WINDCHIME OF MARIN

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation Water temperature in sinks measured at 120.9 degrees F in room #211, 120.5 degrees F in room #203, 119.6 degrees F in room #200, 121.4 degrees F in room #311, and 121.1 degrees F in room #301, finding 6 out of 10 rooms tested not within the allowable range of 105 to 120 degrees F. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/06/2026 Plan of Correction Licensee or Administrator to submit 7 day water log of residents bathroom water facuets showing temperature within range and submit to LPA by POC due date of 7/6/2026 to clear citation. *** $250 Civil Penalty for Repeat citation within 12 month period.

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and BOD observation of unlocked kitchen cabinet under sink in 3rd Floor MC unit to contain disinfectant cleaning supplies which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/29/2026 Plan of Correction Facility removed disinfectant durning inspection, facility to conduct in-service training for staff on how to properly store items that may pose a danger to residents in care by plan of correction due date.

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by: Deficient Practice Statement LPAs observed that the facility had no complaint poster up and visible per regulation requirement, 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.

Official plan of correction

POC Due Date: 06/29/2026 Plan of Correction Licensee agrees to post the CCL Complaint Poster per regulation; Submit a picture showing the poster is in the main entryway no later than POC due date, 6/29/2026.

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin observation, the licensee did not comply with the section cited above in that Food items located in main kitchen were not stored in a safe manner and open items were not covered or closed. Items found uncovered or unsealed or both include:dried green peas & Messa, chicken, hamburger patties out on tray in kitchen, box of frozen peas, mini pies, slices of carrot cake, ice cream containers which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/29/2026 Plan of Correction Facility to conduct in-service training with all kitchen staff on proper storage of food by plan of correction due date.

Official classification

Type B

Official code

87555(b)(25)

Regulation authority

CCR

What the official deficiency says

(25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA ,BOD, and Admin observation, the licensee did not comply with the section cited above in that LPA and Admin observed bleach and other toxins stored in main kitchen next to food preparation area, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/29/2026 Plan of Correction Facility to conduct in-service training with kitchen staff on proper storage of toxins/cleaning products used in kitchen by plan of correction due date. Culinary director or designee will monitor proper storage of toxins cleaning solutions.

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 LPA's interview & record review found resident (R2) was missing 1 Trazadon per count, R3 AM Amlodipine (1 missing) Levothyroxine (3 not given), R4 Benzopril (6 additional pills). which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/29/2026 Plan of Correction Outside source to conduct in-service medication record training with (Allen Flores Group) and submit signed log by all Med Techs dated and name of training and trainer with duration of training, to be submited to CCL by POC due date.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed, Licensee did not complete an evaluation of resident’s (R4) condition prior to admission and keep it in the file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/29/2026 Plan of Correction Licensee will submit a plan of how they will ensure resident’s pre-admission appraisals are completed prior to resident’s admission. Plan of future compliance to be submitted to CCL by POC due date.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review & interview the licensee did not comply with the section cited above in 1 out of 6 records reviewed found R6 did not have TB test results on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/06/2026 Plan of Correction Facility to obtain TB test & results for resident (R6) and submit to LPA by POC due date to clear deficiency.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

87202 Fire Clearance: (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal...This requirement is not met as evidenced by: Based on observation during Annual inspection and information... received from Local Fire Department, Licensee did not comply with the section cited above by not following fire clearance regarding windows and screens resulting in the fire department providing conditional fire clearance until 9/18/2026 or if prior windows and screens fixed to notify CCL & Fire Dept. This is an immediate risk to residents in care.

Official plan of correction

Licensee has initiated the replacement of all residents’ window locks and unapproved screen locks etc., by having two glass companies out (10/29/25 & 10/30/25) who are submitting quotes with the final third soon. Once quote is approved, Licensee/Admin will.. .. provide to CCL and update with progress until complete. **** Immediate Civil Penalties of $500.

