MARIN TERRACE

Official classification

Type A

Official code

87628(a)

Regulation authority

CCR

What the official deficiency says

87628(a)Diabetes: 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 with blood or urine specimens. This requirement is not met as evidenced by: Based on interviews & file review the licensee failed to ensure that resident (R1) was retained at the facility while not able to perform a glucose testing as per physician's report, but the facility did not followed up more than once to ensure R1’s glucose levels were monitored, which poses an immediate risk to the health and safety of residents in care.

Official plan of correction

The Administrator agrees to ensure blood glucose testing is performed by an appropriately skilled medical professional or contact R1’s physician for current blood glucose order and submit plan to CCL to ensure a skilled medical professional is performing the test by POC due date.

Deadline recorded: Mar 11, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

87303(e)(3) Maintenance and Operation Taps delivering water at 125 degree F (52 degree C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Deficient Practice Statement Based on the temperature reading of hot water facets not used by residents, the kitchen sink facet reading was 135.5 and 124 in the bathrooms which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/11/2026 Plan of Correction Administrator agrees to place warning signs for faucets delivering water 125 or above. To clear this violation, Administrator will submit photo proof of each faucet identified in this report with a warning sign placed near the facet to warn the user of the hot water temperature. Photos to be submitted to CCL by POC date by 3/11/26

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports.: (2) Occurrences, such as...major accidents which threaten the welfare, safety or health of residents..., shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA’s record review and interviews with the Administrator, the facility failed to notify the Department about R1’s and R2’s incidents, which could pose a potential risk to the health and safety of residents in care.

Official plan of correction

POC Due Date: 03/24/2026 Plan of Correction The Administrator agrees to review reporting requirements regulation, conduct training with all staff about reporting requirements, and will submit a written policy about the process that staff will follow to ensure that incidents are reported timely to CCL as proof of correction to clear the deficiency by POC due date 3/24/26.

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. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's/Administrator observation and interview, the licensee did not comply with the section cited above in elevator was last inspected on 11/20/23 and permit expired on 11/20/24. Also, the auditory alarm when opening the door leading to second building located in the back of the facility was not working which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/24/2026 Plan of Correction Licensee shall submit self-certification (LIC9098) they have read and understand Regulation 87303. Self-certification shall be submitted to CCLD by POC due date.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

1569.618(c)(3) Employee Scheduling - Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview the licensee failed to have at least one staff member who has CPR and 1st Aid training on duty at all times. Facility has 3 out of 5 caregivers that work at the facility without a valid CPR certificate which poses a potential health, safety risk to residents in care.

Official plan of correction

POC Due Date: 03/24/2026 Plan of Correction Administrator to ensure that at least one staff on duty has CPR training at all times & all staff have First Aid. Administrator to submit self-certification form (LIC9098) ensuring that staff have current CPR trained per regulation by POC due date.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 4 out of 5 staff did not have required training completed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/14/2025 Plan of Correction Facility to ensure staff receive required number of hours for annual training (identified by their start date). Administrator to create written plan describing how facility will ensure training compliance. Self certification of plan to complete staff training by Plan of Correction due date 3/14/2025.

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. The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. ***Based on statements and documents, this requirement not met as evidenced by: R1 sustained rash for approximately 4 weeks prior to receiving medical treatment arranged by facility. This posed an immediate risk to the health of R1.

Official plan of correction

Administration to review the requirements of 87465 and will submit a written declaration confirming compliance to CCL by POC date in order to clear the deficiency.

Deadline recorded: Oct 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

87465(e) Incidental Medical and Dental Care. For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication… Based upon statements, this requirement not met as evidenced by: An OTC sleep aid was observed in R1’s room which was not prescribed by R1’s physician. This posed an immediate risk to R1’s health.

Official plan of correction

Cleared at time of visit. Facility has provided refresher training to staff on the requirements of 87465.

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

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis... This requirement was not met as evidenced by: based on document review and interviews conducted, the licensee did not comply with the section cited above by not contacting emergency services in a timely manner.

Official plan of correction

Administrator agrees to submit proof of in-service training for all direct care staff regarding how to determine when to call 911. Proof of training must include: staff names with signatures, dates, topics covered, who conducted the training, etc. Proof to be submitted by POC due date 08/02/24.

