remain in compliance with this regulation to LPA Irra by POC due date.

Deadline recorded: Jun 13, 2025. 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

Reporting Requirements: Each licensee shall furnish to the licensing agency ... A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below..... This requirement was not met evidenced by: Based on record review, on 3/9/25 staff were informed that R1 was being financially abused by social media " friends " , but the facility did not submit an SOC 341 or incident report to CCL. This week staff were informed of another financial abuse incident. This poses a potential health and safety risk.

Official plan of correction

Executive Director agreed to provide a written plan of correction that includes: 1. In-service training in reg. 87211 2. Copy of facility reporting procedures, and staff protocol re: SOC 341 reporting. 3. Submit to CCL a copy of SOC 341 about most recent financial abuse incident.

Deadline recorded: May 27, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services. The following space and safety provisions shall apply to all facilities: The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met evidenced by: Based on observation and tour of physical plant, LPA observed unswept floors, food on the floor/tables, clutter, and exessive amounts of personal belongings on the floor/ This poses a potential health and safety risk to persons in care.

Official plan of correction

Executive Director agrees to: 1. Conduct an in-service training with all housekeeping and caregiver staff that outlines policies and procedures to maintain clean and sanitary conditions in the facility. 2. Provide a photograph of R1's room.

Deadline recorded: May 27, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(f)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation. All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. This requirement was not met evidenced by: Based on physical plant observation and interviews, R1's room had a strong odor of pet feces and urine. Pet feces was observed in the patio area and pet urine was on R1's room and temporary room. This poses a potential health and safety risk to persons in care.

Official plan of correction

Executive Director agrees to conduct staff training in regulation 87303, and pet services job responsibilities for applicable staff. Submit proof of staff training.

Deadline recorded: May 27, 2025. 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

Maintenance and Operation. 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 evidenced by: Based on observation, resident (R1's) is infested with cockroaches. During today's visit, the room had dead and alive cockroaches, as well as maggots. This poses a potential health and safety risk to persons in care.

Official plan of correction

Executive Director agrees to submit a written plan of correction, proof of staff in-service training, and pest control service plan for R1's room.

Deadline recorded: May 27, 2025. 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 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 8 out 18 rooms had water temperature above 120 DF, ranging from (125.4 DF - 137.6 DF), which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/07/2025 Plan of Correction Staff adjusted the hot water temperature during the visit. Please submit a hot water temperature log showing that the water was tested today and tomorrow, and it met the 105-120 DF range.

Official classification

Type B

Official code

87307(a)(3)(C)

Regulation authority

CCR

What the official deficiency says

(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited. 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 beds in rooms 204, 205 & 209 did not have mattress pads, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/20/2025 Plan of Correction Executive Director shall submit self certification and proof of evidence showing rooms 204, 205 & 209 have mattress pads.

Official classification

Type B

Official code

87555(b)(28)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. 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 11 chocolate pudding glass cups were observed uncovered in the refrigerator, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/20/2025 Plan of Correction Executive Director agreed to submit a written plan of correction and proof that all kitchen staff have been trained on regulation 87555 General Food Service Requirements, and new Food Services Manager receives additional job training.

Official classification

Type B

Official code

87464(f)(6)

Regulation authority

CCR

What the official deficiency says

Basic Services. Basic services shall at a minimum include: Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met evidenced by: Based on interviews conducted and record review, the findings indicate that resident (R1) missed 2 required pre-surgery appointments during the past week, because the facility did not ensure R1 was transported to appointments via facility bus, sister community transport, Dial-A-Ride, or other alternate arrangement. This poses a potential health and safety risk to persons in care.

Official plan of correction

Licensee shall ensure the Residency Agreement is adhered to, makes available transportation to medical appointments, and a contingency plan is in place when 3rd party transportation services are not able to transport residents. Submit a written plan of correction.