Deadline recorded: Oct 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

87464(f)(4). Basic Services. Basic services shall at a minimum include:...Personal assistance and care as.. indicated in the pre-admission appraisal, …such as dressing, eating, bathing..***Based on documents reviewed and interviews conducted, this requirement was not met as evidenced by: Care report-appraisal for 8/26/2025 indicate R1 was to have 2 showers per week although, there were no shower logs for time frame or notes indicating shower refusals, along with 4 staff interviews indicated R1 not showered 8/26 thru 9/11/2025. This posed an immediate risk to the health and personal rights of R1

Official plan of correction

Administration to provided refresher training to staff on the subject of showers provided to residents regarding Regulations 87464(f)(4) and submit by 10/31/2025 type of training and date training will be conducted. Logs and scope of training with signatures to be submitted to CCL/LPA by 11/7/25 to clear citation.

Deadline recorded: Oct 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency...(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident... This requirement has not been met based on document review and interviews revealing due to facility writing wrong number of responsible party they were not reached, as well responsible party indicated they never receive written notice of incident report. This is a potential risk to residents in care.

Official plan of correction

Facility Administrator agrees to have staff who are responsible for inputting contact information and reporting incidents, complete an in-service training regarding regulation 87211 no later than POC due date, 11/7/2025 and submit a copy of signed and dated log.

Deadline recorded: Nov 7, 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 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 was not met as evidenced by: Based on record review, Licensee did not comply with the section cited above and did not ensure that medication was administered to R1 as required. R2 Incident Report stated that PM Med Tech provided wrong medication ??times. This is an immediate health and safety risk to residents in care.

Official plan of correction

Licensee provided proof of training that was conducted on 10/16/2025 on " The Six Rights " , central storage of medications, & medication destruction process when an order is discontinued, for all med techs that administer medications. Deficiency cleared during visit.

Deadline recorded: Oct 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(d)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement... This requirement not met by licensee as evidenced by: R1 eloped from facility and was found by Fire Dept approximately 2 hrs later alone outside of facility property, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator submitted staff training on elopement prevention and procedures. Citation cleared at visit.

Deadline recorded: Sep 5, 2025. 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

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observation (see pics) Housekeeping closet was found unlocked with toxic cleaning chemicals including Mold Armor Rapid clean remediation & R3 room LPA observed unlocked bathroom cabinet with razors and supplies (see pics) which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/25/2025 Plan of Correction Licensee or Administrator will provide an LIC 9098 Proof of Corrections self certifying that CCR Regulation 87309(a) was reviewed with all Memory Care staff by POC due date of 5/7/2025.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights...(a) In addition to the rights listed in Section 87468.1...residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, This requirement is not met as evidenced by: Deficient Practice Statement and competency to meet their needs. This requirement not met by licensee as evidenced by: Based on LPA observations, interview and record review, facility is not meeting resident's needs having only 1 caregiver on each of the 2 floors of 26 dememtia residents (10 two person assist & 16 1 person assist) and only 1 med tech, which poses an potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/25/2025 Plan of Correction Licensee /Administrator will submit plan of how they will cover the amount of residents having multiple needs (10 two person assists) by making sure there are 4 caregivers (2 on each floor) for AM and PM shifts. Not including Med tech and or RCD. Will submit POC to LPA by end of 7/25/2025 to clear POC.

Official classification

Type B

Official code

1569.311

Regulation authority

HSC

What the official deficiency says

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA & Administrator's observation, record review and interview the licensee did not comply with the section cited above in not finding any records indiating attached to smoke detection system or carbon monoxide detectors in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2025 Plan of Correction LIcensee or Administrator to obtaine carbon monoxide detector and put in facility. Administrator will be putting in one on each level and submit to LPA receipt and pictures with self certification they understand the regulation by POC due date of 8/1/2025 to clear citation.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 6 out of 10 resident bathroom faucets were not within regulation temp of 105 to 120 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2025 Plan of Correction Licensee or Administrator to submit 5 day water log of residents bathroom water facuets showing temperature within range and submit to LPA by POC due date of 8/1/2025 to clear citation.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment: (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed, Licensee did not ensure R4 received a medical assessment prior to admission. This poses a potential Health, Safety or Personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2025 Plan of Correction Licensee shall submit self certification they have read and understand Regulation 87458. Self certification shall be submitted to CCLD by 08/1/2025 to clear citation.

