GRACES HOME

Official classification

Type B

Official code

87308(C)

Regulation authority

CCR

What the official deficiency says

87308: Resident and Support Services (c) General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage. Based on observations made by LPA the Administrator failed to ensure that sufficient storage space was made available to store items, and allow for a clean and sanitary environment for residents in care which poses an immediate personal rights violation for residents in care.

Official plan of correction

Administrator agrees to clear out all debris and obsturctions that were observed to be on the premices durring LPA's inspection. LPA will conduct a plan of correction visit to confirm that correction has been made by P.O.C due date.

Deadline recorded: Jul 3, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87308(C)

Regulation authority

CCR

What the official deficiency says

87308: Resident and Support Services (c) General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage. Based on observations made by LPA the Administrator failed to ensure that sufficient storage space was made available to store items, and allow for a clean and sanitary environment for residents in care which poses an immediate personal rights violation for residents in care.

Official plan of correction

Administrator agrees to clear out all debris and obsturctions that were observed to be on the premices durring LPA's inspection. LPA will conduct a plan of correction visit to confirm that correction has been made by P.O.C due date.

Deadline recorded: May 11, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services(d) The following space and safety provisions shall apply to all facilities:(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. Based on observations made by LPA the Administrator failed to meet this requirement by containing large objects along the passage ways of the side exits making the exits inaccessable which poses a potenial saftey risk to residents in care.

Official plan of correction

Administrator agrees to store away or dispose of the objects observed to be obstructing the side exit routes by P.O.C due date. LPA will conduct a P.O.C visit to ensure the correction has been made.

Deadline recorded: May 11, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87219(h)(2)(h)

Regulation authority

CCR

What the official deficiency says

87219 Planned Activities (h) The licensee shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (2) Outdoor activity areas that are easily accessible to residents, protected from traffic, and have adequate shady areas. Based on observations the Administrator failed to meet this requirement by storing large ammounts of objects unerneath the shaded sitting area.

Official plan of correction

Administrator agrees to find adequate storage for the objects located underneath the shaded sitting area by P.O.C due date. LPA will conduct a P.O.C visit to ensure the correction has been made.

Deadline recorded: May 11, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not have First Aid certification for himself or staff on duty at the time of the visit, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/24/2025 Plan of Correction Licensee will ensure that at least one staff on duty that are First Aid certified at any given time. Licensee will provide proof to CCLD by POC due date.

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, Staff #2 does not have 20 hours of training at the time of the visit, which poses a potential health, safety or personal rights risk to persons in care. Staff #2 has 12 hours of training.

Official plan of correction

POC Due Date: 12/24/2025 Plan of Correction Licensee will ensure Staff #2 completes at least 20 hours of training and submit proof to CCLD by POC due date.

Official classification

Type B

Official code

87506(b)(15)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, Resident #3 did not have a signed admission agreement on file, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/24/2025 Plan of Correction Licensee will obtain a signed admission agreement by resident or authorized representative and keep it in resident's file and send proof to CCLD by POC due date.

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 conduct quarterly emergency drills with staff and residents, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/24/2025 Plan of Correction Licensee will conduct and document quarterly emergency drills (i.e., fire, flood, earthquake, active shooter, etc.) and keep in log. Licensee will send copy to CCLD by POC due date.

Official classification

Type A

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by hot water measuing 126.6 degree F which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/05/2024 Plan of Correction This is an emmended report. Original POC date as the 26th of Nov. AD, Mai Ngoc , was advised of POC date on the 26th of Nov

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and recored review, the licensee did not comply with the section cited above by not having valid libility insurance which poses an potential health, safety or personal rights risk to persons in care. ***THIS IS AN EMDED REPORT***

Official plan of correction

POC Due Date: 01/01/2025 Plan of Correction This is an emended deficiency .AD, Mai Ngoc , was advised of POC date on the 26th of Nov

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 requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by having uncleared backyard nor space for residents activity which poses an potential health, safety or personal rights risk to persons in care. ***THIS IS AN AMENDED REPORT***

Official plan of correction

POC Due Date: 01/01/2025 Plan of Correction This is an emended deficiency .. AD, Mai Ngoc , was advised of POC date on the 26th of Nov

Official classification

Type B

Official code

87219(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) Facilities shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (2) Outdoor activity areas which are easily accessible to residents and protected from traffic. Gardens or yards shall be sufficient in size, comfortable, and appropriately equipped for outdoor use. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by which poses an potential health, safety or personal rights risk to persons in care. ***THIS IS AN AMENDED REPORT***

Official plan of correction

POC Due Date: 01/01/2025 Plan of Correction This is an emended deficiency . Original POC date as the 26th of Nov. AD, Mai Ngoc , was advised of POC date on the 26th of Nov

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by: Based on LPA's observation, new staff does not have background clearance to be at the facility. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee will have proof that staff obtain fingerprint and be background cleared in order to work and be at the facility by POC due date.

