OAKHURST BOARD AND CARE

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. The following requirement has not been met as evidenced by: Resident 1 and Resident 2 need current updated assessments, which poses a potential, health, safety, or personal rights risk to residents in care.

Official plan of correction

Administrator will submit updated appraisals for Resident and Resident to LPA by POC date of 11/04/2025.

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

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 2 of 9 bedrooms smell strongly of urine, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/14/2025 Plan of Correction Administrator shall ensure the facility resident bedrooms do not smell of urine, and submit proof to LPA by POC date of 10/14/2025.

Official classification

Type B

Official code

87555(8)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. 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 LPA observred rotten, moldy cabbage inside facility refrgerator, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/14/2025 Plan of Correction Administrator will submit food safety training to LPA by POC date of 10/14/2025.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (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. 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 LPA observed the facillity carpet to be heavily stained, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/14/2025 Plan of Correction Administrator will ensure the facility carpets are cleaned, and send proof to LPA by POC date of 10/14/2025.

Official classification

Type A

Official code

1569.618(a)

Regulation authority

HSC

What the official deficiency says

(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA have never observed the administrator Lucy Leang to be at the facility. There is no schedule indicating when the administrator is at the facility. LPA conducted multiple interviews, and the interviewees did not know who Lucy Leang was. Lucy's file with Administrator information is not current. Staff schedule did not show Lucy on schedule

Official plan of correction

POC Due Date: 09/26/2024 Plan of Correction Licensee will provide updated information for current or new administrator.

Official classification

Type A

Official code

87412(a)(13)(B)

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: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement. 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 which poses an immediate health, safety or personal rights risk to persons in care. LPA did not observe a current administrator's certificate. Correct background clearance was not file in staff files.

Official plan of correction

POC Due Date: 09/26/2024 Plan of Correction Licensee will provide information to LPA regarding Administrator at the facility.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. 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 which poses an immediate health, safety or personal rights risk to persons in care. 9/20/24 LPA observed a cabinet with resident's medications to be unlocked and accessible to residents

Official plan of correction

POC Due Date: 09/26/2024 Plan of Correction Licensee will provide a plan to LPA to correct the deficiency listed above.

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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 which poses an immediate health, safety or personal rights risk to persons in care. LPA observed resident's medications being kept in a weekly pill planner.

Official plan of correction

POC Due Date: 09/26/2024 Plan of Correction Licensee will provide a plan to LPA to correct the deficiency listed above.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. On 9/20/24 and 9/25/24 LPA observed auditory alarms on the exits to not be on or in working order.

Official plan of correction

POC Due Date: 09/26/2024 Plan of Correction Licensee will provide an explanation to LPA how the deficiency above will be corrected.

Official classification

Type A

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. 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 which poses an immediate health, safety or personal rights risk to persons in care. LPA reviewed a sample of resident's Centrally Stored Log which was not properly completed for R1

Official plan of correction

POC Due Date: 09/26/2024 Plan of Correction Licensee will submit verification of how the deficiency listed above will be corrected.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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 which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee/staff was not able to provide verification of current insurance.

Official plan of correction

POC Due Date: 10/04/2024 Plan of Correction Licensee will provide verification of current insurance for the facility.

Official classification

Type B

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

(g) All personnel records shall be maintained at the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. On 9/20/24 LPA was not able to review personnel records due to not being at the facility.

Official plan of correction

POC Due Date: 10/04/2024 Plan of Correction Licensee will provide a plan on how to correct the deficiency listed above and will provide verification to LPA.

Official classification

Type B

Official code

87412(c)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. 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 which poses/posed a potential health, safety or personal rights risk to persons in care. On 9/20/24 LPA was not able to review staff files due to not being at the facility. On 9/25/24 LPA was able to review staff files which did not have verification of current training.

Official plan of correction

POC Due Date: 10/04/2024 Plan of Correction Licensee will update and maintain staff files, verification will be sent to LPA.

