Medication handling and storage
Cited in 3 reports, with 3 deficiencies in total.
PRESERVE AT WOODLAND HILLS, THE
6221 FALLBROOK AVENUE, Woodland Hills CA 91367
60 bedsLatest official report Aug 12, 2026Licensed
Additional info
- Telephone
- (747) 226-5834
- Licensee
- WELBROOK WOODLAND HILLS OPCO LLC;WOODLAND HILLS MC
- Administrator
- SUSAN WEISBARTH
- Contact
- SUSAN WEISBARTH
- License first date
- Aug 27, 2021
- License effective date
- Aug 27, 2021
- District office
- WOODLAND HILLS N.ASC · (818) 596-4334
- Regional office
- 29
- Clients served
- 935 - ELDERLY, 983 - RCFE / DEMENTIA, 985 - RCFE / HOSPICE
Summary
The available records show 28 Type A and 16 Type B deficiencies for this facility.
- Most recent inspection
- Aug 12, 2026
- Most recent deficiency
- Aug 12, 2026
No later report is available, so the records do not show what happened afterward.
What Type A and Type B mean
- Type A
- Violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
- Type B
- Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
At a glance
Counts cover the five-year public record. Typical figures are the median for the 212 Los Angeles County facilities licensed for 50 or more beds.
In the available public five-year record, CCLD published 51 reports for this facility: 20 inspections, 31 complaint investigations, and 0 licensing or administrative records.
Those records contain 28 Type A and 16 Type B deficiencies.
2 deficiencies have explicit official correction or clearance evidence in the loaded records.
- Official inspections
- 20
- Recorded deficiencies
- 44
- Type A deficiencies
- 28
- Type B deficiencies
- 16
- Substantiated complaints
- 14
- Repeated topics
- 4
More than the typical 7
4 in the last 12 months
Well above the typical 8
5 in the last 12 months
Well above the typical 3
0 in the last 12 months
Well above the typical 5
5 in the last 12 months
Well above the typical 3
0 in the last 12 months
Last 36 months
Repeated topics
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
Staffing, personnel, and training
Cited in 2 reports, with 4 deficiencies in total.
Admission, assessment, and eviction
Cited in 2 reports, with 2 deficiencies in total.
Basic services and supervision
Cited in 2 reports, with 2 deficiencies in total.
Official report history
All preserved reports from the most recent to the oldest, sortable by report type.
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Admission, assessment, and evictionType B
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Feb 27, 2025
Correction not verified in available records
Complaint
Allegations1 substantiated · 3 unsubstantiated · 0 unfounded · 1 cited
Medical and dental careType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Dec 20, 2024
Correction not verified in available records
Complaint
Allegations0 substantiated · 13 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 2 unsubstantiated · 0 unfounded · investigated over 3 visits
No deficiencies recorded in this reportComplaint
Part of the complaint whose outcome is recorded on Nov 13, 2024 · Control 29-AS-20240830143412
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 3 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Part of the complaint whose outcome is recorded on Nov 13, 2024 · Control 29-AS-20240830143412
No deficiencies recorded in this reportComplaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Resident rightsType A
- 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 record says corrected or clearedOn or before Sep 4, 2024
Plan of correction recorded
Correction deadline recordedDeadline Sep 5, 2024
Complaint
Allegations0 substantiated · 1 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations2 substantiated · 0 unsubstantiated · 0 unfounded · 2 cited
Basic services and supervisionType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Aug 14, 2024
Correction not verified in available records
Health conditions and treatmentsType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Aug 14, 2024
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Administrator qualificationsType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Aug 1, 2024
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Admission, assessment, and evictionType B
- 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.
Plan of correction recorded
Correction deadline recordedDeadline May 15, 2024
Correction not verified in available records
Complaint
Allegations1 substantiated · 1 unsubstantiated · 0 unfounded · 1 cited
Incident reportingType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Apr 4, 2024
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 1 cited
Fire safety and emergency preparednessType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Dec 12, 2023
Correction not verified in available records
Complaint
Allegations0 substantiated · 2 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations0 substantiated · 3 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
Allegations3 substantiated · 2 unsubstantiated · 0 unfounded · 3 cited
Medical and dental careType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Aug 19, 2022
Correction not verified in available records
Basic services and supervisionType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Aug 19, 2022
Correction not verified in available records
Administrator qualificationsType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Aug 19, 2022
Correction not verified in available records
Complaint
Allegations7 substantiated · 0 unsubstantiated · 0 unfounded · 6 cited · investigated over 2 visits
Health conditions and treatmentsType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Jul 15, 2022
Correction not verified in available records
Staffing, personnel, and trainingType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Jul 15, 2022
Correction not verified in available records
Resident rightsType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Jul 15, 2022
Correction not verified in available records
Staffing, personnel, and trainingType B
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Jul 29, 2022
Correction not verified in available records
Complaint
Allegations2 substantiated · 0 unsubstantiated · 0 unfounded · 2 cited
Facility condition and maintenanceType B
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Jul 22, 2022
Correction not verified in available records
Facility condition and maintenanceType B
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Jul 22, 2022
Correction not verified in available records
Complaint
Allegations4 substantiated · 0 unsubstantiated · 0 unfounded · 4 cited
Resident rightsType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Jun 30, 2022
Correction not verified in available records
Resident rightsType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Jun 30, 2022
Correction not verified in available records
Facility condition and maintenanceType A
- 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 record says corrected or clearedOn or before Jun 3, 2022
Correction deadline recordedDeadline Jun 30, 2022
Facility condition and maintenanceType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Jun 30, 2022
Correction not verified in available records
Complaint
Part of the complaint whose outcome is recorded on Jul 13, 2022 · Control 29-AS-20211203112208
Medical and dental careType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline May 12, 2022
Correction not verified in available records
Staffing, personnel, and trainingType B
- 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.
Plan of correction recorded
Correction deadline recordedDeadline May 20, 2022
Correction not verified in available records
Complaint
Allegations1 substantiated · 0 unsubstantiated · 0 unfounded · 2 cited
Resident rightsType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Mar 18, 2022
Correction not verified in available records
Facility condition and maintenanceType A
- 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.
Plan of correction recorded
Correction deadline recordedDeadline Mar 16, 2022
Correction not verified in available records
Source and limits
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
Read the data methodology