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

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 5 out of 5 sinks accessible to residents in care which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/24/2024 Plan of Correction Administrator agrees submit a self certification stating that they turned down water heater by POC due date of 4/24/2024. Administrator agrees to submit a daily hot water temperature log for all sinks used by residents for the week of 4/242024 through 05/01/2024. Temperature log to be submitted to CCL by 05/02/2024.

Official classification

Type A

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 5 out of 5 persons which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/24/2024 Plan of Correction Administrator agrees to submit a plan which addresses how facility will ensure staff are receiving required initial and annual training and how hours will be tracked. Plan to be submit to CCL by POC due date of 4/24/2024.

Official classification

Type A

Official code

87468.1(a)

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: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by having cameras in 2 residents bedrooms which poses an immediate personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/24/2024 Plan of Correction Administrator agrees to contact responsible parties to remove cameras from both residents rooms and submit self certification stating that cameras have been removed to CCL by POC due date of 4/24/2024

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (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 by having expired canned foods which poses an immediate health risk to residents in care.

Official plan of correction

POC Due Date: 04/24/2024 Plan of Correction Administrator agress to develop and implement a system which will address how they will ensure to properly store food to ensure quality of food and safety of residents. Administrator will submit written policy as proof of correction to CCL by POC due date of 04/24/2024.

Official classification

Type A

Official code

87705(c)(4)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by not having staff in back cottage while resident(s) were in the building which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/24/2024 Plan of Correction Administrator agrees to submit a plan to CCL which addresses how they will ensure a staff is in the back cottage at all times by POC due date of 04/24/2024. Administrator agrees to hold an all staff meeting by 05/15/2024 that covers why there must be staff in back cottage at all times, and how they will implement the policy. Meeting conducted must have a sign in sheet with names, dates, and signatures, as well as the topics covered in meeting.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by leaving the door unlocked to the laundry room which stores toxic substances which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/24/2024 Plan of Correction Administrator agrees to submit a plan to CCL which addresses how they will ensure toxic substances are stored inaccessible at all times by POC due date of 04/24/2024. Administrator agrees to hold an all staff meeting by 05/15/2024 that includes why facility must store toxic substances inaccessible, and how they will implement the policy. Meeting conducted must have a sign in sheet with names, dates, and signatures, as well as the topics covered in meeting.

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, the licensee did not comply with the section cited above by having exit doors not equipped with auditory devices which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/24/2024 Plan of Correction Administrator agrees to submit self certification stating how they are going to ensure that all exit doors are going to remain equipped with auditory devices and maintained in operating condition. Administrator agrees to test all exit doors and replace any alarms that are inoperable. Self certification to be submitted to CCL by POC due date of 04/24/2024.

Official classification

Type B

Official code

87303(f)(3)

Regulation authority

CCR

What the official deficiency says

(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 05/01/2024 Plan of Correction Administrator agrees to purchase waste bins with tight fitting covers and replace all waste bins without covers by POC due date of 05/01/2024. Proof of purchase to be submit to CCL by 05/01/2024.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 4 out of 5 staff records reviewed which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 05/01/2024 Plan of Correction Administrator agrees to audit all staff CPR/First Aid training records and finalize which staff needs an updated CPR/First Aid on file. Administrator agrees to send updated First Aid/CPR for S1, S2, S3, S4, and S5 to CCL by POC due date of 04/23/2024.

Official classification

Type B

Official code

87412(a)(11)

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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 2 out of 5 staff which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 05/01/2024 Plan of Correction Administrator agrees to audit staff records and determine which staff are missing a health screening report, and submit health screenings for S1 and S2 to CCL by POC due date of 05/01/2024.

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 5 of 5 residents (R1, R2, R3, R4 and R5) who needs their care plan to be updated, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/08/2024 Plan of Correction Licensee to update and complete resident's Needs & Services Plan, with appropriate signatures of Administrator and resident's responsible party by POC due date of 05/08/2024. Facility to submit self certification ensuring compliance with regulation to CCL by POC due date of 5/08/2024.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) 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 record review, the licensee did not comply with the section cited above which poses a potential 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 provide proof of disaster drill being conducted by POC due date of 05/01/2024.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by having residents whose beds are equipped with half rails without physicians orders on file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/08/2024 Plan of Correction Administrator agrees to get bed rail orders for all residents who require a bed rail. Proof of physicians orders to be provided to CCL by POC due date of 05/08/2024.