Deadline recorded: Dec 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(g)(1)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation .Facilities which have machines and do their own laundry shall: Have adequate supplies available and equipment maintained in good repair. This requirement was not met evidenced by: Based on interviews and observation, the 2nd floor Resident Laundry Room has a dryer that is in disrepair. During the inspection, LPAs also observed the basement washer in disrepair. Both have been in disrepair for approximately 4 weeks. This poses a potential health and safety risk to persons in care.

Official plan of correction

Interim Administrator stated he approved the order for a new dryer and washer that should be delivered by early next week. Please submit a copy of the invoice and a picture of the installed new dryer and washer.

Deadline recorded: Oct 21, 2024. 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 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 room #261 was [131.6DF], rm # 253 [127.7 DF], rm #241 [120.3 DF], rm# 236 [122.8 DF], rm #235 [123.5 DF], rm # 233 [ 124.4 DF], rm # 210 [124.4 DF, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/20/2024 Plan of Correction Administrator shall submit written proof of how the deficiency was corrected by tomorrow.

Official classification

Type A

Official code

87555(b)(28)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. 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 at 12:12 PM LPA observed an open large size package of hot dogs being thawed in the kitchen sink where dirty dishes are rinsed and and uncovered plates of pie desserts were observed in the refrigerator, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/20/2024 Plan of Correction Administrator shall submit by tomorrow written proof of how the deficiency will be corrected. Proof of staff training shall be submitted by Wednesday, 4/25/24.

Official classification

Type B

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

Basic Services. Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. Based on record review and interviews conducted resident (R1) required bowel incontinence care since May 2023, due to change in condition to bed-bound. R1 has been left lying in feces and urine and was not provided incontinence care as indicated in care plans. This poses a potential health and safety risk to residents in care.

Official plan of correction

Executive Director agreed to re-assess all bed-bound and residents receiving incontinence care, and update their care plans. Submit proof of staff training, staff signature logs, and a written plan that addresses Hoyer lift issues. In addition, facility shall review all resident records to ensure Care Plans have been updated. NOTE: R1 moved out on 12/21/23.

Deadline recorded: Jan 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87101(c)(3)(A)

Regulation authority

CCR

What the official deficiency says

Definitions. " Care and Supervision " means those activities which if provided shall require the facility to be licensed... " Care and Supervision " shall include, but not be limited to, any one or more of the following activities provided by a person or facility to meet the needs of the residents: (A) Assistance in dressing, grooming, bathing and other personal hygiene; This requirement was not met evidenced by: Per record review & photographs, caregiver staff failed to provide grooming assistance as indicated in care plans, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Executive Director agreed to submit a written plan plan that addresses care responsibilities/protocols for residents with declining/change in health conditions, and grooming responsibilties. NOTE: R1 moved out on 12/21/23.

Deadline recorded: Jan 25, 2024. 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

Personal Rights of Residents in All Facilities. (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 was not met evidenced by: Based on photograph evidence and observations made on 12/19/23, R1's bed sheets/linens were observed to be dirty with urine, feces, and food; which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Executive Director shall ensure all resident's are accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet their needs. Submit a written plan and proof of staff training.

Deadline recorded: Jan 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(3)(B)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services.The following space and safety provisions shall apply.... All persons shall be protected against hazards within the facility through provision of the following:(B) Information and instruction regarding life protection and other appropriate subjects. Based on photographs and observations made the findings indicate that staff failed to remove hazardous items i.e. toothpicks, plastic knives from R1's bed, which can cause skin tears. This posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Executive Director shall ensure all staff follow care and supervision protocols. Submit a written plan and proof of staff training.

Deadline recorded: Jan 25, 2024. 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 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 rooms 229 (120.3 DF), 235 (120.9 DF), 243 (122.3 DF), 251 (121.8 DF), 252 (122.1 DF), 257 (121.2 DF) had water temperature that exceeded above 12 DF; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/19/2023 Plan of Correction Staff shall adjust the hot water temperature in the building and submit a temperature log (tested 3 times a day) for the above mentioned rooms.

