LA POSADA

Official classification

Type B

Official code

87211(a)(1)

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 in (A) through (D) below..... This requirement was not met evidenced by: Based on record review, the findings indicate from December 2025- February 2026 a total of 30 incident reports and one (1) death report were submitted late, which posed a potential health and safety risk to persons in care.

Official plan of correction

Executive Director agreed to: 1. Submit a written plan of correction addressing incident reports/death reporting requirements and facility procedures. 2. Staff in-service training on regulation 87211

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

Official classification

Type B

Official code

87506(b)(17)(E)

Regulation authority

CCR

What the official deficiency says

Resident Records. Each resident’s record shall contain at least the following information: Documents and information required by the following: (E) Section 87463, Reappraisals; and... This requirement was not met evidenced by: Based on record review of electronic health records, multiple residents' service plans were not updated despite documented changes in condition. Service plans were completed late and/or there was no service plan in the file; this poses a potential health and safety risk to persons in car.

Official plan of correction

Executive Director agreed to submit a written plan of correction /certification that residents (R1 -R4's) services plans are updated and proof of staff in-service training in resident records and service plans.

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

Official classification

Type B

Official code

87463(b)(1)(E)

Regulation authority

CCR

What the official deficiency says

Reappraisals. The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition.....Significant changes in condition...Illness or injury that results in a significant change in the health care or dietary needs of the resident. This posed a potential health and safety risk. Based on record review, residents (R4 & R5) had a change in condtion that resulted in hospitalizations. Documentation of completed reassessments upon return were not observed or provided during the 2/13/26 initial complaint visit. This posed a potential health and safety risks to persons in care.

Official plan of correction

Executive Director agreed to submit copies of R4 & R5's reappraisals and proof of staff in-service training.

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

Official classification

Type B

Official code

87206(a)

Regulation authority

CCR

What the official deficiency says

Advertisements and License Number. In accordance with Health and Safety Code Sections 1569.68 and 1569.681, licensees shall reveal each facility license number in all public advertisements, including Internet, or correspondence. This requirement was not met evidenced by: Based on record review and interviews, the findings indicate the facility website has listed an incorrect license number that belongs to another Licensee's facility. In addition, the Resident Handbook lists the previous operator/ licensee's number. This poses a potential, health, safety risks to persons in care.

Official plan of correction

Licensee agreed to correct the website license number and the Resident Handbook license information. *The website license number was fixed during the visit. Submit picture evidence of corrections.

Deadline recorded: Jun 26, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(b)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services. Toilets and bathrooms shall be conveniently located...... This requirement was not met evidenced by: In July 2025, staff began locking the 1st floor public restrooms because a resident fell twice in the public restroom. Housekeepers were instructed to lock the restroom. As as result, some residents had incontinence accidents because they were not allowed to use the restroom and did not make it in time to their room bathroom. This posed a potential health, safety, and personal rights risk.

Official plan of correction

Executive Director agreed to submit a written plan of correction that addresses the July 2025 1st floor public bathroom closure, and rectification. A staff in-service will be conducted.

Deadline recorded: May 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(18)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements. The following food service requirements shall apply: Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents. This requirement was not met evidenced by: Based on interviews, in the month of July 2025 the facility experienced staff shortages that affected meal service preparation and meal times services, causing residents to wait from 20-45 minutes for their lunch and/or dinner meals. This posed a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

Executive Director agrees to oversee delivery of meals and meal times. Staff in-service will be provided.

Deadline recorded: May 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87219(f)

Regulation authority

CCR

What the official deficiency says

Planned Activities. In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities....This requirement was not met evidenced by: Based on record review and interviews, the findings indicate that the facility did not have an Activity Director since the end of 2024. An activity assistant was responsible for activities, but the staff member went on leave and was off occassionally, and as a result planned activities did not occur. This posed a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

Executive Director agrees to oversee activity calendar on a monthly basis and submit a written plan of correction.

Deadline recorded: May 7, 2026. A deadline is not proof that correction was completed.

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 that on 2/26/26 LPAs observed the Memory Care Unit multi-purpose activity room refrigerator was unlocked and had tweezers in the freezer. In addition, the arts/crafts storage cabinet was unlocked and contained nail polish and nail polish remover, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/28/2026 Plan of Correction Submit a written plan of correction by tomorrow that addresses the tweezers and nail polish found in the Memory Care Unit. Submit by 3/6/2026 proof of staff in-service training.