Deadline recorded: Sep 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

Administrator - Qualifications and Duties ... facilities shall have a qualified and currently certified administrator. 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. This requirement is not met as evidenced by: Based on LPA's observation, facility lacks enough staffing and back up administrator while away, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee to provide a written statement of understanding of the regulation and forward to LPA by POC due date.

Deadline recorded: Sep 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements ... (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to ... This requirement is not met as evidenced by: Based on LPA's observation, licensee can not recall if the incident on 02/01/2023 was reported to CCLD. LPA searched past SIRs during the time of incident and there is no LIC624 reporting the incident from the facility.

Official plan of correction

Licensee to provide a written statement of understanding of the regulation and forward to LPA by POC due date.

Deadline recorded: Sep 27, 2024. 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

Basic Services ... Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not being met as evidenced Based on interview and review of documents licensee failed to supervise R1 in which they left the facility unassisted and ended up at emergency at hospital.

Official plan of correction

Licensee to provide a written statement of understanding of the regulation and forward to LPA by POC due date.

Deadline recorded: Sep 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

" Care of Persons with Dementia " ... Each resident with dementia shall have an annual medical assessment ... done at least annually ... of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidence by: Based on LPA's review of resident records, LPA discovered outdated Physician Report sign and dated by Physician 02/17/2023.

Official plan of correction

Licensee will obtain updated physician's report by COB of POC due date 10/02/24.

Deadline recorded: Oct 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87205(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This requirement was not met as evidence by faciltiy received a notice to pay electricity bill or face a disruption in service. This poses an immediate health and safety risks to persons in care.

Official plan of correction

Licensee has since paid the remaining balance of the electricity bill. Licensee has setup a auto pay with updated credit card to avoid rejected payments in the furture.

Deadline recorded: Mar 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

87463(c) Reappraisals. The licensee shall arrange a meeting … when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first. This requirement was not met as evidence by: Following R1’s fall the facility failed to CONTINUED... CONTINUE...complete a reappraisal despite R1 being unable to walk. R1 was able to walk with assistance prior to fall. This poses a potential risk to residents in care.

Official plan of correction

L/AD Mai will read and submit proof of understanding for CCR 8746: Reappraisals and submit proof of undetrstanding to CCLD by POC Deadline of 4/28/2023.

Deadline recorded: Apr 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211(a)(1)(D) Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following…A written report…Any incident which threatens the welfare, safety or CONTINUED... health of any resident…This requirement is not met as evidence by: Licensee failed to submit a written report to the Licensing agency regarding R1’s unwitnessed fall in October of 2022 or hospitalization on 8/26/22. This poses a potential risk to residents in care.

Official plan of correction

L/AD Mai will read and submit proof of understanding for CCR 87211: Reporting Requirements and submit proof of undetrstanding to CCLD by POC Deadline of 4/28/2023.

Deadline recorded: Apr 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Personnel Requirements- General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…This requirement was not met as evidence by: The facility failed CONTINUED... CONTINUE...to seek immediate medical attention for R1 in part due to the caregiver needing to care for two other residents. The facility lacked sufficient staffing to be able to meet the resident’s need for immediate medical attention. This poses an immediate risk to residents in care.

Official plan of correction

L/AD Mai will read and submit proof of understanding for CCR 87411: Personnel Requirements and submit proof of undetrstanding to CCLD by POC Deadline of 4/25/2023.

Deadline recorded: Apr 25, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(d)

Regulation authority

CCR

What the official deficiency says

87405(d) Administrator- Qualification and Duties. The administrator shall have the qualifications specified…Knowledge of the requirements for providing care and supervision … and ability to conform to the applicable laws, rules and regulations. This CONTINUED... CONTINUE...requirement was not met as evidence by: Administrator failed to ensure the facility was properly staffed; failed to submit necessary written reports to licensing and failed to seek appropriate medical attention for R1. This poses an immediate risk to residents in care.

Official plan of correction

L/AD Mai will read and submit proof of understanding for CCR 87305: Administrator Qualification and Duties and submit proof of undetrstanding to CCLD by POC Deadline of 4/25/2023.

Deadline recorded: Apr 25, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

87465(g) Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health…This regulation was not met as evidence by: Resident was found on ground CONTINUED... CONTINUED...following an unwitnessed fall sometime in October of 2022. Despite reporting hip pain and being unable to walk, no medical attention was sought. R1 was transferred to the hospital approximately a month later and diagnosed with a hip fracture.

Official plan of correction

L/AD Mai will read and submit proof of understanding of CCR 87465: Incidental Medical and Dental Care to CCLD by POC deadline of 4/25/2023. This poses an immediate risk to residents in care. $500 IMMEDIATE CIVIL PENALTY IS ASSESSED.

