Staffing, personnel, and trainingType B
- 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 2 out of 3 staff files reviewed and were observed missing proof of all of the required annual training hours which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/07/2026 Plan of Correction Licensee to submit proof of all of the required annual training hours completed by both Staff 2 (S2) and Staff 3 (S3) as well as a self-certifiation which states that all staff have completed the required annual training hours to CCL by POC due date 09/07/2026.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.69(b)
- Regulation authority
- HSC
What the official deficiency says
(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 Based on record review, the licensee did not comply with the section cited above in 2 out of 3 staff files reviewed and were observed missing proof of all of the reuired annual medication training hours which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/07/2026 Plan of Correction Licensee to submit proof of all of the required annual medication training hours completed by both Staff 2 (S2) and Staff 3 (S3) as well as a self-certifiation which states that all who assist with medication administration have completed the required annual training hours to CCL by POC due date 09/07/2026.
Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87506(a)
- Regulation authority
- CCR
What the official deficiency says
(a) 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 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 resident files reviewed where each was observed missing one or more of the required documents which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/07/2026 Plan of Correction Licensee to submit a self certification that all resident files have all of the documents required per regulation to CCL by POC due date of 09/07/2026.
Fire safety and emergency preparednessType B
- 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 by not being able to produce any logs or proof that any emergency drills have been conducted within hte last year which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/07/2026 Plan of Correction Licensee to submit proof that an emegency drill has been conducted and self-certification that they understand and agree to comply with regulation which requiers a drill be conducted on every shift no less than quarterly to CCL by POC due date of 09/07/2026.