Official classification

Type B

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

(g) All personnel records shall be maintained at the 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 that staff (S7-S9's) files were 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: 03/06/2026 Plan of Correction Submit self-certification that S7-S9's files have been found and all required file documents have been filed.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 staff (S2, S3 & S5) do not have proof of 1st Aid/CPR training in their files, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction Submit copies of S2, S3 and S5's 1st Aid/CPR training certificates.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 the facility did not provide proof that an emergency drill was conducted within the last quarter, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction Submit proof that an emergency drill has been completed.

Official classification

Type B

Official code

87307(a)(3)(C)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services (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 was not met evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that rooms, 101, 104, 106, 107,110, 111, 112, 113, 202, 211, 311, 320 did not have a mattress pad, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction Submit a written plan of correction and picture proof that mattress pads have been placed on the beds in rooms , 101, 104, 106, 107,110, 111, 112, 113, 202, 211, 311, 320.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 staff (S4 & S6) do not have health screening/TB clearance on file, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction Submit copies of S4 & S6's health screening and TB exam clearance.

Official classification

Type B

Official code

87555(b)(7)

Regulation authority

CCR

What the official deficiency says

(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and kitchen observation, the licensee did not comply with the section cited above in that residents R4 & R8 have renal/kidney disease (dialysis) that require a renal diet, but they are not being served the modified diet, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction Administrator shall ensure all files of residents with special diet needs have a physician order on file and it is communicated with kitchen and med-tech staff. Submit a plan of correction indicating how the deficiency was addressed, and if needed obtain updated physician orders.

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 residents (R2, R7, R8, R9 & R10) medical assessments are more than 12 months old, ranging from 11/2022 - 1/2025, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/20/2026 Plan of Correction Submit updated copies of R2, R7, R8, R9 & R10 medical assessments.

Official classification

Type A

Official code

87465(b)

Regulation authority

CCR

What the official deficiency says

(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. 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-R4) were missing physician ordered medications, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/27/2026 Plan of Correction Staff shall contact the resident's pharmacy and obtain refill medications for residents (R1-R4) by tomorrow.

Official classification

Type B

Official code

87555(b)(3)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements. The following food service requirements shall apply: Between-meal nourishment or snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician. This requirement was not met evidenced by: Based on observation on 2/6/2025, the Memory Care Unit did not have adequate inventory of snacks in the refrigerator or cabinet, and interviews revealed snacks in the memory care unit were not always provided in between meal times. This poses a potential health, safety, and personal rights risks to persons in care.

Official plan of correction

Executive Director agreed conduct staff in-service training on Title 22 regulation 87555 and facility procedure regarding snack inventory and distribution. Submit plan of correction.

Deadline recorded: Aug 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities...... shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and records review, the findings indicate that on several dates in the month of Jan. 2025 caregiver staff did not reposition hospice resident (R1) every 2 hours as required. R1 had a pressure injury. This posed an immediate health and safety risk to the resident.

Official plan of correction

Executive Director shall conduct staff training on incontinence care, repositioning, care and supervision, and adherence to facility Plan of Operation protocol procedures. Submit a written plan by tomorrow, and proof of staff training by Tue. May 6, 2025.

Deadline recorded: May 3, 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. 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 and interviews conducted staff did not notify R1's responsible party of the bruise staff observed on 1/17/25 under R1's right eye. Responsible party observed the bruise on 1/20/25. Note: Staff did not submit an incident report to CCL as required. This posed a potential health and safety risk to persons in care.

Official plan of correction

Executive Director shall provide in-service training regarding reporting procedures/requirements. Please submit a written plan and proof that all caregiver and med-tech staff were trained.

Deadline recorded: May 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(d)(3)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements - General. All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following....(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. Based on interviews and record review, the findings indicate noc shift (S8) repositioned bedridden resident (R1), and the following day (1/17/25) staff observed bruising under R1's eye. This posed a potential health and safety risk to resident in care.

Official plan of correction

Executive Director shall ensure that all staff receive repositioning and procedure training of bedridden residents. Submit plan of correction and proof of staff training.

Deadline recorded: May 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(11)

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 have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. Based on record review, the findings indicate that resident (R1) was prohibited visits from former staff (S5). R1's family invited former staff to the facility when R1's was close to dying. This posed a potential health, safety, and personal rights risk to the resident in care.