Deadline recorded: Apr 25, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)(2)

Regulation authority

CCR

What the official deficiency says

87705(f)(1)(2):Care of Persons With Dementia(f) the following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools, and other items that could constitute a danger to the resident(s). (2) OTC medication, supplements or vitamins, alcohol, cigarettes & CONTINUE... CONT...toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by while LPA Quiroz conducted tour along with L/AD Mai between 9:53am-12:50pm, LPA Quiroz observed pair of scissors in kitchen area, diabetic CONT...

Official plan of correction

L/AD Mai removed pair of scissors in kitchen area and diabetic lancet from diningroom table. LPA Quiroz provided L/AD Mai with copy of CCR 87705. L/AD Mai will read and agree to understanding of CCR 87705 and provide training to staff listed on LIC 500 by POC deadline of 2/8/2023. AD removed lancet and scisscors. Corrected during visit. used lancet on diningroom table. This poses an immediate risk to residents in care.

Deadline recorded: Feb 8, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

87307(d)(6)Personal Accommodations and Services(d)The following space and safety provisions shall apply to all facilities:(6)All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: While LPA Quiroz toured facility along CONT with L/AD Mai, LPA Quiroz observed excessive amount of storage items in garage area and back yard east side location of facility premises but not limited to: window panels, gardening tool items varying in sizes from small to large, unused items,gallons of paint CONTINUED...

Official plan of correction

LPA Quiroz printed and provided copy of CCR 87307 to (L/AD) Mai. (L/AD) will read and understand and provide training to staff listed on LIC 500 (Personnel Report) and agreed to clean garage and back yard area by POC due date of 2/10/2023. in backyard area and automobile door white in color. This was verified with L/AD Mai. This poses an immediate risk to residents in care.

Deadline recorded: Feb 7, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation (87303)(a)(1): (a) The facility shall be clean, safe, sanitary and in good repair at all times... for the safety and well-being of residents, employees and visitors.(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. CONTINUED... This requirement is not being met as evidenced by, between 9:53am-12:50pm while LPA Quiroz toured facility along with L/AD Mai, LPA Quiroz observed food particles and grease stains on the kitchen stove, kitchen counters, sink area and food crumbs on the kitchen floor area CONT...

Official plan of correction

LPA Quiroz provided Licensee with CCR 87303 to L/AD Mai. L/AD Mai will read and agree to understanding of CCR 87303 and provide training to staff listed on LIC 500 Upon arrival to the facility, Caregiver 1 assisted with cleaning of kitchen area. This poses a potential risk to residents in care CONT... LPA Quiroz observed food in the refrigerator area not labeled, trash particles through out living room and kitchen area a This poses a potential risk to residents in care.

Deadline recorded: Feb 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87207

Regulation authority

CCR

What the official deficiency says

False Claims 87207: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was met as evidenced by: Upon arrival to facility, L/AD Mai CONTINUED... CONT...indicated Caregiver had just left to go get bread to eat. During interview conducted with caregiver, Caregiver indicated she had not been present at facility since 2/2/23. This was verified with L/AD Mai. This poses an immediate risk to residents in care.

Official plan of correction

L/AD Mai will read and understand CCR 87207 False Claims and submit proof of understanding to CCL by 2/8/2023.

Deadline recorded: Feb 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87506(b)(10)

Regulation authority

CCR

What the official deficiency says

(b) Each resident’s record shall contain at least the following information:(10)Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions.This requirement was not met as evidenced by: During today's record review CONT... LPA Quiroz did not observe physician reports for R1 and R2. This was verified wtih L/AD Mai who indicated not having physician reports for R1 and R2 indicating they were admitted without a physician report. This poses an immediate risk for residents in care.

Official plan of correction

L/AD Mai agreed to call physician for R2 and receive copy of updated physician report and submit to CCL by 2/7/2023 and agreed to call and schedule an appointment for R1 and have medical report completed by 2/8/2023.

Deadline recorded: Feb 8, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements-87211(a)(2) (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(2) Occurrences, such as epidemic outbreaks...which threaten the welfare, safety or health CONT... of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidenced by: During today's record review for R1, LPA Quiroz observed resident's discharge

Official plan of correction

L/AD Mai agreed to read and understand CCR 87211 and submit proof of understanding. lpa Quiroz will call OCPH and report positive case and submit COVID-19 Covid script to CCL by 2/7/2023 COB. paper work from UCI Medical center indicating covid positive status upon admission and discharge. This was verified with L/AD Mai indicating he forgot to report to OCPH and CCL. This poses an immediate risk to residents in care.

