Facility condition and maintenanceType A
- Official classification
- Type A
- Official code
- 87307(a)
- Regulation authority
- CCR
What the official deficiency says
(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: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interviews the rollaway bed is used for staff sleeping in the living room. This poses an immediate health and safety to persons in care.
Official plan of correction
POC Due Date: 07/22/2026 Plan of Correction Administrator will remove rollaway bed from bedroom 2 and place in storage.
Hazardous items and storageType A
- 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 cited above as there were unsecured laundry soap in facility kitchen. This poses an immediate health and safety risk to persons in care.
Official plan of correction
POC Due Date: 07/22/2026 Plan of Correction Corrected during visit.
Medication handling and storageType A
- Official classification
- Type A
- Official code
- 87465(h)(2)
- Regulation authority
- CCR
What the official deficiency says
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the administrator did not comply with the cited above as there was unsecured medications in the small refrigerator near the kitchen table. This poses an immediate health and safety risk to persons in care.
Official plan of correction
POC Due Date: 07/22/2026 Plan of Correction Corrected during visit
Health conditions and treatmentsType A
- Official classification
- Type A
- Official code
- 87608(a)(3)
- Regulation authority
- CCR
What the official deficiency says
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations and records reviewed the administrator did not comply with the cited above in 1 out of 3 residents, R2 does not have physician's orders for a half rail on their hospital bed. This poses an immediate health and safety risk to persons in care.
Official plan of correction
POC Due Date: 07/24/2026 Plan of Correction Administrator requested a physician's order from R2's responsible party for the half rails. Administrator will forward the order to LPA prior use of half rails.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(c)
- Regulation authority
- CCR
What the official deficiency says
(c) 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 requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the cited above in 5 out of 6 staff members as none of the staff had any recorded training. This poses a potential health and safety risk to persons in care.
Official plan of correction
POC Due Date: 08/03/2026 Plan of Correction Administrator stated will conduct trainings per HSC 1569.625 and 1569.69 and provide proof to LPA by POC due date.
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 observations and records reviewed the licensee did not comply with the cited above as facility has not conducted any emergency drills . This poses a potential health and safety risk to persons in care.
Official plan of correction
POC Due Date: 07/27/2026 Plan of Correction Administrator stated will create an emergency drill log and conduct Quarter 3's emergency drill. Administrator will provide proof to LPA by POC due date.
Staffing, personnel, and trainingType A
- Official classification
- Type A
- Official code
- 87411(a)(2)
- 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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on observations and records reviewed the licensee did not comply with the cited above in 3 out of 6 staff members as they are not associated to the facility. S1, S2 and S3 were not associated to the facility but all have background clearances. This poses an immediate health and safety risk to persons in care.
Official plan of correction
POC Due Date: 07/22/2026 Plan of Correction Administrator will associate all staff and provide proof to LPA by POC due date.