Official classification

Type B

Official code

1569.69(a)(1)

Regulation authority

HSC

What the official deficiency says

1569.69(a)(1) Medication Administration Training (a)Each residential care facility for the elderly shall ensure that each employee …who assists residents with the self-administration of medications meets all the following training requirements: (1)In facilities licensed for 16 or more.. employee shall complete 24 hours of initial training…consisting of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction..which shall be completed within the first four weeks of employment. This requirement is not met as evidenced by: Based on: Record review & interview with Administrator, S1 lacks proof of required HSC 1569.69(a)(1) medication training, 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.

Official plan of correction

Licensee to ensure that all staff obtain the H & S Code initial medication training as required; Submit proof of S1’s, medication training (16 hrs of hands on shadowing training) by POC due date of 8/20/2024.

Deadline recorded: Aug 20, 2024. 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

87625(b)(3) Managed Incontinence (b)In addition to Section 87611, General .., the licensee shall be responsible for :(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: Based on statements and observation, this requirement is not met as evidenced by: On 8/22/24 LPA & staff observed 3rd floor of facility and R1 & R2’s rooms having strong incontinence odors. This poses a potential health & safety risk to R1, R2 & other residents in care.

Official plan of correction

Licensee to ensure an in-service is conducted with all staff regarding incontinent care services to residents. Submit plan of future compliance with this regulation, ensuring staff are checking on resident and changing resident timely... & staff are cleaning floors to keep facility free of odors from incontinence. Submit proof of training. All POC documentation is due 8/20/24.

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

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(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: Deficient Practice Statement Based on LPAs observations, the Licensee did not comply with the section cited above. LPAs observed razors & a pair of scissors and other sharp objects in an unlocked resident bathroom cabinet accessible to residents in care along with a 5 gallon bucket of pain in unlocked staff room in kitchenette. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/01/2024 Plan of Correction Licensee to submit 1) Self-Certification stating that training will be conducted with facility staff, 2) an In-Service Training will be done reviewing Regulation Care of Persons with Dementia 87705(f)(1). Self Certification to be submitted to Community Care Licensing (CCL) by POC due date of 5/1/2024, and Training to be submitted by due date of 6/13/2024.

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: Deficient Practice Statement Based on observation (see pics), licensee did not comply by having a bed frame on 3rd floor east side emergency exit door, restricting ability of residents to exit, which poses an immediate health, safety or personal rights risk to persons in care. **Immediate Civil Penalty assessed in the amount of $500.

Official plan of correction

POC Due Date: 05/31/2024 Plan of Correction Administrator to send in written statement indicating that they understand regulation 87203 and will ensure future compliance -as proof of correction by POC due date 5/31/2024. Beds have beds have been removed.

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 Two (2) staff lack proof of required annual training, per LPA's file reviews, the licensee did not comply with the section cited above in two out of five files reviews, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/13/2024 Plan of Correction Licensee to ensure all four direct care staff obtain required annual training; Submit proof of training by POC due date of 6/13/24.

Official classification

Type B

Official code

87555(b)(23)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by: Deficient Practice Statement LPA observed food, half a quiche uncovered in kitchenette drawer, accessible to residents in care, & unwrapped/uncovered ice cream in freezer & uncovered pie from previous day in refrigerator . This is a risk of resident's health & safety and/or a personal rights risk to residents in care.