Official plan of correction

Executive Director agreed to submit a written plan of correction that addresses policy regarding former employee visits after separation from employer and proof of staff training. If changes to the Employee Handbook and Residence and Care Agreement will be made, submit updated forms for approval.

Deadline recorded: Apr 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of: On 7/1/2024, at approximately 6:30 PM Memory Care Unit resident (R1) climbed out of a 1st floor bedroom window, fell, and sustained head injuries and dislocated shoulder. Staff responsible for supervision of residents in activity room was assisting another resident in the bathroom. This posed an immediate health, saferty, and personal rights risk to persons in care.

Official plan of correction

Executive Director shall submit a plan of correction that includes in-service training regarding elopement, wandering behavior, methods of redirection, resident care and supervision procedures, and staff/resident ratio in Memory Care unit.

Deadline recorded: Mar 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents ..... shall have all of the following personal rights: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. Based on interviews, on 5/30/24 former staff (S10) handled Memory Care Unit resident (R2) in a rough manner by grabbing arm which caused bruising, instead of using redirection techniques. S10 was terminated. This posed a potential health and safety risk to the resident in care.

Official plan of correction

Executive Director shall conduct staff training in Title 22 Personal Rights 87468, 87468.1, & 87468.2 and will submit training log with staff signatures. Submit proof of staff training.

Deadline recorded: Mar 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468(a)(8)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents ..... shall have all of the following personal rights: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. Based on interviews, on 5/30/24 former staff (S10) handled Memory Care Unit resident (R2) in a rough manner by grabbing arm which caused bruising, instead of using redirection techniques. This posed a potential health and safety risk to the resident in care.

Official plan of correction

Executive Director shall conduct staff training in Title 22 Personal Rights 87468, 87468.1, & 87468.2 and will submit training log with staff signatures. Submit proof of staff training.

Deadline recorded: Mar 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of: On June 4, 2021 at approximately 1:30 pm resident (R1) eloped out of the facility after exiting the memory care unit delayed egress door without staff knowlede when staff (S6) exited out, and did not ensure the door closed properly. This posed an immediate safety risk to this resident in care.

Official plan of correction

Executive Director shall submit a plan of correction that includes in-service training regarding elopement, wandering behavior, methods of redirection, and resident care and supervision procedures.

Deadline recorded: Mar 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored: All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. Based on interviews and record review, med-tech staff altered resident medications by using house supply and labeling the medications with electronic MAR information instead of obtaining medication refills in a timely manner. This posed an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Executive director shall conduct in-service training for all med-tech staff. Submit proof of correction by tomorrow.

Deadline recorded: Mar 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care Services. 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. Based on record review and interviews, med-tech staff were logging in the electronic (MAR) database that medications were administered but did not administer the medications. This posed an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Administrator shall: 1. Submit proof of staff training. 2. Submit a written plan that addresses centrally stored record keeping/inventory protocols, refill procedures, and facility auditing of medications.

Deadline recorded: Mar 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

Resident Records. 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: Based on interviews, a resident's medical file was lost/missing from the med-tech room. Staff did not find the file. A new file was created. This poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

Executive Director shall provide in-service training to all staff that access and update resident files. Submit proof of staff training.

Deadline recorded: Mar 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(B)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements. Each licensee shall furnish to the licensing agency such reports..... 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.... Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement was not met evidenced by:On 7/31/2024, resident (R1) sustained a right hand injury that resulted in an open flesh wound tear of approximately 4 inches, while the resident was transferred from the shower chair to the toilet. Facility faxed the incident report until 8/14/24, which posed a potential health and safety risk.

Official plan of correction

Executive Director shall ensure all Unusual Incident Reports are reported to CCL within 7 days of the occurrence of any reportable events. 1. Submit a written Plan of Correction 2. Proof of staff in-service training *Note: LPA obtained a file copy of the incident report.

Deadline recorded: Feb 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

Basic Services. Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met evidenced by: Based on record review and interviews conducted, the findings indicate that on 7/31/2024 (R1) sustained a right hand injury while the resident was transferred from the shower chair to the toilet by 1 staff instead of 2 staff, which posed an immediate health and safety risk to the resident.

Official plan of correction

Executive Director agreed to: 1. Submit a written Plan of Correction by tomorrow explaining facility procedures pertaining to 2-person assist responsibilities while bathing and care coordination. 2. Conduct in-service training for all caregiver staff regarding transfers, and body check assessments.