Official classification

Type A

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. 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 faucets measured below 125 DF [123.4, 124.9]; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/19/2023 Plan of Correction Staff shall adjust the hot water temperature and ensure the hot water temperature in the kitchen is at least 125 DF, and hot water sink areas are identified by warning signs. Submit proof of correction.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that room 117's walls were in disrepair; which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/01/2023 Plan of Correction Staff shall submit picture proof evidence of room repairs.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 one (1) staff did not have current 1st Aid/CPR training on file; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/01/2023 Plan of Correction Staff shall submit proof of 1st Aid/CPR training by POC due date.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ... provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: 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 resident (R1's) furosemide 40 mg was not administered as prescribed (1/2 the pill remained in the bubble pack) and was missing Hydralazine HCL 25 mg, and R2 was missing fish oil/D3 360-1200 mg AM bubble pack, and bedtime Tylenol 325 mg bubble packs; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/19/2023 Plan of Correction Facility called the pharmacy and ordered the medications. Submit proof of correction by tomorrow.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities.(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met by evidence of: Based on client and staff interviews, as well as document review, it was confirmed that S1 was rough, aggressive and inappropriate towards. which poses an potential health, safety, or personal rights risk to persons in care.

Official plan of correction

Administrative Assistant agreed to conduct Personal Rights In-Service training with all staff and review Title 22 Regulations Section 87468.1 Personal Rights. Facility must adhere to Plan of Operation. All traing logs shall be submited to LPA for review by POC due date.

Deadline recorded: May 26, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident-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. The requirement was not met as evidenced by R1 was not sent to hospital in a timely manner

Official plan of correction

Administrator will ensure residents regularly observed for changes in physical, mental and emotional and social functioning and Administrator will retrain the staff on regularion and send the training log to LPA by POC due date.

Deadline recorded: Jan 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(d)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. The requirement was not met as evidenced by: Administrator did not follow up with staff about R1's condiiton.

Official plan of correction

Administrator will ensure to meet by the qualification. Administrator will send a plan and submit proof of correction by POC due date.

Deadline recorded: Jan 30, 2023. 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

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 is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that Room # 211 & # 201 had plumbing issues, and room # 231 had broken vertical blinds, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/24/2022 Plan of Correction Administrator shall submit proof of correction by POC due date.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465(c)(2) Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: 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 was missing medication Acetaminophen 325 mg, Resident (R2) has prescribed medications on Physician's Report, but they were not listed on the Medication Administration Report. No proof that R2 refuses medication physician orders was documented. R2 had Acetaminophen 500 mg in the room, but it was not listed on the MAR; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/18/2022 Plan of Correction Administrator shall submit a written plan stating how this deficiency will be correct. Facility shall contact resident physician. A RN or Pharmacist shall conduct staff in-service training regarding medication administration. Provide proof of in-service.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified ... below. Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met by evidence of: On 10/10/21 R1 sustained a fall resulting in scrapes and bruising to the kneee, which was not reported to authorized representive or Community Care Licensing. This poses a potential health and safety risk.

Official plan of correction

Administrator shall review Title 22 Regulations 87211 and submit a written plan on steps the facility will take in the future related to any incident which threatens the welfare, safety or health of any resident. In addition, staff shall receive in-service training on reporting requirements and documentation.

Deadline recorded: Dec 24, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.269(a)(21)

Regulation authority

HSC

What the official deficiency says

Enumerated rights; severability. Residents of residential care facilities for the elderly shall have all of the following rights: To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement was not met by evidence of: Based on interview and record review resident (R1's) itemized bill records were not provided to authorized representative within two business days. Facility provided a copy of the itemized bill until Nov 4, approximately 2 weeks after phone request was made. This poses a potential health and safety risk.

Official plan of correction

Administrator shall develop and implement a policy and procedure to include California Health and Satefy Code regulation, 1569.269, as to how this facility will handle requests for residents records in a timely manner. Additionally, Administrator shall train the designated personnel on this policy and procedure and include proof of this training to LPA by POC due date.

Deadline recorded: Dec 24, 2021. A deadline is not proof that correction was completed.