Official plan of correction

POC Due Date: 06/13/2024 Plan of Correction Licensee to ensure that the facility is following regulations, and that cold food items are kept cold at appropriate temperature, and hot foods are kept at appropriate hot temperature and covered. Licensee to ensure food is also safe for resident consumption. Licensee to submit how the food service will be handled regarding residents picking up their meals and/or having their meals delivered where the food is kept healthy and safe to serve to residents in care.Submit policies and procedures on the above. Plan of correction is due 6/13/24.

Official classification

Type B

Official code

87705(d)

Regulation authority

CCR

What the official deficiency says

(d) In addition to requirements specified in Section 87303, Maintenance and Operation, safety modifications shall include, but not be limited to, inaccessibility of ranges, heaters, wood stoves, inserts, and other heating devices to residents with dementia. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 2 out of 2 water heating food warmers in 2nd & 3rd floor dementia facility kitchettes were not secured from residents in care which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/13/2024 Plan of Correction Administrator to enclose or remove food warming devices in both kitchenettes and submit proof by 6/13/2024 with a written statement of understanding of regulation 87705(d).

Official classification

Type B

Official code

1569.69(b)

Regulation authority

HSC

What the official deficiency says

1569.69(b)Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement is not met as evidenced by: Deficient Practice Statement Two (2) staff lack proof of required HSC 1569.69(b) medication training, per LPA's file reviews, the licensee did not comply with the section cited above in two out of five file reviews, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/13/2024 Plan of Correction Licensee to ensure that all staff obtain the H & S Code annual medication training as required; Submit proof of the staffs, four (2), medication training by POC due date of 6/13/24.

Official classification

Type B

Official code

80087(a)

Regulation authority

CCR

What the official deficiency says

80087(a)Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times. This requirement is not met as evidenced by: Deficient Practice Statement *Based on observation facility did not maintain facility in good repair by: 3rd floor, black coloring on floor under kitchenette sink where water leak use to be, a missing bedroom door to room 314 & bathroom wall to resident (R1)’s room at all times through out of the facility which poses a potential health, safety risk to clients in care.

Official plan of correction

POC Due Date: 06/13/2024 Plan of Correction Licensee must maintain the facility clean, safe, sanitary, and in good repair at all times. Facility agrees to ensure that the entire facility will be clean and in good repair at all times. Facility to fix flooring under kitchette, bedroom door, bathroom wall to R1's room. Administrator to submit an LIC 9098 self-certification that facility is in good repair to CCL by POC date of 6/13/2024 and pictures of corrected issues in order to clear the deficiency.

Official classification

Type A

Official code

87211(a)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following:(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by:LPA learned that the facility was made aware about the incident in late November 2023 and failed to report to the Department of Social Services-Community Care Licensing Division which presents an immediate health, safety and personal rights risk to the residents in care. As well, CCL has not received any reports from facility since 11/21/2023 (4 weeks), when they use to submit SIR’s Hospice Initiations, Death Reports, & SOC’s weekly.

Official plan of correction

Licensee shall submit an LIC 9098 understanding the regulation. Licensee shall submit a Plan for Future Compliance and how this plan will be implemented. Licensee shall retrain ALL staff that provide Care and Supervision regarding Reporting Requirements and submit signed, dated doc to CCL by POC 12/20/23 Plan of Correction for 2nd document due on December 20, 2023.

Deadline recorded: Dec 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance- (e) All individuals subject to a criminal record review pursuant to H & S Health and Safety Code Section 1569.17(e) shall prior to...residing...in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department... This requirement is not met as evidenced by: Based on LPAs record review and interview with Administrator, facility did not ensure private agency caregiver (I1) was fingerprint cleared and had been working at the facility for approximately three months when incident happened and has been let go. This presents an immediate health and safety risk to residents in care.