Deadline recorded: Feb 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care...The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met evidenced by: Based on interviews and records review, facility staff did not comply with the section above. On 7/31/2024, R1 sustained a hand injury at 7AM, and med-tech staff failed to arrange for timely medical attention which resulted in R1 being transported to the hospital until after 10 PM. This posed an immediate health and safety risk to resident in care.

Official plan of correction

Executive Director agree to the following 1. Staff are retrained in regulation 87465. 2. Submit proof of staff training. 3. Submit a written plan that specify facility procedures.

Deadline recorded: Feb 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care Services. A plan for incidental medical and dental care shall be developed by each facility…..the licensee may assist persons with self-administration as needed. This requirement is not met as evidenced by: Based on interviews and MAR record review, med-tech staff failed to order and obtain a refill for “Latanoprost 0.005 %” eye drops and on 7/6/24 asked family to order the refills and pick up the medication. Additionally, on 8/8/24 medication Donepezil HCL 5mg was not administered at the physician order time, and was given at 6 PM, instead of bedtime. This posed an immediate health and safety risk to the resident in care.

Official plan of correction

Executive Director agreed to: 1. Ensure all med-tech staff take state approved vendored training on incidental medical and dental care. 2. Submit proof of completed staff training to CCL.

Deadline recorded: Feb 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

Managed Incontinence.... the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met evidenced by: Based on record review and interviews the findings indicate that on multiple dates R1 was not provided incontinence care at least every 2 hours as required, and on 8/10/24, R1’s bed sheets were soiled with urine and the resident had not received incontinence care. This posed a potential health and safety risk to the resident in care.

Official plan of correction

Executive Director agrees to conduct staff training in incontinence care, responsibilities, and facility protocols. Submit proof of staff training.

Deadline recorded: Feb 25, 2025. 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. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interviews, during (Jun 2024-Aug. 2024, PM staff were not locking the front doors at 7 PM as required. On 8/3/24, at midnight R1’s family stopped by the facility to check if the front doors were locked. They were found unlocked. On 8/1/24, Administration staff were notified of the concern. This posed a potential health and safety risk to residents in care.

Official plan of correction

Executive Director is to ensure that all residents are afforded a safe, comfortable, and healthful environment to reside in. Please submit a written plan on how the facility has and/or will address the issue of individuals entering the facility after 7 PM.

Deadline recorded: Feb 21, 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 12 out 22 resident rooms and a kitchen sink hot water readings measured between 120 DF- 124.2 DF, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/16/2024 Plan of Correction Submit plan of correction by tomorrow and hot water temperature log of all resident rooms.

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 record review, the licensee did not comply with the section cited above in that resident R1’s Medication Administration Record (MAR) dated Nov. 2024 listed 2 medication that were not filled. Acetaminophen 325 mg, 2 tabs every 4 hours PRN for fever over 100DF & Acetaminophen 325 mg 2 tabs every 6 hrs PRN for mild pain. This poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/16/2024 Plan of Correction Submit proof by tomorrow that R1's medications have been ordered via Omni Care, and picture proof of filled medications. In addition, proof of staff in-service training shall be submitted by Nov. 20, 2024.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 staff (S5 & S10) did not have health screenings or TB clearance on file, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2024 Plan of Correction Administrator agreed to submit proof of S5 & S10's health screening/TB clearance.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 6 out 11 staff files do not have required annual training hours, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2024 Plan of Correction Licensee shall ensure all staff are completing required training at the facility. Submit proof of completed staff training hours.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

PERSONNEL REQUIREMENTS - GENERAL All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 9 out 11 staff files had expired 1st Aid/CPR training and/or no proof of training, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2024 Plan of Correction Administrator shall ensure all staff maintain current 1st Aid/CPR training. Submit proof of training for all staff listed on LIC 811 to not have current training.

Official classification

Type B

Official code

87507(e)

Regulation authority

CCR

What the official deficiency says

Admission Agreements. The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. This requirement was not met evidenced by: Based on record review of email correspondence, R1's family never received a copy of the admission agreement after it was signed, until multiple requests later. On 8/5/24, the copy was provided, but R1 was admitted on 11/17/23.

Official plan of correction

Administrator shall submit a copy of the plan of operation addressing Admission agreements, a written plan, and proof that R1's authorized representative were issued the copy of the admission agreement. *This is a repeat violation. Civil penalties are being assessed.

