Staffing, personnel, and trainingType A
- Official classification
- Type A
- Official code
- 87411(f)
- Regulation authority
- CCR
What the official deficiency says
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, Licensee did not comply with the section cited above. 2 of 4 staff members did not have proof of health screening or negative TB test. This poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 04/02/2026 Plan of Correction Licensee to submit self-certification stating that identified staff members will obtain proof of health screening and negative TB test. Self Certification to be submitted by POC due date of 04/02/2026. Proof of documents to be submitted by POC due date of 04/13/2026.
Food serviceType B
- 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 observations made, Licensee did not comply with the section cited above. Multiple instances of unlabelled foods were observed. LPA also observed that facility freezer drawer had frozen liquid and food particles. This poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 04/13/2026 Plan of Correction Licensee to conduct in-service training on proper storage of food, including labelling and ensuring food storage areas are clean. Training to include the following: Date, Topic, Job Role, Staff Names, and Signatures. Training to be submitted to CCL for review and approval by POC due date of 04/13/2026.
Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(h)
- Regulation authority
- CCR
What the official deficiency says
(h) The following requirements shall apply to medications which are centrally stored: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and observations made, Licensee did not comply with the section cited above and did not ensure that resident medications were centrally stored and recorded on the LIC622 as required.This poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 04/13/2026 Plan of Correction Licensee to conduct in-service training on properly centrally storing medication. Training to include the following: Date, Topic, Job Role, Staff Names, and Signatures. Training to be submitted to CCL for review and approval by POC due date of 04/13/2026.
Medication handling and storageType B
- Official classification
- Type B
- 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 observations made, Licensee did not comply with the section cited above. Multiple medications were observed to be prepoured for noon and bedtime medication. This poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 04/13/2026 Plan of Correction Licensee to conduct in-service training on pre-pouring expectations. Training to include the following: Date, Topic, Job Role, Staff Names, and Signatures. Training to be submitted to CCL for review and approval by POC due date of 04/13/2026.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(a)(2)
- Regulation authority
- HSC
What the official deficiency says
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations made, Licensee did not comply with the section cited above. Licensee did not ensure that there was enough water on-site in the event facility had to shelter-in-place for 72 hours. This poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 04/13/2026 Plan of Correction Licensee to submit receipts and/or photos of obtained water to meet emergency disaster requirements by POC due date of 04/13/2026.