PRESERVE AT WOODLAND HILLS, THE

Official classification

Type B

Official code

1569.312(a)

Regulation authority

HSC

What the official deficiency says

1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as R1 eloped from the facility while under the care of staff and was found away from the facility approximately 45 minutes later which poses a potential safety risk to clients in care.

Official plan of correction

Management stated that residents with exit-seeking behaviors will not be in rooms with windows leading outside of the facility. Management also stated that staff will get additional training to respond to the facility's Vigil signal system which notifies staff of restlessness. Proof of training and exit- seeking procedures will be sent to CCLD by due date.

Deadline recorded: Aug 19, 2026. 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

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, observation, and record review, the licensee did not comply with the section cited above as two (2) out of three (3) resident pull cords tested during the visit had staff response times ranging from 18-24 minutes, which poses a potential health and safety risk to clients in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction Management stated that staff will receive training on signal response times. Proof of training will be sent to CCLD by due date.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: 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 as two (2) out of four (4) staff files were missing a health screening and TB test and one (1) was also missing first aid certification which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction Management stated health screenings, TB test, and first aid will be completed. Proof will be sent to CCLD by the due date.

Official classification

Type B

Official code

1569.686(a)(1)

Regulation authority

HSC

What the official deficiency says

1569.686 (a) A licensee shall notify the department, the State Long-Term Care Ombudsman, all residents, and, if applicable, their legal representatives, in writing, within two business days... (1) A notice of default... This requirement is not met as evidenced by: Based on interview and record review, Licensee failed to ensure The Department, LTCO, residents and their responsible parties were notified of the default received by Licensee, which caused a potential health and safety risk to residents in care.

Official plan of correction

The court appointed receiver notified The Department and residents of the default. ED will review the section cited, as well as Health and Safety Code 1569.482 and submit a statement of understanding to CCL by the due date. Civil penalty is assessed for violation of this section [Health and Safety code 1569.686(c)].

Deadline recorded: Dec 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws... This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as Resident #1 (R1) was administered Resident #2’s (R2)’s morning medications by Staff #3 (S3). This posed a potential health and safety risk to persons in care.

Official plan of correction

S3 received training on medication administration after the error and will receive additional training. Administrator stated that staff will receive vendored training by Guardian Pharmacy and will provide proof of the scheduled in-service to LPA by the due date.

Deadline recorded: Oct 2, 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 5 out of 6 resident restroom sink water did not measure within the required range which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/26/2025 Plan of Correction Staff will adjust water temperature and test water temperatures for 5 days and submit CCLD the logs by POC due date.

Official classification

Type A

Official code

87303(i)

Regulation authority

CCR

What the official deficiency says

(i) Facilities shall have signal systems which shall meet the following criteria: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above in the facility did not have a call ssystem in resident rooms and bathrooms which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/26/2025 Plan of Correction Staff will inquire a third party vendor and receive a quote or service request and send CCLD proof by POC due date.

Official classification

Type A

Official code

87309(b)

Regulation authority

CCR

What the official deficiency says

(b) Residents may have access to items specified in subsection (a) for personal use unless there is documentation, as specified in Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, that indicates the resident's or other residents’ safety would be at risk if allowed access. 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 residents had access to items their Physician deemed as at risk which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/26/2025 Plan of Correction The Health and Services Director (HSD) secured R3's razors during the visit. The Executive Director and HSD will secure the cleaning supplies located under R1's restroom sink and send CCLD proof by POC due date.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) 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 is not met as evidenced by: Deficient Practice Statement Based on interview, record review, and observation, the licensee did not comply with the section cited above as staff did not respond to residents calls for assistance in a timely manner, which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/26/2025 Plan of Correction The Executive Director will conduct an in service training with all Staff to address Staff's response time to resident's needs. The Executive Director will send CCLD a statement of understanding with Staff signatures by POC due date.

Official classification

Type B

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws... This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above as Resident #1 (R1)'s Benzonatate medication was left unattended by Staff #1 (S1) which Resident #2 (R2) self-administered. This posed a potential health and safety risk to persons in care.

Official plan of correction

S1 received one-on-one training from HSD Nunez and attended a training session vendored by Guardian Pharmacy on 04/07/2025. A corrective action form was issued to S1 and HSD stated that each medication technician will be shadowed for a full day. HSD will submit a training plan for each medication technician to CCLD by 05/01/2025.

Deadline recorded: May 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws... This requirement is not met as evidenced by: Based on medication review and interview, the licensee did not comply with the section cited above as Resident #1 (R1)'s Lorazepam medication was not administered by Staff #1 (S1) as prescribed, which posed a potential health and safety risk to persons in care.

Official plan of correction

S1 no longer works at the facility. HSD stated they will schedule a vendored training soon and will submit proof to CCL of the scheduled date by 04/01/2025.

