GUARDIAN ANGEL HOME CARE II

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 observation, the licensee did not comply with the section cited above in LPA observed cleaning solutions accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/29/2026 Plan of Correction Licensee will conduct training with staff on safely storing chemicals and send proof to LPA by POC date of 01/29/2026.

Official classification

Type B

Official code

87706(a)

Regulation authority

CCR

What the official deficiency says

(a) In addition to the requirements in Section 87705, Care of Persons with Dementia, licensees who advertise, promote, or otherwise hold themselves out as providing special care, programming, and/or environments for residents with dementia or related disorders shall meet the following requirements: This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed the licensee did not comply with the section cited above in facility does not have required narrative with additional dementia information in plan of operation as required, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/12/2026 Plan of Correction Licensee will submit dementia narrative that will be included in facilities plan of operation to LPA by POC date of 02/12/2026.

Official classification

Type B

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, the licensee did not comply with the section cited above in the administrator of this facility is not present during normal working hours, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/12/2026 Plan of Correction Licensee will submit a plan to have an administrator or manager present during normal working hours and submit to LPA by POC date of 02/12/2026.

Official classification

Type B

Official code

87219(a)

Regulation authority

CCR

What the official deficiency says

(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include: 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 the facility does not have planned activities for residents, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/12/2026 Plan of Correction Licensee will submit calendar of planned activities to LPA by POC date of 02/12/2026.

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, the licensee did not comply with the section cited above in Resident 2's medications are not logged into Centrally stored medication record, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/12/2026 Plan of Correction Licensee will conduct training on documenting resident medications into the centrally stored records and submit to LPA by POC date of 02/12/2026.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(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. 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 Resident 1 does not have annually updated Needs and services plan, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/12/2026 Plan of Correction Licensee will audit and updated all facility residents needs and services plan and submit to LPA by POC date of 02/12/2026.

Official classification

Type B

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (a)Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply:(1) There shall be common rooms such as living rooms, dining rooms, dens or other recreation/activity rooms. They shall be of sufficient space and/or separation to promote and facilitate the program of activities and to prevent such activities from interfering with other functions. 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 a large bed inside the facility common area, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/12/2026 Plan of Correction Licensee will remove the bed and send proof to LPA by POC date of 02/12/2026.

Official classification

Type B

Official code

87411(d)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: 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 staff 1 does not have required training, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/11/2026 Plan of Correction Licensee will submit proof staff 1 has required training and submit to LPA by POC date of 02/11/2026.

Official classification

Type A

Official code

80072(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.The following requirement has not been met as evidenced by: Based on interviews conducted resident 1 slept on the floor despite no documentation in medical assesment., which poses a potential, helth, safety, or personal rights risk to residents in care.

Official plan of correction

Licensee will conduct training on personal rights and submit to LPA by POC date of 12/13/2025.

Deadline recorded: Dec 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (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. The following requirement has not been met as evidenced by: Resident 1 was observed not properly positioned in their bed, which poses an immediate, health, safety, or personal rights risk to residents in care.

Official plan of correction

Licensee will conduct training on correct positioning and submit to LPA by POC date of 12/13/2025.

Deadline recorded: Dec 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

80072(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.The following requirement has not been met as evidenced by: Based on interviews conducted resident 1 slept on the floor despite no documentation in medical assesment., which poses a potential, helth, safety, or personal rights risk to residents in care.

Official plan of correction

Licensee will conduct training on personal rights and submit to LPA by POC date of 12/13/2025.

Deadline recorded: Dec 13, 2025. A deadline is not proof that correction was completed.

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. The following requirement has not been met as evidenced by: Resident 1 was admitted to the facility 12/2024, and medical assessment is dated 09/2020, which poses a potential, health, safety, or personal rights risk to residents in care.

Official plan of correction

Licensee will submit resident 1's current medical assesment to LPA by POC date of 12/22/2025.