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 by not ensuring that the facility remains free from odors from incontinence which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/01/2024 Plan of Correction Administrator agrees to submit self certification stating that they reviewed the regulation as well as how they will ensure compliance by POC due date of 05/01/2024

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 record review, the licensee did not comply with the section cited above in 5 out of 5 residents which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/01/2024 Plan of Correction Administrator agrees to update residents (R1, R2, R3, R4, R5) medical assessments, by POC due date of 05/08/2024. Facility to submit self certification stating how they will ensure compliance with regulation to CCL by POC due date of 5/08/2024.

Official classification

Type B

Official code

87211(a)(1)(B)

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…(1) A written report shall be submitted to the licensing agency & person responsible for the resident within 7 days of the occurrence of any of the events…(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement has not been met as evidence by: Based on LPA’s records review and interviews conducted Administrator did not ensure that CCL was notified of incidents involving R1 after falls. Per hospice records revealed that R1 had incidents of falls and changes of conditions that were not reported to them nor CCL, which poses a potential health & safety risk to residents in care.

Official plan of correction

Administrator to ensure all incidents that threaten the safety of residents are reported to CCL per regulation. Administrator to review regulation, contact an outside vendor to conduct training for all staff on reporting requirements. Signed statement that the regulation was reviewed & sign in sheet for all staff trained to be submitted by POC due date. Administrator was informed that the Department will be scheduling an informal virtual office meeting to address areas of concerns & overall compliance of the facility.

Deadline recorded: Mar 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269(a)(6)

Regulation authority

CCR

What the official deficiency says

§1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (6) To care, supervision, & 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 has not been met as evidence by: Based on LPA’s records review and interviews. The facility staff did not ensure that R1 was provided with adequate supervision by locking the back door of the main building blocking R1 from coming inside as well as staff not going to check on R1 every two-three hour as ordered by their physician, which is an immediate risk to the health and safety of residents in care.

Official plan of correction

The Licensee/Administrator agrees to submit a plan to ensure facility is following up on resident’s needs and observation of the resident to CCL by POC due date to clear the citation. *Immedicate civil penalty issued in the amount of $250 for repeated violation within 12 months (11/2023). Administrator was informed that the Department will be scheduling an informal virtual office meeting to address areas of concerns & overall compliance of the facility.

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

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement has not been met as evidence by: Based on LPA’s records review and interviews. The facility staff failed to call 911 or other medical personnel as the hospice agency after R1 had a fall and changes of conditions, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Licensee/Administrator agrees to submit a plan regarding timely medical care after resident’s fall and will train staff as to the regulation. Administrator agrees to send proof of training & written fall plan in how to ensure what staff are to do after a fall to CCL by POC due date to clear the citation. Administrator was informed that the Department will be scheduling an informal virtual office meeting to address areas of concerns & overall compliance of the facility.

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

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, & competent to provide the services necessary to meet resident needs...ensure provision of personal assistance & care...This requirement has not been met as evidence by: Based on interviews conducted and records review. Facility staff did not assist R1 with shower & toileting as ordered by their physician supposedly due to their aggressive behavior after R1 came back from hospital, which poses an immediate risk to the health and safety of the residents in care.

Official plan of correction

Administrator agrees to submit a written plan in how staff will assist residents with showering & toileting at all times by POC due date. Administrator was informed that the Department will be scheduling an informal virtual office meeting to address areas of concerns & overall compliance of the facility.

Deadline recorded: Mar 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(3)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f) Basic services shall at a minimum include: (3) Three nutritionally well-balanced meals and snacks made available daily, including low salt or other modified diets prescribed by a doctor as a medical necessity…This requirement has not been met as evidenced by Based on LPA’s observation, records review and interviews with the administrator revealing that facility was not providing meals that meet Recommended Dietary Allowances. This is a potential risk to residents in care.

Official plan of correction

Facility agrees to submit a planned menu that meets the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council by POC due date to clear the deficiency. Administrator was informed that the Department will be scheduling an informal virtual office meeting to address areas of concerns & overall compliance of the facility.

Deadline recorded: Mar 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of...(a) Residents in all RCFE shall have all of the following personal rights: (2) To be accorded safe, healthful & comfortable accommodations ...This requirement has not been met as evidence by: Based on LPAs observation and record review the facility failed to ensure resident's R1 personal rights where met when R1 was found unattended on the floor wearing only pull-up diaper, which poses a potential health and safety risk to residents in care.

Official plan of correction

Administrator agrees to submit a written plan to ensure facility is following up on residents’ needs by POC due date. Administrator was informed that the Department will be scheduling an informal virtual office meeting to address areas of concerns & overall compliance of the facility.