Deadline recorded: Apr 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87456(a)

Regulation authority

CCR

What the official deficiency says

87456 Evaluation of Suitability for Admission (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 This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as Resident #1 (R1) was admitted without an admission agreement and appraisal which posed a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

Current administration is knowledgeable on proper admission procedures per regulation and provided proof to LPA during the visit of admission procedures. POC has been met.

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

Official classification

Type A

Official code

1596.312(a)

Regulation authority

HSC

What the official deficiency says

Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interviews conducted, evidence submitted and file review, the licensee did not comply with the section cited above. Facility staff failed to provide the necessary care and supervision to R1 and R2 which allowed the residents to elope from the facility unassisted, which poses an immediate health and safety risk to residents in care.

Official plan of correction

ED stated they will increase the delayed egress. ED will submit a written plan of action outlining the actionable changes the facility will take to prevent R2's elopement behavior by 01/08/2024 to CCL.

Deadline recorded: Jan 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465(a)(4) Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review and observations, the licensee did not comply with the section cited above, as the facility staff did not properly assist with R1’s self-administered medications per physician’s order which poses an immediate health and safety risk to residents in care.

Official plan of correction

Within 24 hours, the ED will notify the LPA when medication training will be completed. Administrator stated that training for all medication staff will be completed and submit documentation to CCL by 12/31/2024.

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

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews, record review, and evidence from a credible witness, the Licensee did not comply with the section cited above in that three (3) staff members did not respect a resident's dignity which poses an immediate personal rights risk for persons in care.

Official plan of correction

All staff members involved have been suspended and are in the process of termination. The facility has been actively hiring new staff and training on personal rights is being provided and will continue to be provided on an ongoing basis. POC is cleared.

Deadline recorded: Sep 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464(f) 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 is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above cited section, as facility accepted R1, who could not perform own glucose testing and facility did not have skilled professional to perform the glucose test which posed an immediate health risk to residents in care.

Official plan of correction

On 08/08/2024, R1 was moved out of the facility due to the facility not being able to meet R1 diabetic needs. The Administrator will submit a statement of understanding regarding the above regulation by due date. Additionally, Administrator stated that he will submit a plan on how the facility will ensure residents' basic services will be met by due date.

Deadline recorded: Aug 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87628(a)

Regulation authority

CCR

What the official deficiency says

87628(a) Diabetes (a)The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing…, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above as R1 could not perform own glucose testing and facility did not have skilled professional to perform the glucose test which posed an immediate health risk to resident in care.

Official plan of correction

On 08/08/2024, R1 was moved out of the facility due to the facility not being able to meet R1 diabetic needs. The Administrator will a statement of understanding regarding the above regulation by due date.

Deadline recorded: Aug 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on 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 3 (three) out of 5 (five) staff did not have their 40 hours of initial training which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/06/2024 Plan of Correction Administrator will ensure that all staff who require 40 hours initial training will have it completed by 09/06/2024. Administrator will email training logs to CCL by 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, the licensee did not comply with the section cited above in that 2 (two) out of 5 (five) staff did not have their 20 hours of annual training which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/06/2024 Plan of Correction Administrator will ensure that all staff who require 20 hours annual training will have it completed by 09/06/2024. Administrator will email training logs to CCL by due date.

Official classification

Type A

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405(a) Administrator Qualifications and Duties. All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section…This requirement was not met as evidenced by: The Licensee did not comply with the regulation cited above as the Administrator/ ED quit without proper notice, abandoning the facility which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee will provide a plan and documents to CCL to update the Certified Administrator on record assigned to manage and oversee this facility by 08/01/2024.

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

Official classification

Type B

Official code

1569.652(c)

Regulation authority

HSC

What the official deficiency says

§1569.652 (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued...resident’s estate, within 15 days after the personal property is removed. This requirement is not met as evidenced by: Based on interview and record review, the Licensee did not comply with the above cited section, as R1 passed away and all belongings were removed as of 12/30/2023 and refund has yet to be issued, which poses a potential personal rights risk to residents in care.

Official plan of correction

Executive Director sent a new refund request to the Licensee's accounting department during today's visit to request the refund be issued as soon as possible. Executive Director will provide proof to CCL by POC due date of refund issued.

Deadline recorded: May 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish to the licensing agency...(1) A written report shall be submitted to the licensing agency within 7 days of the occurrence... (D) Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: Based on interviews and record review, facility's former Administrator was aware of the alleged sexual assault R1 made and failed to notify CCLD and follow mandated reporting requirements. This posed an immediate health and safety risk to residents in care.

Official plan of correction

Former Administrator was terminated. The current Administrator shall do the following: 1.Administrator to review Regulation 87211 and Mandated Reporting requirements and submit Statement of Understanding. 2. Provide in-service to all staff on Mandated reporting requirements.

