FLANDERS COURT OF CARMEL, LLC

Official classification

Type B

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(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. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate 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: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above. The facility both extinguishers are out of compliance wit expired tags which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction Licensee will provide plan of correction by POC due date to LPA by email

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 and interview, the licensee did not comply with the section cited above. Dishwasher located in the kitchen does not work which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction Licensee will provide plan of correction by POC due date to LPA by email

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 observation, interview, and record review, the licensee did not comply with the section cited above. Records reviews revealed that files reviewed missing updated annual reasessment evaluations which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction Licensee will provide plan of correction by POC due date to LPA by email

Official classification

Type B

Official code

87463(h)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above. Records reviews revealed that R1 file missing updated medical evaluation which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction Licensee will provide plan of correction by POC due date to LPA by email

Official classification

Type B

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(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. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate 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: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2025 Plan of Correction POC proof to be provide to LPA by email

Official classification

Type B

Official code

87303(f)

Regulation authority

CCR

What the official deficiency says

(f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2025 Plan of Correction Provide images of removed items clogging walk ways inside and outside of the facility. Clutter restricting path for staff and residents to walk/ambulate with no safely withput potential danger and/or fire hazard.

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/28/2025 Plan of Correction Staff or Administrator will provide emergency and/or fire drill records, that has to be comleted quarterly and recorded in teh facility files.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons With Dementia(c )(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 for 2 out of 6 residents, which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2024 Plan of Correction Administrator has agreed to schedule a medical assessment for Resident 1 and Resident 2.

Official classification

Type A

Official code

87204(a)

Regulation authority

CCR

What the official deficiency says

Limitations - Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. **This was not met as evidenced by LPA observed 8 residents currently in facility of which a2re identified as Independent Living.

Official plan of correction

Licensee to submit written plan by POC due date to bring facility into compliance. Licensee/Administrator to continue to work with APS to find suitable housing to meet resident needs. Licensee/Administrator to contact Department no later than 11/21/22 with updates and relocation information for residents.

Deadline recorded: Oct 20, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 was not met as evidenced observation of facility storing unused wheel chairs, walkers, chairs, space heaters in the bathrooms showers and areas of the patio outside of exits.

Official plan of correction

Licensee to ensure that all excess unused wheelchairs, walkers, chairs, space heaters be properly stored and not in areas intended for use of residents.

Deadline recorded: Nov 4, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 **This was not evidenced by no training documents on file since 2019 or proof of first aid of first aid for S#1. Training records for staff #2 are incomplete.

Official plan of correction

Licensee to submit proof of training and proof of first aid for S#1 and completed training records for S#2 to Department by POC due date.

Deadline recorded: Sep 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87208(a)(7)

Regulation authority

CCR

What the official deficiency says

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:(7) Sketches, showing dimensions. **This was not met as evidenced by facility has added a building in back yard, use of rooms in facility has changed.

Official plan of correction

Licensee to submit updated floor plan and LIC 9054 to Department by POC due date.

Deadline recorded: Sep 9, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(c)(3)

Regulation authority

CCR

What the official deficiency says

87465(C) Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident in unable to determine his or her own need for nonprescription PRN medication but communicate his/her symptoms clearly, facility staff designated by the licensee shall permitted to assist the resident with self - administration, provided all of the following requirements are met. (3) A record of each dose is maintained in residents records. The record shall include the date and time the PRN medication was taken, the dosage taken and the residents response. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, the licensee did not comply with the section as LPA observed PRN medications not being logged into residents records which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/10/2022 Plan of Correction Administrator will submit proof of logging PRN's into Medication Administration Record to LPA by 05/10/2022 POC date.