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 which poses an immediate health, safety or personal rights risk to persons in care. LPAs observed that Resident #2 (R2) Medical Assessment dated April 9, 2026, states that R2 is bedridden and confirmed that R2 is bedridden due to R2 being unable to reposition herself on her own. The facility's fire clearance does not allow them to retain a bedridden resident.
Official plan of correction
POC Due Date: 07/03/2026 Plan of Correction The Designee stated that the facility will submit a request to update their fire clearance to allow them to retain a bedridden resident. The Designee stated that he will provide LPA a written request, an updated LIC200, and an updated facility sketch, via email or fax by POC due date,
Health conditions and treatmentsType A
- Official classification
- Type A
- Official code
- 87615(a)
- Regulation authority
- CCR
What the official deficiency says
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: 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 which poses an immediate health, safety or personal rights risk to persons in care. During a file review, LPAs observed that Resident #3 (R3) currently had a gastrostomy tube. LPAs also observed that R3 is currently not receiving hospice services. During the visit, LPAs observed and verified that R3 currently has a gastrostomy tube in place.
Official plan of correction
POC Due Date: 07/03/2026 Plan of Correction The Designee stated that the facility will submit an exception request for the resident requesting for the facility to retain the resident with a prohibited health condition. The Designee stated that he will provide LPA the written request via email or fax 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 observation and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPAs observed the facility did not conduct an emergency disaster drill last quarter. LPAs observed the facility conducted their last emergency disaster drill on January 7, 2026.
Official plan of correction
POC Due Date: 07/13/2026 Plan of Correction The Designee stated that he will conduct an emergency disaster drill with all facility staff. The Designee agreed to provide LPA proof of the disaster drill training via email or fax by POC due date.