Deadline recorded: Apr 4, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on the investigation, observations and interviews, the licensee did not comply with the section cited above, as the door to exit the dining room to the lobby was locked and does not have delayed egress, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator has contacted their fire protection system company to release the magnetic lock on the door by 12/12/2023. He will staff the reception area 24 hours/day until they can make the door delayed egress and LAFD inspects the door for compliance.

Deadline recorded: Dec 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)(A-F)

Regulation authority

CCR

What the official deficiency says

87465(h)(6)(A-F) Incidental Medical and Dental Care.The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on medication review, the licensee did not comply with the section cited above, as medications were not documented on the Centrally Stored Medications and Destruction Record for one out of two residents (R1), which poses a potential health and safety rights risk to persons in care.

Official plan of correction

POC Due Date: 08/25/2022 Plan of Correction The Administrator agreed to do the following: 1. Audit R1's medications, and ensure all medications are properly documented on the Centrally Stored Medications and Destruction Record within the next 24 hours. 2. Conduct an in-service with staff, reviewing the policies and procedures as it relates to documentation. Submit completion by 8/26/2022.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

87465(a)(1) Incidental Medical and Dental Care.(a) A plan for incidental medical and dental care shall be developed by each facility...(1) The licensee shall...assist in... medical...care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above. The Administrator and the Health Services Director did not take action to have R1 transported to a medical facility timely which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee will submit plan how you will ensure residents receive timely medical care. Submit to CCL by 8/19/2022 An immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1548(c)(1)

Deadline recorded: Aug 19, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident... When changes... 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. This requirement is not met as evidenced by: Based on interviews the licensee failed to notify R1's responsible party of R1's change in condition immediatley upon discovery, which poses an immediate health and safety risk to residents in care.

Official plan of correction

1. Licensee with submit plan on how they will ensure residents reporting parties are notified of changes. 2. Review regualtion 87211 reporting requirements with management and submit to CCL no later than 8/19/22.

Deadline recorded: Aug 19, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a)... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility... This requirement is not met as evidenced by: Based on interviews an administrator was not available for immediate guidance during incident on 4/8/2022 which poses an immediate health and saftey risk to persons in care.

Official plan of correction

The licensee will submit a plan on supervisor coverage and develop a schedule to ensure appropriate supervisory coverage is maintained 24/7 and provide proof to CCL no later than 8/19/2022.

Deadline recorded: Aug 19, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

87615(a)(1) Prohibited Health Conditions. (a) Persons who require health services for or have a health condition including... those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as R1 was retained at this facility with unstageable pressure injuries, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Schedule a training regarding Prohibited Health Conditions and Pressure Injuries. Verification of scheduled training with the trainers credentials will need to be submitted by 7/15/2022 and completion of training must be submitted no later than 7/29/2022. An immediate civil penalty of $500 is assessed.

Deadline recorded: Jul 15, 2022. 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

87411(a) Personnel Requirements. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on interviews and record review, licensee failed to ensure that the facility had an adequate number of staff to meet the residents needs, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Submit a Staffing Plan to CCL and updated schedule by 7/15/2022.

Deadline recorded: Jul 15, 2022. 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 . 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 the investigation, the licensee did not comply with the section cited above regarding resident care needs and services for R1, R4, R5, and R6 which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Submit a Plan of Action, indicating how the facility plans to maintain voluntary compliance for R4, R5, R6. Submit Plan by 7/15/2022. 2. Review the care plans for the residents that are currently in the facility. Identify any changes that are needed, and update plans accordingly. Inform the CCL when this is completed, but no later than 8/5/2022.

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

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

1569.625( b)(1) Staff training; legislative findings. Staff members...who assist residents with personal activities of daily living to receive training. This training shall consist of 40 hours of training ….and shall be completed within the first four weeks of employment. This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above in eight out of twelve staff, which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to the following: 1. Submit a Plan of Action, detailing how the facility will maintain compliance with the regulation. 2. Audit staff files and ensure all staff have the forty (40) hours of initial training. Submit completion by 7/29/2022

Deadline recorded: Jul 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary, and in good repair at all times…This requirement is not met as evidenced by: Based on the investigation, and interviews, the licensee did not comply with the section cited above, as four out of 20 bedrooms were observed unclean, which poses a potential health and safety risk to residents in care.

Official plan of correction

The ED will post a cleaning schedule for housekeeping and caregiver duties in each room, which will show the date, time, name, and initials of the staff who conducted cleaning for each bedroom. The ED will send schedule to LPA as proof of correction.

Deadline recorded: Jul 22, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary, and in good repair at all times…This requirement is not met as evidenced by: Based on the investigation, and interviews, the licensee did not comply with the section cited above, as four out of 20 bedrooms were observed to lack toilet paper in the paper toilet dispenser, which poses a potential health and safety risk to residents in care.