Deadline recorded: Dec 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. The following requirement has not been met as evidenced by: Based on interview with staff and LPA observation the facilities Administrator is not present at facility sufficient number of hours to manage the facility, which poses a potential, health, safety or personal rights risk to residents in care. v

Official plan of correction

Licensee will submit the LIC500 to LPA by POC date of 12/22/2025.

Deadline recorded: Dec 22, 2025. A deadline is not proof that correction was completed.

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 2's appraisal has not been updated since 09/2020, which poses a potential, health, safety, or personal rights risk to residents in care.

Official plan of correction

Administrator will submit current updated appraisal for resident 2 by POC date of 12/22/2025.

Deadline recorded: Dec 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(i)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following:(1) Name of the resident.(2) The prescription number and the name of the pharmacy.(3) The drug name, strength and quantity destroyed.(4) The date of destruction. The following requirement has not been met as evidenced by: Based on records reviewed the facility is not correctly documenting medication destruction, which poses a potential, health, safety or personal rights risk to residents in care.

Official plan of correction

Administrator will conduct medication destruction training with facility staff and submit proof to PLPA by POC date of 09/24/2025.

Deadline recorded: Sep 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87470(c)

Regulation authority

CCR

What the official deficiency says

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. 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 the facility does not have an Infection Control Plan, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/29/2025 Plan of Correction Licensee will submit Infection Control Plan to LPA by 01/29/2025 POC date.

Official classification

Type A

Official code

1569.2(c)

Regulation authority

HSC

What the official deficiency says

1569.2(c) “Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. The following requirement has not been met as evidenced by: Based on interviews conducted facility staff was informed by hospice stafff, Resident 1 was a fall risk and should not be left alone. Staff 1 left Resident 1 alone while on the commode resulting in Resident 1 falling and fracturing their hip, which poses an immediate health, safety, or personal rights risk to residents in care.

Official plan of correction

Licensee agrees to conduct staff training on 'Care and Supervision " and submit proof to LPA by POC date 05/04/2023.

Deadline recorded: May 4, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

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. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. The following requirement has not been met as evidenced by: Resident 1 fell in the facility restroom on 11/29/2022, and was not taken to the hospital for care until the next day 11/30/2022, which poses an immediate health, safety, or personal rights risk to residents in care.

Official plan of correction

Licensee will conduct training with facility staff on " Incidental Medical and Dental " and " timely medical care " send proof to LPA Hurt by POC date of 05/04/2023.

Deadline recorded: May 4, 2023. A deadline is not proof that correction was completed.

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 record review, the licensee did not comply with the section cited above in Resident 1's medication was not logged on centrally stored medication log correctly which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2023 Plan of Correction Administrator shall conduct Medication logging training with facility staff and submit proof to LPA by 03/31/2023 POC date.

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 th facility hallway bathroom door does not properly close, and the facility master bathroom toilet does not work correctly which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2023 Plan of Correction Administrator shall repair both bathrooms and submit proof to Licensing by 03/31/2023 POC date.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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 the licensee did not comply with the section cited above when 2 bottoles of Clorox wipes were found to be accessible to 5 out of 5 clients which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/26/2022 Plan of Correction Caregiver removed the Clorox wipes and locked them in a secure cabinet. POC CLEARED during inspection.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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 when 2 window screens were observed not in good reparit and multiple holes in the walls of the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/28/2022 Plan of Correction Licensee agrees to have the window screens in the facility replaced and to fill/patch all the holes in the walls of the bathroom and resident rooms.

Official classification

Type B

Official code

87632(d)(2)

Regulation authority

CCR

What the official deficiency says

d) If the Department grants a hospice care waiver it shall stipulate terms and conditions of the waiver… which shall include, but not be limited to, the following requirements: (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. 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 when Licensee did not notify the Department of the initiation of hospice care for 1 resident which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/28/2022 Plan of Correction Licensee agreed to submit a written statement detailing the steps the facility will take to ensure the requirements of section 87632 Hospice Care Waiver are met.