Deadline recorded: Nov 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. Based on record review and interviews conducted, the findings indicate that R1 had a decline in health since Jan. 2024, with change in condition, which prompted R1's doctor to inform staff on 7/9/24, that a Cardiologist and Pulmonologit consult was needed. Per record review, staff did not follow up or obtain referral documentation.

Official plan of correction

Administrator agreed to: 1. Submit proof the MD specialist consult appointments have been scheduled. 2. Submit a written plan of correction. 3. Conduct med-tech staff training on physician referral follow-up protocols, note charting, and requesting updated physician's reports when there is a change in condition.

Deadline recorded: Oct 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

Observation of the Resident . The licensee shall ensure ...When changes ... 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. Based on record review, staf observed deterioration of physical health condition in R1 since early Jan. 2024, but did not bring to the attention the resident's change in condition, nor was a medical exam requested. This poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator stated that on 7/30/24, facility requested an updated Physician's Report from hospice MD. 1. Submit proof that all caregiver and med-tech staff were trained in regulation 87466, and change in condition.

Deadline recorded: Oct 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care Services. 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. Based on record review, med-tech staff did not dispense medications to at least 10 residents as directed by Physician; records indicate some residents went 2-5 days without medications, which poses an immediate health, safety or personal rights risk to persons in care.

Official 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, refill procedures, and facility auditing of medications.

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

Official classification

Type B

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

Oxygen Administration - Gas and Liquid. (3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by: Based on observation, rooms 301, 314 & 326 have oxygen tanks in their rooms, and a " No Smoking-Oxygen in Use " sign was not posted outside resident room doors, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator shall ensure that a No Smoking-Oxygen In Use sign is posted on resident doors when oxygen tanks are used inside the room. Submit picture proof that the signs are posted and staff in-service training.

Deadline recorded: Sep 11, 2024. A deadline is not proof that correction was completed.

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 dialysis appointments on June 6, 2024 & July 4, 2024, because the facility did not ensure the resident was transported to appointments via Access transport, and/or facility van, or other alternate arrangement. This poses an immediate health and safety risk to persons in care.

Official plan of correction

Licensee shall ensure the admission agreement is adhered to, makes available transportation to medical appointments, and a contigency plan is in place when 3rd party transportation services do not pick-up residents. Submit written POC and staff training.

Deadline recorded: Aug 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(B)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements..(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) 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 ..(B) Any serious injury as determined..and occurring while the resident is under facility supervision. This requirement is not met as evidenced by: Based on interview and records review, the Administrator failed to meet the reporting requirement and did not submit an Unusual Incident/Injury Report to CCL concerning R1's fall on 10/14/2022 which poses/posed a potential health, safety or personal rights risk to residents in care.

Official plan of correction

Administrator will ensure that the reporting requrements are met and to send a written/signed statement that Title 22 Regs. 87211 has been read, reviewed and understood to CCL/LPA by POC due date.

Deadline recorded: May 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews, records review conducted by Investigator Santana, the licensee did not comply with the section cited above in which due to lack of care and supervision, R1 sustained a left hip fracture as a result of a fall while under the care of the facility.

Official plan of correction

Licensee/Administrator shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 87468.2(a)(4). Written POC must be submitted to CCL/LPA by POC due date.

Deadline recorded: May 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents...(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement is not met as evidenced by: Based on interviews, records review conducted by Investigator Santana, the licensee did not comply with the section cited above in which due to lack of care and supervision contributed to a delay in obtaining timely medical attention for R1.

Official plan of correction

Licensee/Administrator shall develop a written Plan of Correction to ensure compliance with California Code of Regulations Title 22, Section 87468.2(a)(1). Written POC must be submitted to CCL/LPA by POC due date.

Deadline recorded: May 21, 2024. A deadline is not proof that correction was completed.

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 ........ 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. Based on records review and interviews, med-tech staff failed to order R1's insulin medication and on 10/5/23 the resident ran out of insulin resulting in dangerously elevated blood sugar levels; which posed an immediate health and safety hazard to the resident.