Official plan of correction

Administrator to ensure all individuals subject to a criminal record review are fingerprint cleared and associated to facility if volunteering or working at facility. Facility to submit a written statement they understand regulation 87355(e)(1) and will be in future compliance. Facility to submit statement to CCL by POC due date 12/15/2023. Civil Penalties in the amount of $500.00

Deadline recorded: Dec 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

(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: This requirement is not met as evidenced by: Based on LPA record review and interview with Administrator & RCD facility did not ensure to obtain a criminal record clearance for staff (S1) prior to work, reside or provide care to residents in care which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Law Enforcement removed staff (S1) from the premises and facilty will not schedule S1 again. Licensee will submit a self-certification LIC9098 ensuring that regulation was understood to CCL by POC due date. ***Civil Penalty is being assesed for the amount of $500.

Deadline recorded: Aug 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review conducted on May 15, 2023, the Administrator did not comply with the section cited above in 3 out of 5 staff members who are required, did not have current First Aid as required by Title 22 regulations. This poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 05/18/2023 Plan of Correction Administrator to ensure that all required staff have current first aid certification at all times. Licensee to submit proof of First Aid Certification for staff S1, S2, & S3 to CCL by POC date of EOB 5/18/2023.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance- (e) All individuals subject to a criminal record review...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: Deficient Practice Statement Based on observation, interview and record review, today's visit and verification with CCL: Licensee did not ensure the regulation above due to S2 & S3 who were fingerprint cleared but NOT associated to this facility as required. This is an immediate risk to the Health & Safety of residents in care.

Official plan of correction

POC Due Date: 05/18/2023 Plan of Correction Licensee agrees to associate S2 & S3 to facility. Facility to submit a written statement they understand regulation 87355(e)(2) and will be in future compliance. Facility to submit statement to CCL by POC due date 5/18/2023.

Official classification

Type A

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

87705(b)(2) Care of Persons with Dementia: Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by: Deficient Practice Statement Based on a review records and interview with RCC it was found that resident (R1) had been reported by facility to be missing from facility care. Medical documents indicate diagnosis of dementia.

Official plan of correction

POC Due Date: 05/17/2023 Plan of Correction Facility provided in-service training conducted, for regulation 87705 Care of Persons with Dementia with staff. But has not submitted LIC9098 with date & signatures of staff, to be submitted by 5/17/2023. Facility has also fixed electrical issue, and increased status checks.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

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. Based on LPAs observation and interview the facility failed to ensure toxins are stored inaccessible to residents in care which poses an immediate health and safety risk to residents in care.

Official plan of correction

In addition, Administrator to conduct an in-service training and will submit proof of training to include regulation discussed, attendees signature and date/time of training. Submit roster to CCL by 6/07/2022.

Deadline recorded: May 27, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

87705(f)(1)Care of Persons w/Dementia - The following shall be stored inaccessible to residents with dementia: 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 the licensee failed to maintain sharp objects /scissors locked in the facility resident bedroom which poses an immediately Safety risk to residents in care. LPA toured the facility & observed a box of razzors, nail clippers, and an unlocked pair of scissors in resident's R2 bathroom.

Official plan of correction

danger to the resident's in care. Facility to submit a LIC 9098 self certification that all items that constitute danger has been removed, and that caregivers & housekeepers are aware of this regulation by POC date of 5/27/2022.

Deadline recorded: May 27, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

This requirement is not met as evidenced by: 87303(e)(2) Maintenance & Operation.Hot water provided for the use of residents shall be maintained between 105 and 120 degrees F. This requirement is not met as evidenced by: Based on observation the licensee failed to have hot water temperature between 105 & 120 F in 7 of 9 resident's bathrooms which poses an immediate Health, Safety risk for residents in care. LPA toured the facility w/ Interim adm. and observed that 7 of the 9 hot water temperature ranged between 121.8 and 124.5 degrees F.

Official plan of correction

Facility to begin monitoring for the next 7 days. Interim Admin to submit a 7 day log taken from the resident's bathrooms to CCL by 6/07/2022.

Deadline recorded: May 27, 2022. A deadline is not proof that correction was completed.