SENIOR'S RETREAT, INC.

Official classification

Type A

Official code

87355(e)(3)

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 Guardian records, S3 is background cleared but is not associated to this facility and has been working for more than 5 days, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

POC Due Date: 06/26/2026 Plan of Correction Licensee stated they will associate S3 to this facility by submitting a completed LIC 9182 (12/25) along with a copy of S3's driver's license to the regional office by POC due date.

Official classification

Type B

Official code

87470(c)

Regulation authority

CCR

What the official deficiency says

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by: Deficient Practice Statement Based on documents and admission, the facility does not have an infection control plan, which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 07/23/2026 Plan of Correction Licensee stated they will review Provider Information Notice (PIN) 22-18-ASC, as well as related PINs, and submit the Infection Control Plan to LPA by POC due date.

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 documents, the facility's liability insurance expired on 06/17/26 and AD stated they are still in negotiations with the insurance company over a possible rate increase and the policy will be renewed any day now and be retroactive to the expiration date of the current insurance, which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/23/2026 Plan of Correction Licensee stated they will work to complete the insurance renewal and submit proof of insurance with a retroactive date that corresponds to the previous expiration date to LPA by POC due date.

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, the 2 fire extinguishers do not have inspection tags or receipts attached indicating they were purchased or inspected in the last year, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 07/23/2026 Plan of Correction Licensee stated they will submit proof that the fire extinguishers were purchased in the last year to LPA by POC due date.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on documents, S2's health screening does not have a TB test result and S3's TB test results do not indicate whether S3 is fit to perform their duties, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 07/23/2026 Plan of Correction Licensee stated they will submit completed health screens to LPA by POC due date.

Official classification

Type B

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations and documents, the facility does not have doctor's orders for R1's folic acid and R3's multivitamin, vitamin c, and melatonin, which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 07/23/2026 Plan of Correction Licensee stated they will obtain orders for these supplements and submit proof to LPA by POC due date.

Official classification

Type B

Official code

87458(c)(7)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (7) A description of any known behavioral expression as defined in Section 87101, Definitions. This requirement is not met as evidenced by: Deficient Practice Statement Based on documents, the physician's reports for R1 and R5 are on the old form and do not contain required information, including behavioral expressions, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 07/23/2026 Plan of Correction Licensee stated they will obtain new physician's reports on the new form for these residents and submit proof to LPA by POC due date.

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 documents, the appraisals for R1 and R5 are more than a year old, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 07/23/2026 Plan of Correction Licensee stated they will reappraise these residents and submit proof to LPA by POC due date.

Official classification

Type B

Official code

87608(a)(5)

Regulation authority

CCR

What the official deficiency says

Postural Supports (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...(5) Under no circumstances shall… postural supports include tying, depriving, or limiting the use of a resident's hands or feet. This requirement was not met as evidenced by: Based on witness and staff interviews a geri-chair was used to restrain a resident which poses a potential health and safety risk.

Official plan of correction

POC: Resident has moved. LPA spoke with AD regarding geri-chair use requiring an exception from the Department. AD will read Postural Support regulations and email LPA a signed Memo of Understanding. AD will also in-service staff on restraints by the POC due date and email documentation to LPA.

Deadline recorded: May 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

87464 (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing... This requirement is not met (cont'd) as evidenced by: Based on LPA interviews one of four residents was in a soiled diaper for a period of time. This poses an immediate health and safety risk for residents in care.

Official plan of correction

AD stated staff will be in-serviced and documentation, dated and signed by staff, will be emailed to LPA by POC due date.

Deadline recorded: Mar 21, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (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: (1) Obtain a California clearance… This requirement was not met as evidenced by: Based on an interview with S1, the licensee did not ensure ID1 was background cleared prior to working at the facility, which poses an immediate safety risk to persons in care.

Official plan of correction

Licensee has already removed ID1 from the facility and understands ID1 can not return until fingerprint cleared and properly associated to the facility. Licensee will read and review regulation section 87355 Criminal Record Clearance and submit a statement of acknowledgement and understanding to LPA Haley by the poc due date.

Deadline recorded: Jan 27, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities... shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not being met as evidenced by R1 not being accepted back at the facility after being discharged by the hospital.

Official plan of correction

Licensee stated they will read and review regulation sections 87468 (Personal Rights) and regulation section 87224 (Evictions). Licensee will send LPA Haley a signed statement of acknowledgement and understanding upon completion by the POC due date. 1.27.25 at 12 noon.

Deadline recorded: Jan 27, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not being met as evidenced by S1 admitting to using a colostomy bag on the rectum/bottom area of Resident 1 to prevent loose stool from causing additional damage to the residents’ skin area that was already damaged and being treated.

Official plan of correction

Licensee stated they will read and review regulation sections 87468 (Personal Rights). Licensee will send LPA Haley a signed statement of acknowledgement and understanding upon completion.

Deadline recorded: Jan 27, 2025. 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

87303 Maintenance and Operation (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 was not met as evidenced by S1 admitting to having issues with the facility heater heating the entire facility. S1 arranged for major repairs to the heating system January 18, 2025 and provided receipts.

Official plan of correction

The facility heater has already been repaired. LPA verified the heater is in good working condition during the complaint visit. No further action necessary.

Deadline recorded: Jan 27, 2025. A deadline is not proof that correction was completed.

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 AD interview, the licensee did not comply with the section cited above, as liability insurance for the facility is not being currently maintained, which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/17/2024 Plan of Correction AD stated liability insurance will be obtained and maintained for the facility and LPA provided with proof via email by POC date.

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 staff interview and record review, the licensee did not comply with the section cited above, as two of two staff providing direct care and supervision do not hold a current, unexpired CPR and first aid training card, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 07/17/2024 Plan of Correction AD stated training will be completed and LPA provided with proof via email by POC 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 AD interview and staff record review, the licensee did not comply with the section cited above as staff training does not include 20 hours annually, eight hours of which shall be dementia care training, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/17/2024 Plan of Correction AD stated staff training would begin to be conducted immediately to meet regulations requirement and LPA will be provided with proof via email by POC date.

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 AD interview and staff record review, the licensee did not comply with the section cited above, as staff did not complete 10 hours of initial training, consisting of 6 hours of hands-on shadowing training, and 4 hours of other training or instruction, which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/17/2024 Plan of Correction AD stated staff training will be conducted immediately to meet regulations requirement and LPA will be provided with proof via email by POC date.