WHITTIER COTTAGE II

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 due to two resident insulin pens and lancets were observed in a Zip-Loc bag on the refrigerator door shelf. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/04/2026 Plan of Correction Licensee will send a plan regarding scheduling a training with staff regarding the following: Licensee will conduct an in-service training regarding the proper storage of resident medication to ensure safety. Licensee will send LPA the topics discussed in training and the sing-in sheet for participating staff. Licensee will obtain a lock box appropriate for the storage of medication requiring refrigerator and send LPA purchase receipt and photo of the box in the refrigerator.

Official classification

Type A

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews and observation, the licensee did not comply with the section cited above due to LPA observing live and dead roaches on the kitchen counter by the sink in the top and bottom kitchen cabinets inside the shelf area. Also observed were several roach traps underneath the kitchen sink and on the counter by the kitchen faucet. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/04/2026 Plan of Correction Licensee will schedule an appointment with pest management company by POC due date and will send LPA proof of treatement. Licensee will conduct in-service regarding cleaning and sanitazing surfaces for pest management and prevention and send the plan on when the training will take place and the topics that will be discussed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above due to R2’s Quatiapine Fumarate 25 mg tablet, evening dose, was not given to resident on June 29, 2026. Medication observed in the bubble pack during inspection which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/04/2026 Plan of Correction Licensee will email LPA, a plan for inservice training regarding proper medication management and policy and procedures to ensure staff competency in administering medication by POC due date.

Official classification

Type A

Official code

87465(c)(3)

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: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. 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 due to Administrator stated that the facility uses Medication Administration Log (MAR) for resident medication management; however, R1 did not have a July 2026 MAR log in place. LPA observed Administrator take out a blank MAR log from a binder and then proceeded to fill in the July 1 and July 2, 2026 a.m. medication administration for R1’s Metformin tablets. Also, per administrator interview, R2 refused to take their Quatiapine Fumarate 25 mg tablet, evening dose on 6/26/2026, but did not document it correctly on R2's June MAR log. MAR June 26, 2026 evening dose was signed by staff as administered which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/04/2026 Plan of Correction Licensee will email LPA, a plan for inservice training regarding proper medication management and policy and procedures to ensure staff competency in administering medication and documentation by POC due date.

Official classification

Type B

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

(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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, the licensee did not comply with the section cited above due to the inside of the kitchen cabinets observed with roach droppings and food particles like grease and crumbs on the shelves above and below the sink which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/10/2026 Plan of Correction Licensee will conduct a deep clean of all inside of the kitchen cabinets and send photos of clean surfaces to LPA by POC due date. Licensee will also conduct an in-service training regarding cleaning practices and send LPA the training topics and sign-in sheet by POC due date.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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) (interview) (record review)], the licensee did not comply with the section cited above due to water temperature in bathroom #1 was 129.7- and 125.5-degrees F. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/03/2026 Plan of Correction Deficiency cleared at time of visit. Administrator adjusted the water heater temperature and water then measured at 105.7 and 105.3 (within compliane range).

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above due to broken bed frames, cleaning tools like mop bucket and broken trashcans were observed obstructing the outdoor walkway on the side of the house, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/10/2026 Plan of Correction Licensee will remove all obstructions items mentioned above and send LPA photo of cleared walkway by POC due date.

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above due to facility not having the appropriate Complaint Information poster. Staff proceeded to attempt to post the " Let Us No " poster from the Dept. of Social Services while LPA observed, during the visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/03/2026 Plan of Correction Licensee posted poster during visit.

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 due the following: according to record review and staff interview, S4 and S5 do not have a Health Screening/TB clearance. Administrator indicated that S4 was hired on 6/15/2026 and S5 was hired on 6/26/2026. Administrator further indicated that both S4 and S5 have not completed a medical assessment yet, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/17/2026 Plan of Correction Licensee will email LPA a copy of health screenings/TB clearances by POC due date.

Official classification

Type B

Official code

87411(d)

Regulation authority

CCR

What the official deficiency says

(d) 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, as appropriate for the job assigned and as evidenced by safe and effective job performance: 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 due to: S4 and S5 do not have proof of training in their file. Administrator indicated that S4 and S5 have not completed their job training orientation since their initial hiring, which is 6/15/2026 for S4 and 6/26/2026 for S5. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/17/2026 Plan of Correction Licensee will email LPA, proof of on-boarding training/orientation for S4 and S5 by POC due date.

Official classification

Type B

Official code

1569.626(a)(1)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. 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 due to: S4 and S5 do not have proof of DEMENTIA training in their file. Administrator indicated that S4 and S5 have not completed their job training orientation since their initial hiring, which is 6/15/2026 for S4 and 6/26/2026 for S5. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/17/2026 Plan of Correction Licensee will email LPA, proof of Dementia for S4 and S5 by POC due date.

Official classification

Type B

Official code

87506(b)(9)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (9) Name, address and telephone number of physician and dentist to be called in an emergency. 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 due to: LPA did not observe an LIC 601/Identification and Emergency Information in R1's file. Staff indicated that they do not have it. The whereabouts of the form are unknown which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/10/2026 Plan of Correction Licensee corrected at time of visit. Family member filled it out and signed during visit.

Official classification

Type B

Official code

87458(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: 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 due to: R3 does not have a current medical assessment in place (Physician's Report). Last assessment was conducted on 6/27/2023 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/17/2026 Plan of Correction Licensee will send LPA a current copy of R3's medical assessment by POC due date.

Official classification

Type B

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

(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: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above due to: resident bedroom #1 and garage have stored oxygen tanks, but signage was not posted in both areas in which they are kept which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/03/2026 Plan of Correction Deficiency corrected at the time of visit. Administrator posted signage during visit.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance (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: (2)Obtain a California clearance or a criminal record exemption as required by the Department or... This evidence was not met as required. During interview with Administrator was confirmed that S1 worked at the facility 3 days without fingerprint clearance.

Official plan of correction

Licensee / Administrator shall make sure all staff are fingerprinted and associated prior to working in a facility. Per Administrator Staff 1 is no longer working in the facility. Immediated $300 civll Penalty issued

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

Official classification

Type B

Official code

87705(5)

Regulation authority

CCR

What the official deficiency says

87705(5) Care of Persons with Dementia (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, LPA obserevd R1 does not have an updated Medical assessment and last one was dated in 2022 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/05/2024 Plan of Correction The administrator will send the updated LIC602 to LPA by POC due date.

Official classification

Type B

Official code

87456(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, LPA observed all residents's pre-admission appraisal form is empty which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/05/2024 Plan of Correction The administrator will ensure prior to accept a resident and has to perform a pre-admission appraisal and will send the plan to LPA for about future residents admission by POC due date.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, LPA did not observe R1's needs and service plan ,which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/05/2024 Plan of Correction The administrator will send R1's needs and service plan to LPA by POC due date.