SENIOR'S RETREAT OF BREA, INC., THE

Official classification

Type A

Official code

87465(a)(5)(D)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility... :(5) Facility staff...may assist persons with self-administration..: (D) Assistance with self-administration does not include forcing a resident to take medication, ... or otherwise infringing upon a resident's right to refuse to take a medication. This requirement is not met as evidenced by: Based on LPA's interviews and record review this was not met for R1 which poses an immediate health and safety risk to persons in care

Official plan of correction

Administrator (AD) will provide LPA with a written Memo of Understanding regarding regulations 87465 and 87468 and will email signed documenation by POC due date.

Deadline recorded: Dec 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports. (a) Based on the individual's preadmission appraisal... 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... This requirement was not met as evidenced by: Based on LPA observations, interview and record review this was not met in one of one residents which poses an immediate health and safety risk to persons in care.

Official plan of correction

AD will obtain documentation for postural supports at a medical appointment on 12/04/25 with any additional documentation and will email physician's orders for bed rails to LPA by 12/05/2025.

Deadline recorded: Dec 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.311

Regulation authority

HSC

What the official deficiency says

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, the licensee did not comply with the section cited above for all residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/10/2025 Plan of Correction Administrator (AD) will have fire alarms serviced after 5pm on May 9, 2025,. AD will send a video to LPA on Plan of Correction Date showing integrated smoke and carbon monoxide alarms are operational.

Official classification

Type A

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 interview and record review, the licensee did not comply with the section cited above in one of one residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/12/2025 Plan of Correction Administrator is working with resident's family to obtain a Medical Assessment by End-of-Business on May 12, 2025. LPA will scan and email LPA resident's Medical Assessment.

Official classification

Type B

Official code

87307(a)(3)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations, the licensee did not comply with the section cited above in three of four resident bedrooms which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/16/2025 Plan of Correction Administrator (AD) will provide beds and linens for the three vacant resident rooms by Plan of Correction Date. AD will send photos of each bedroom to LPA as proof of compliance.