Official plan of correction

The ED will post a cleaning schedule for housekeeping and caregiver duties in each room, which will show the date, time, name, and initials of the staff who conducted cleaning for each bedroom. The ED will send schedule to LPA as proof of correction.

Deadline recorded: Jul 22, 2022. 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(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following....: 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 was not met as evidenced by: Based on the investigation, and interviews, the licensee did not comply with the section cited above, as residents were not properly supervised, due to insufficient staff in numbers, which led to falls due to the delayed assistance, which poses an immediate personal rights risk to residents in care.

Official plan of correction

The ED will submit an Operational Procedure that describes the steps taken to ensure staff monitor the Vigil system and respond within the expected 5 minutes time frame to pendant calls. Additiionally the ED will send a sign in sheet and agenda for staff refersher training.

Deadline recorded: Jun 30, 2022. 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(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following....: 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 was not met as evidenced by: Based on the investigation, and interviews, the licensee did not comply with the section cited above, as staff did not respond to residents pendant signal, due to insufficient staff in numbers, which led to delayed assistance, and poses an immediate personal rights risk to residents in care.

Official plan of correction

The ED will submit an Operational Procedure that describes the steps taken to ensure staff respond to pendant calls within 5 minutes and that enoiugh staff is available to ensure care and supervision of all residents currently residing at the faciltiy.

Deadline recorded: Jun 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(i)(1)(B)

Regulation authority

CCR

What the official deficiency says

87303(i)(1)(B) Signal System- (i)Facilities shall have signal systems (1)All facilities licensed for 16 or more… shall have a signal system which shall: (B)Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met as evidenced by: Based on the investigation, and interviews, the licensee did not comply with the section cited above, as the signal system is not functioning properly, which poses an immediate personal rights risk to residents in care.

Official plan of correction

The ED showed the LPA the system is up and running, and functionng propertly. The deficiency has been cleared as of today's visit 6/3/2022.

Deadline recorded: Jun 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary, and in good repair at all times…This requirement is not met as evidenced by: Based on the investigation, and interviews, the licensee did not comply with the section cited above, as a housekeeping staff was not hired at the time of the visit, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The ED provided proof of housekeeping staff being hired as of 05/18/2022. This deficiency has been claered as of today's visit on 6/3/2022.

Deadline recorded: Jun 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465(a)(4) Incidental Medical and Dental. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on observation, the licensee did not comply in the section cited above for three out of three residents (R1, R2, R3), which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Host an in-service training around the self-administration of medications, specifically discussing PRN documentation, protocol when medications require refills, and completing the Centrally Stored Medication and Destruction Record. Submit the training sign-in sheet to CCL no later than 5/12/2022.

Deadline recorded: May 12, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

87412(a) Personnel Records. The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidenced by: Based on records review, the licensee did not comply in the section cited above for three out of thirteen staff members, as their files were incomplete, which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Audit the files for staff currently working in the facility. Inform the Department when this is complete and all files are in order, but no later than 5/20/2022.

Deadline recorded: May 20, 2022. 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(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following....: 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 was not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as residents were not properly supervised which led to an elopement, which poses an immediate personal rights risk to residents in care.

Official plan of correction

Per the visit the facility conducted an in-service training on 3/9/22 and conducted elopement drills on 2/25/22, 2/28/22, 3/2/22, 3/10/22 and 3/13/22. The facility has committed to conducting elopement training on a monthly basis and will send sign in sheet no later than 3/18/22. The LPA obtained documents from the previous elopement drills.

Deadline recorded: Mar 18, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary, and in good repair at all times…This requirement is not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as one (1) out of three (3) delayed egress doors were inoperable, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Per the visit the facility fixed the delayed egress. The licensee agreed to provide proof of date of service to CCL no later than 3/18/22.

Deadline recorded: Mar 16, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705(f)(2) Care of Persons with Dementia. (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as items were accessible to residents with dementia, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Buisness Office Manager agreed to do the following: 1. Items were secured during today’s visit. Plan of Correction met. This is a repeat violation. Civil penalty of $250 assesed.

Deadline recorded: Feb 2, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355(e)(2) 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) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, as S1 was not associated to the facility since 10/5/2021 and has continued to work at the facility, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Executive Director agreed to do the following: 1. Ensure that S1 is associated to the facility prior to allowing S1 to return to work. S1 will not work at the facility until proof of association is obtained.

Deadline recorded: Dec 10, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705(f)(2) Care of Persons with Dementia. (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as items were accessible to residents with dementia, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Executive Director agreed to do the following: 1. Items were secured during today’s visit. Plan of Correction met.

Deadline recorded: Dec 10, 2021. A deadline is not proof that correction was completed.