Fire safety and emergency preparednessType A
- Official classification
- Type A
- 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 record review, the licensee did not comply with the section cited above in 1 out of 1 accordion doors installed in resident room #1 which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/28/2026 Plan of Correction Licensee to remove the latch on the accordion door and all items obstructing the pathway accessing both bedroom doors by POC due date 07/28/2026.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 1569.625(b)(1)
- Regulation authority
- HSC
What the official deficiency says
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on 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 3 out of 3 staff files reviewed which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/28/2026 Plan of Correction Licensee to submit proof of all of the required initial training hours for S3, S4, and S5 by POC due date 08/28/2026.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.69(a)(2)
- Regulation authority
- HSC
What the official deficiency says
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. 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 3 out of 5 staff files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/28/2026 Plan of Correction Licensee to submit proof of all of the required initial medication training hours for S3, S4, and S5 by POC due date 08/28/2026.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87458(a)
- Regulation authority
- CCR
What the official deficiency says
(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. 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 resident files reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/28/2026 Plan of Correction Licensee to submit a copy of the required physician's report for R1 and R2 by POC due date 08/28/2026.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87458(c)(1)(A)
- Regulation authority
- CCR
What the official deficiency says
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. 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 5 which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/28/2026 Plan of Correction Licensee to submit a copy of the required proof of ngeative TB results for R1 and R2 by POC due date 08/28/2026.