Deadline recorded: Mar 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269(a)(6)

Regulation authority

CCR

What the official deficiency says

§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) 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 has not been met as evidence by: Based on LPA’s records review and interviews conducted with staff, the Administrator did not ensure that resident (R1) was assisted with proper care while residing in the facility, which poses an immediate risk to the health & safety of resident in care.

Official plan of correction

Administrator agrees to submit a plan to ensure facility is following up on resident’s care needs to CCL by POC due date.

Deadline recorded: Nov 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211

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… (1) A written report shall be submitted to the licensing agency & person responsible for the resident within 7 days of the occurrence of any of the events…(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement has not been met as evidence by: Based on LPA’s records review and interviews conducted Executive Director did not ensure that CCL was notified of two incidents involving R1 after hospitalizations that occurred on 12/6/23 and 3/29/23 which poses a potential health & safety risk to residents in care.

Official plan of correction

Administrator to ensure all incidents that threaten the safety of residents are reported to CCL per regulation. Administrator to review regulation, contact an outside vendor to conduct training for all staff on reporting requirements. Signed statement that the regulation was reviewed and sign in sheet for all staff trained to be submitted by POC due date.

Deadline recorded: Jun 22, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506(a)-Record Keeping: The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by: Based on observation, during the Case Management-Deficiency inspection, LPA re-reviewed Resident #1's file and observed that there was no updated Care Plan in the resident record. Furthermore, this was previously cited on December 16, 2022 on Record Keeping.

Official plan of correction

Plan of Correction along with ALL training due on January 13, 2023. Plan of Correction shall include updating ALL resident records and provide staff training. In addtiion, Licensee/Administrator shall provide a written summary on how future compliance will be met. **Civil Penalty Assessed in the amount of $250.00**

Deadline recorded: Jan 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(9)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements: (b)The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met as evidenced by: Based on a tour of the facility kitchen and the fridge, LPA observed three cans of whipped cream that had an expiration date of August 8, 2022.

Official plan of correction

Plan of Correction shall include the facility Interim Administrator provide staff training with a sign-in sheet and a plan for future compliance. Plan of Correction due by: January 10, 2023

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

Official classification

Type B

Official code

87463(a)(b)(c)

Regulation authority

CCR

What the official deficiency says

87463(a)-Reappraisals: The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: (b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement was not met as evidenced by: Based off of document reviews, there was no reappraisal completed for Resident #1 which presents a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Plan of Correction shall include ensuring that residents have gotten appraisals and reappraisals performed and provide staff training. In addtiion, Licensee/Administrator shall provide a written summary on how future compliance will be met. Plan of Correction due on December 23, 2022.

Deadline recorded: Dec 23, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)(15)

Regulation authority

CCR

What the official deficiency says

87506(a)-Record Keeping: The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. Based off of document reviews, the facility did not retain a copy of the Admission Agreement in the file which presents a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Plan of Correction shall include updating ALL resident records and provide staff training. In addtiion, Licensee/Administrator shall provide a written summary on how future compliance will be met. Plan of Correction due on December 23, 2022.

Deadline recorded: Dec 23, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(b)

Regulation authority

CCR

What the official deficiency says

87211(b)-Reporting Requirements: (b) Any suspected physical abuse that results in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within two (2) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not as evidenced by: Based off of interviews and a review of the SOC 341, the SUSPECTED elder abuse was not properly reported via an incident report or a SOC 341. This is an immeidate health, safety and personal rights risk to residents in care.

Official plan of correction

Plan of Correction shall include retraining ALL staff regarding Reporting Requirements and Mandated Reporting requiremenets. In addition, Licensee/Administrator shall provide a written summary on how future compliance will be met moving forward. Administrator requested an extension for December 28, 2022. LPA granted extension.

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

Official classification

Type B

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

87464(f)(4)-Basic Services: (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement was not met as evidenced by: Based off document reviews of the Level of Care plan, the document indicated that the resident will be receiving regular bathes via two staff members and not sponge bathes. This regulation is a potential health, safety and personal rights risk to resident(s) in care.

Official plan of correction

Plan of Correction shall include following the Level of Care document and conduct staff training. In addition, Licensee/Administrator shall provide a written summary on how future compliance will be met moving forward. Plan of Correction due date for staff training and written summary: December 23, 2022.

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