GOLDEN APRICOT MANOR

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview, the licensee did not comply with the section cited above in 1 out of 9 residents, as the facility is retaining 1 bedridden resident based on their physician's report which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2025 Plan of Correction Administrator is to remain in complince with their fire clearance at all times. Administrator is to either obtain an updated physician's report identifying the resident as a non-ambulatory resident, continue working with the city's buildings and plannings department to obtain the occupancy code required by the fire department since 12/4/2024, or relocate the resident to another facility. Administrator will email LPA the facility's plan by the POC due date.

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 2 out of 9 residents as Rooms #2 and #3 had hot water tempeartures that exceed 120 Degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2025 Plan of Correction **POC Cleared** Administrator is to ensure the water temperature for all residents remains within 105 - 120 Degrees Fahrenheit at all times. Administrator is to adjust the water temperature for the identified rooms and email a water log of the temperatures to LPA by the POC due date.

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 1 out of 4 staff members, as 1 staff member does not have first aid/CPR training in their file, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/28/2025 Plan of Correction Administrator is to ensure that all staff have updated first aid and CPR training in their files at all times. Administrator is to email staff #1's file to LPA by the POC due date.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 2 out of 9 residents, as 2 did not have a pre-admission appraisal completed before moving in, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/10/2025 Plan of Correction **POC Cleared** Administrator is to ensure all pre-admission appraisals are complete before all residents move into the facility at all times. Administrator is to complete the pre-admission appraisal for the 2 residents and email them to LPA by the POC due date.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 6 residents, because 2 residents were identified as bedridden based on their physician's reports, and the license does not have an approval for any bedridden residents on the fire clearance, which poses an immediate safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/08/2024 Plan of Correction Administrator is to ensure that the facility is operating within the limits of the license at all times. Administrator is to notify the local fire department of the bedridden residents, and submit a request to CCLD including an LIC200 along with an updated facility sketch that identifies the bedridden room(s), by the POC due date.

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 6 out of 6 residents, because there was observable mold on the ceiling of the resident's shower, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/28/2024 Plan of Correction Administrator is to ensure that the facility shall be clean, sanitary, and in good repair at all times. Administrator is to clear the mold on the shower's ceiling and email LPA photograph proof that it has been removed by the POC due date.

Official classification

Type B

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 1 out of 6 residents, as one of the resident's hot water was entirely cut off in their room's bathroom, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/28/2024 Plan of Correction Administrator is to ensure that all faucets used by residents for personal care shall deliver hot water at all times. Administrator is to restore the hot water in resident bathroom #3 and email LPA a water temperature log for 7 days showing that the water is meeting the required range by the POC due date.

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 4 out of 5 staff, because 4 staff files reviewed did not document that annual retraining had been conducted in the past 12 month related to dementia care, hospice care, postural supports, and restricted health conditions, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/21/2024 Plan of Correction Administrator is to ensure that documented retraining on dmentia care, hospice care, postural supports, and restricted health conditions is kept on file at the facility at all times. Administrator is to email LPA the facility's plan on how they will conduct annual retrainings on the required topics by the POC due date.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) 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: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 3 out of 6 residents, because there are 3 residents that have a dementia diagnosis and have not had their physician's report or reappraisal updated within the past 12 months, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/21/2024 Plan of Correction Administrator is to ensure that all residents that have a Dementia diagnosis have their physician's reports and appraisals updated every 12 months. Administrator to email LPA the facility's plan on how they will ensure that they will update the resident's physician's report and appraisals when required to do so, and also work on submitting LPA the identified residents updated Physician's Reports and appraisals by the POC due date.

Official classification

Type A

Official code

87705(I)(2)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia. The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement was not met by evidence of: Based on physical plant inspection at 9:53 AM LPA observed one of the side gates had a lock that requires a key. LPA spoke to LA County Fire Department; it was explained to Assistant Administrator that locked perimeter gates are not allowed per fire safety code. This poses an immediate healt and safety risk.

Official plan of correction

Assistant Administrator removed the lock from the side gate. ***Cleared during the visit.

Deadline recorded: Oct 1, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia. 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 was not met by evidence of: Based on observation at 9:36 am 2 knives were observed on the dish rack, and the knives/sharps drawer was unlocked. This poses an immediate healthy & safety risk to residents in care.

Official plan of correction

Staff removed the unlocked knives observed in the dish rack and unlocked sharps drawer. ***Cleared during the visit.

Deadline recorded: Oct 1, 2021. 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

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: Based on physical plant observations none of the residents in care (total of 7) had mattress pads on their beds. One (1) resident's hospital bed did not have sheets on the mattress. This poses a potential health and safety risk.

Official plan of correction

Administrator agreed to ensure that all resident beds have mattress pads, and sheets at all times. Submit proof of correction by POC due date.

Deadline recorded: Oct 4, 2021. A deadline is not proof that correction was completed.