Official plan of correction

Administrator submitted proof of staff in-service training " CCLD Medication Guide " that was conducted on 12/6/2023 by former Wellness Director. Administrator agreed to ensure that medication administration procedures are being evaluated routinely, especially when new med-tech staff are hired. Licensee shall provide medication admininstration in-service training to all staff that dispense medications. This training shall be provided by pharmacy and/or registered nurse. Submit proof of training by POC due

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

Official classification

Type A

Official code

87411(d)(4)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them.... (4) Knowledge required to safely assist with prescribed medications which are self-administered. This requirement was not met evidenced by: Based on interviews and record review, on 10/29/23 med-tech left another resident's medications in R1's room and asked the resident to take the medications, which posed an immediatel health and safety risk to persons in care.

Official plan of correction

Administrator shall ensure that all staff are trained in job responsibilities,facility procedures, and all med-techs are adhering to company procedures. Administrator provided in-service training that was conducted on 12/6/23. However, new med-tech staff have been onboarded. Therefore, new staff in-service training shall be submitted by POC due date.

Deadline recorded: May 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87207

Regulation authority

CCR

What the official deficiency says

False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met evidenced by: Based on record review, the findings indicate that on 10/10/23, staff faxed to CCLD an incident report that contained falsified information and omitted details of R1's incident (10/5/23), in which staff did not refill in time R1's insulin. The report stated that paramedics were called, but they were not. This poses a potential health and safety risk to persons.

Official plan of correction

Administrator agreed to conduct staff in-service training on emergency call protocols, and incident report writing and oversight. Submit proof of staff training.

Deadline recorded: May 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met by evidence of: Based on interviews conducted and record review, between Aug. 2021- Feb. 2022, there were staff shortages, and so the facility hired registry staff, but still could not meet the needs of residents. This posed a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to submit a plan that ensures sufficient staffing is in place at all times, and staff receive continuous training in personnel responsibilities.

Deadline recorded: Mar 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities. To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on interviews and record review, between Nov. 2021- Feb. 2022, residents were not being showered at least 2 times per week due to staffing shortages related to the COVID-19 pandemic. This posed a potential health and safety risk to residents in care.

Official plan of correction

Administrator agrees to conduct staff training on care plans and bathing schedules. Submit a written POC and proof of staff training.

Deadline recorded: Mar 1, 2024. A deadline is not proof that correction was completed.

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 residents that required feeding assistance were being fed 30 minutes after food was serveda as a result of staff shortages between Nov. 2021 - Feb. 2022. This posed a potential health and safety risk to residents in care.

Official plan of correction

Administrator agreed to conduct staff training in Basic services and submit a contigency plan that addresses potential staff shortages and meal assistance.

Deadline recorded: Mar 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(e)

Regulation authority

CCR

What the official deficiency says

Admission Agreements (e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. 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 during file review of resident files it was observed that residents' admission agreement forms on file and being provided to residents and their responsible parties are not of the current licensee, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/04/2024 Plan of Correction Administrator agreed to issue residents an admission agreement approved by CCL during licensure with current licensee's name. Submit self-certification and a written statement that addresses how the deficiency was corrected.

Official classification

Type B

Official code

87307(a)(3)(C)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services. Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillowcases, mattress pads, bath towels, hand towels and wash cloths.... This requirement was not met by evidence of: 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 rooms 107, 110, 115, 218 did not have mattress pads, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/14/2023 Plan of Correction Administrator agreed to ensure that all resident beds have mattress pads. Submit proof of correction by POC due date.

Official classification

Type A

Official code

87355(e)(3)

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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 staff (S1) has worked at the facility since 2019, is cleared, but not associated to the facility; which poses an immediate health, safety or personal rights risk to persons in care. Civil penalty assessed.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction Staff (S1) shall be associated to the facility by tomorrow. Submit Guardian proof.

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 there are discarded mattresses, chairs, and other furniture in the outdoor parking lot, the roof's rain gutter pipe had a missing pipe, the laundry room ceiling had exposed electrical wiring and an opened ceiling, and the parking lot floor had a steel beam sticking out of the ground,which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/14/2023 Plan of Correction Administrator agreed to submit picture proof evidence that the aforementioned items were discarded.

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 staff (S2- S6) do not have 1st Aid/CPR certificates on file and/or have expired cards, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/14/2023 Plan of Correction Administrator shall submit proof of 1st Aid/CPR cards for staff (S2- S6) by POC due date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 the last emergency drill was conducted on 7/6/2023, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/14/2023 Plan of Correction Administrator agreed to provide proof of emergency drill by POC due date.