Deadline recorded: Feb 8, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)(2)

Regulation authority

CCR

What the official deficiency says

87705(f)(1)(2):Care of Persons With Dementia(f) the following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools, and other items that could constitute a danger to the resident(s). (2) OTC medication, supplements or vitamins, alcohol, cigarettes & CONTINUE... CONT...toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by while LPA Quiroz conducted tour along with L/AD Mai between 10:13am-10:42am, LPA Quiroz observed knives, scissors, OTCmedications and R4's medication in bedroom area CONT...

Official plan of correction

L/AD Mai removed knives, alcohol and over the counter medication during today's visit. LPA Quiroz provided L/AD Mai with copy of CCR 87705. L/AD Mai will read and agree to understanding of CCR 87705 and provide training to staff listed on LIC 500 by POC deadline of 11/15/2022. CONT...Medication in kitchen area observed to be without name label and bottle of wine in refrigerator area.This was verified with L/AD Mai throughout facility inspection visit. This poses an immediate risk to residents in care. CIVIL PENALTY ASSESSED.

Deadline recorded: Nov 15, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation (87303)(a)(1): (a) The facility shall be clean, safe, sanitary and in good repair at all times... for the safety and well-being of residents, employees and visitors.(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. CONTINUED... This requirement is not being met as evidenced by, between 10:13am-10:42am while LPA Quiroz toured facility along with L/AD Mai, LPA Quiroz observed food particles and grease stains on the kitchen stove, kitchen counters, sink area and food crumbs on the kitchen floor area CONTINUED...

Official plan of correction

LPA Quiroz printed CCR 87303 and provided copy to L/AD Mai. L/AD Mai will read and agree to understanding of CCR 87303 and provide training to staff listed on LIC 500 (L/AD) Mai indicated " I will clean all areas " by 11/18/2022. CONT... LPA Quiroz observed food packaged not labeled on kitchen counter and in the refrigerator area not labeled, spider webs and trash particles through out living room, kitchen area and uncleaned bathroom with soiled clothes in R3's bedroom area. This poses a potential risk to residents in care.

Deadline recorded: Nov 15, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

87307(d)(6)Personal Accommodations and Services(d)The following space and safety provisions shall apply to all facilities:(6)All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: While LPA Quiroz toured facility along CONT with L/AD Mai, LPA Quiroz observed excessive amount of storage items in garage area and back yard east side location of facility premises but not limited to: Toilets, sinks, window panels, tool items, unused items, CONTINUED...

Official plan of correction

LPA Quiroz printed and provided copy of CCR 87307 to (L/AD) Mai. (L/AD) will read and understand and provide training to staff listed on LIC 500 (Personnel Report) and agreed to clean garage and back yard area by POC due date of 11/18/2022. CONT...This was verified with (L/AD) Mai indicating " Yeah, I need to clean it up and take it to my moms place. " This poses an immediate risk to residents in care.

Deadline recorded: Nov 17, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)(2)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance-All individuals subject to a criminal record review shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption (2) Request a transfer of a criminal record clearance. This requirement was not met as evidence by; Staff #1 has been working at the facility for approximately 1 month and does not have a criminal record clearance through the Department. This poses an immeidate health and saftey risk to residents in care.

Official plan of correction

Licensee will immediately have Staff #1 fingerprinted and provide proof to Licensing.

Deadline recorded: Apr 27, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(2)(C)

Regulation authority

CCR

What the official deficiency says

Personal Accomations and Services- Resident bedrooms shall meet the following requirements; No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement was not met as evidenced by Residents are being showered in the master bedroom that is being occupied by Resident #3.

Official plan of correction

Licensee agrees to have the construction of common bathroom in hallway completed by 5/10/22. Proof will be provided that bathroom/shower is completed.

Deadline recorded: May 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personel Requirements-General-Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by; Records reviewed and interviews conducted disclosed that residents present during the visit were non-ambulatory, had limited mobility and needed assistance with all ADL's due to their cognitive ability. LPAs observed only 1 staff present during the visit. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Adminstrator agrees to hire adequate staff to meet the needs of all residents and to have more than 1 staff present at all times. LIcensee/Adminstrator will provide proof of adequate staffing and proof of understanding via written certification and an LIC 500 form by 4/27/22

Deadline recorded: Apr 27, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(f)(1)(2)

Regulation authority

CCR

What the official deficiency says

87705-Care of Persons With Dementia (f) the following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools, and other items that could constittute a danger to the resident(s). (2) OTC medication, supplements or vitamins, alcohol, cigarettes & toxic substances such as plants, gardening supplies,and disinfectants.

Official plan of correction

Administrator will designate himself to be responsible for unlocking and locking all dangerous items and and maintaining a log.At the time of visit S1 locked and secured medications and disinfectanctants. Administrator to conduct training on how to properly lock medications and cleaning supplies. Administrator to send copy of documentation to LPA due by 11/30/21

Deadline recorded: Nov 30, 2021. A deadline is not proof that correction was completed.