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 observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed some of the staff training verification in the staff files did not have the amount of time spent on training.

Official plan of correction

POC Due Date: 10/04/2024 Plan of Correction Licensee will submit verification on how this discrepancy will be correct.

Official classification

Type B

Official code

87465(b)

Regulation authority

CCR

What the official deficiency says

(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed R2's records which has did not have updated PRN form with correct medication listed.

Official plan of correction

POC Due Date: 10/04/2024 Plan of Correction Licensee will provide explaination of how deficency will be corrected.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. LPA reviewed R1's records which has physician reported dated 9/21/2020.

Official plan of correction

POC Due Date: 10/04/2024 Plan of Correction Licensee will have a current physician's report for all residents with a dementia diagnosis.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). (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: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed box cutter/razor in unlocked kitchen drawer, shed in the back of the facility unlocked with tools and other hazardous items, gardening items & cigarette butts left outside and accessible.

Official plan of correction

POC Due Date: 09/26/2024 Plan of Correction Licensee will provide documentation on plan to correct the deficiency listed above

Official classification

Type A

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 observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed one caregiver at the facility answering medication questions to family members, trying to conduct a tour, playing bingo with residents, give water to resident, make dinner, and tend to other resident needs

Official plan of correction

POC Due Date: 09/26/2024 Plan of Correction Licensee will create a plan to correct deficiency listed above and provide to LPA

Official classification

Type B

Official code

1569.695(b)

Regulation authority

HSC

What the official deficiency says

(b) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA is not observe documentation emergency drills to be conducted at the facility.

Official plan of correction

POC Due Date: 10/04/2024 Plan of Correction Licensee will provide plan to correct to LPA.

Official classification

Type B

Official code

87470(2)(A)(D)

Regulation authority

CCR

What the official deficiency says

(2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary. These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material. (D) Facility items that cannot be disinfected shall be discarded immediately in an appropriate waste receptacle with a tight-fitting cover or otherwise made inaccessible to human contact or transmission. 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 which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed soiled toilet paper to be on the floor of the bathroom, trash can with no fitted lid, and brown markings on the back of the bathroom door.

Official plan of correction

POC Due Date: 10/04/2024 Plan of Correction Licensee will create plan to correct deficiency listed above and submit to LPA.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. 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 which poses/posed a potential health, safety or personal rights risk to persons in care. Centrally Stored Medication log was not properly completed.

Official plan of correction

POC Due Date: 09/15/2023 Plan of Correction Administrator Desginee- Ester Jackson will be retraining the staff. Verification of training will be sent to LPA by 9/15/23.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on observation & interview the licensee failed to keep scissors and gas can inaccessible to residents in care. This poses an immediate health, safety, or personal rights risk to residents in care.

Official plan of correction

Scissors were removed and put away inaccessible to residents. Pictures will be sent verifiying gas can has been removed an inaccessible to residents.

Deadline recorded: Aug 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: Based on observation & interview the licensee failed to have operating auditory devices to monitor exits. LPA tested front door and side door. This poses potential health, safety, or personal rights risk to residents in care.

Official plan of correction

Owner is going to have maintenance look to see if a wire is not tripped. Owner will verify alarms are working and provide verification to LPA.

Deadline recorded: Sep 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 when LPA and S1 observed at 09:19 AM five knives on kitchen counter unlocked. At 09:29 AM, LPA and S1 observed multiple tools unlock and stored in the keys and batteries drawer in the kitchen. At 09:42 AM, LPA and S1 observed a wrench on the counter in the master bathroom unlocked which are accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/03/2022 Plan of Correction Staff immediately removed knives and tools. Knives and tools were removed and stored under locked kitchen sink. POC cleared during visit.

Official classification

Type A

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

87405(d)(2) Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, Fire Extinguisher has a service date of 05/13/21, which poses an immediate health and safety risk to the residents.

Official plan of correction

POC Due Date: 09/03/2022 Plan of Correction Fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 09/3/22.