Official classification

Type B

Official code

87633(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act (Health and Safety Code Section 1569 et seq.), all other requirements of Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver. 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 there are 23 residents enrolled in hospice services, but the facility only has a hospice waiver for 20; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/14/2023 Plan of Correction Administrator agreed to submit a hospice waiver increase by POC due date.

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 during medication review, the licensee did not comply with the section cited above in that two (2) residents [R1 & R2} had unfilled PRN medications, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2023 Plan of Correction Administrator shall ensure all missing PRN medications are filled by tomorrow. In addition, all staff that dispense medications shall receive in-service training. Submit in writting how this was corrected and attach proof of training by tomorrow.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 the Memory Care Unit had an unlocked drawer with 2 pairs of scissors and sharp office supplies, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2023 Plan of Correction Administrator shall submit a written plan of correction, proof of staff training, and a video/picture of the Memory Care unit cabinet showing that a lock was installed in the drawer.

Official classification

Type B

Official code

87468.2(a)(25)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities.... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To protection of their property from theft or loss according to Health and Safety Code sections 1569.152, 1569.153, and 1569.154. This requirement was not met evidenced by: Based on record review and interviews, the findings indicate that staff (S1) took $10 from resident (R1) to buy lottery tickets, but never gave the lottery tickets to the resident. This poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator agreed to conduct staff training regarding Personal Property Procedures and Theft and Loss. Submit proof of staff training by POC due date.

Deadline recorded: Oct 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia. Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in that annual assessments for two (2) Dementia residents R1 & R2 are older than 1 year; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator shall ensure all Dementia residents have annual medical assesssments. 1. Submit proof that R1 & R2 have current annual assessments. 2. Submit proof of staff in-service training.

Deadline recorded: Jul 20, 2023. 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 evidenced by: Based on record review, the facility received a formal medical records request on Jan. 26, 2023 and failed to provide the records within 2 business days, as required per regulation; which poses a potential health and safety risk to persons in care.

Official plan of correction

Administrator agreed to submit a written plan of correction addressing resident records, enumerated rights; severability, and facility procedures regarding resident records request. Submit by POC due date.

Deadline recorded: Feb 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(16)

Regulation authority

CCR

What the official deficiency says

87555 (b)(16) General Food Service Requirements (b) The following food service requirements shall apply: (16) In facilities licensed for sixteen (16) to forty-nine (49) residents, one person shall be designated who has primary responsibility for food planning, preparation and service. This person shall be provided with appropriate training. This requirement is not met as evidenced by: Staff (S1)/Dining Services Director's food handling certificate expired on 3/25/2022. Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in S1/Dining Services Director does not have a current Food Handling Training Certificate which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/13/2022 Plan of Correction Facility Administrator to submit proof of staff (S1) of a current Food Handling Training Certificate by POC due date.

Official classification

Type B

Official code

87307(a)(3)(C)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services. Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths.... This requirement was not met by evidence of: This requirement is not met as evidenced by: Rooms 102, 104, 108, 110, 212, 214, 216, 220, 309, 311 did not have mattress pads. Deficient Practice Statement Based on physical plant observations, the majority of rooms in the Memory Care unit had no mattress pads; rooms 102, 104, 108, 110, 212, 214, 216, 220, 309, 311 did not have mattress pads in the beds. This poses a potential health and safety risk.

Official plan of correction

POC Due Date: 12/13/2022 Plan of Correction Administrator agreed to ensure that all resident beds have mattress pads. Submit proof of correction.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. 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 all the Memory Care unit rooms had window auditory alarms that do not have sound to alert staff. The alarm system registers in the front desk area that does not always have staff; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/16/2022 Plan of Correction Administrator shall ensure that all auditory devices on the exit doors and windows are turned on, and operable at all times. Administrator agreed to submit a written plan of correction and proof of staff training by tomorrow.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation (c) All window screens shall be clean and maintained in good repair. 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 windows by the 2nd floor game room did not have window screens; which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/13/2022 Plan of Correction Administrator shall submit picture proof that window screens were installed in the game room window.

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 ........ Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Residents (R1- R4) were missing medications ordered by their MD. Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in that residents (R1-R4) were missing medications; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/17/2022 Plan of Correction Administrator shall submit a written plan stating how this deficiency will be correct. Facility shall contact pharmacy and place prescription order. A RN or Pharmacist shall conduct staff in-service training regarding medication administration. Provide proof of in-service.