CAMBRIDGE COURT

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in one of three staff files, which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2026 Plan of Correction AD stated required staff training will be completed a copy provided to LPA 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 record review, the licensee did not comply with the section cited above in two of three staff files which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2026 Plan of Correction AD stated staff training will be completed and a copy provided to LPA via email by POC date.

Official classification

Type B

Official code

87209(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) The use of alternate concepts, programs, services, procedures, techniques, equipment, space, personnel qualifications or staffing ratios, or the conduct of experimental or demonstration projects shall not be prohibited by these regulations provided that: (2) A written request for a waiver or exception and substantiating evidence supporting the request shall be submitted in advance to the licensing agency by the applicant or licensee. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and staff interview, the licensee did not comply with the section cited above as R1's bedroom does not have required furnishings and a written request for exception was not submitted to licensing agency, which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2026 Plan of Correction AD stated a written request for a waiver or exception and substantiating evidence supporting the request will be submitted to LPA via email by POC date.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a separate, complete, and current record is maintained... 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, as three residents' MARs were observed to be incomplete, which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2026 Plan of Correction AD stated MARs will be completed and staff training regarding maintaining accurate MARs for residents will be conducted and a copy provided to LPA via email by POC date.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309(a)... the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances...and other similar items which could pose a danger to residents are in locked storage and are not left unattended... This requirement is not met as evidence by: Based on observation, the licensee did not ensure toxic chemicals and cleaning solutions were inaccessible to residents in care which poses an immediate safety risk to residents in care.

Official plan of correction

Licensee did not ensure the facility keeps toxic chemichals and cleaning solutions inaccessible to residents in care. Facility stated they will review the regulation and provide CCLD with a signed statement of understanding by August 25, 2026.

Deadline recorded: Aug 25, 2026. 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 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports.. (1) A written report shall be submitted to the licensing agency .. within seven days..(D) Any incident which threatens the welfare, safety or health of any resident.. This requirement is not evidenced by: Based on records reviewed, the Licensee did not ensure that the facility submitted a written report for the power outage that occurred on June 19, 2026, within seven days. This poses a potential health and safety risk to persons in care.

Official plan of correction

The Executive Director stated that she will complete a written statement that the facility will abide by the regulation cited. The Executive Director agreed to provide LPA the written statement via email or fax by POC due date.

Deadline recorded: Jul 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(h)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation: (h) Emergency lighting shall be maintained. At a minimum this shall include flashlights, or other battery powered lighting, readily available in appropriate areas accessible to residents and staff... This requirement is not evidenced by: Based on interviews conducted, the Licensee did not ensure that the facility had sufficient emergency lighting available during the power outage that occurred on June 19, 2026. This poses a potential health and safety risk to persons in care.

Official plan of correction

The Executive Director stated that she has already purchased additional emergency lightings for the facility after the power outage. The Executive Director stated that she will conduct a training with the staff regarding the locations of emergency lighting. The Executive Director agreed to provide LPA proof of the training via email or fax by POC due date.

Deadline recorded: Jul 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

§1569.695 Emergency Plans: (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. Based on records reviewed, the Licensee did not ensure that the morning or afternoon shifts conducted an emergency disaster drill in the second quarter of 2026. This poses a potential health and safety risk to persons in care.

Official plan of correction

The Executive Director stated that she will have the two remaining shifts complete an emergency disaster drill. The Executive Director agreed to provide LPA proof of the emergency disaster drill via email or fax by POC due date.

Deadline recorded: Jul 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87212(a)

Regulation authority

CCR

What the official deficiency says

87212 Emergency Disaster Plan: (a) Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available. This requirement is not evidenced by: Based on records reviewed and interviews conducted, the Licensee did not ensure that the facility followed the emergency disaster plan during the power outage that occurred on June 19, 2026. This poses a potential health and safety risk to persons in care.

Official plan of correction

The Executive Director stated that she will complete a written statement that the facility will follow the emergency disaster plan. The Executive Director stated that she will also conduct a training with all staff regarding the facility's emergency disaster plan procedures. The Executive Director stated that she will provide LPA the written statement and the training via email or fax by POC due date.

Deadline recorded: Jul 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

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...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not evidenced by: Based on records reviewed, the Licensee did not ensure that R2 and R3 had their routine medications present at the facility, despite having active orders for the medications. This poses an immediate health and safety risk to persons in care.

Official plan of correction

The Executive Director stated that she will conduct an in service training with all staff regarding medication management and orders. The Executive Director agreed to provide LPA proof of training via email or fax by POC date.

Deadline recorded: May 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance … (e) All individuals subject to a criminal record review … shall prior to working… (2) Obtain a California clearance… This requirement was not met as evidenced by: Based on admission and records, the licensee did not ensure S1 was background cleared prior to working at the facility for more than five days, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

During the inspection, the licensee had S1 removed from the facility and LPA confirmed. Licensee stated they will have S1 background cleared and submit proof to LPA by POC due date.

Deadline recorded: Apr 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (a) 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 evidenced by: Based on documents and interviews, the licensee did not ensure the facility had sufficient staff, including by having only one caregiver on February 28, 2026, resulting in rushed care for residents, which poses a potential safety risk to persons in care.

Official plan of correction

Licensee stated they will create a plan to improve staffing, including a contingency plan for staff callouts, and submit proof to LPA by POC due date.

Deadline recorded: Mar 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87224(a)

Regulation authority

CCR

What the official deficiency says

87224 Eviction Procedures (a) The licensee may evict a resident ... Thirty (30) days written notice to the resident is required... This requirement was not met as evidenced by: Based on admission, the licensee did not follow the 30-day eviction procedure when they refused to accept R1 back from the hospital, which poses an immediate personal rights risk to persons in care.

Official plan of correction

Licensee stated they will review Section 87224, submit a statement of understanding, and create and submit a protocol for ensuring eviction procedures are followed with residents in the future to LPA by POC due date.

Deadline recorded: Feb 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(B)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) … (1) A written report shall be submitted to the licensing agency … within seven days of the occurrence of … (B) Any serious injury… This requirement was not met as evidenced by: Based on documents, the licensee did not ensure R1’s hospitalization on January 3, 2026, was reported to the OCRO, which poses a potential safety risk to persons in care.

Official plan of correction

Licensee stated that they will retrain staff on reporting requirements and submit proof to LPA by POC due date.

Deadline recorded: Mar 4, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained.. to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C) This req is not met as evidenced by: Based on observation, Licensee failed to ensure hot water is maintained between 105 and 120 degrees F. Water temperature measured 98.2 degrees F in resident restroom. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee to adjust water temperature and forward proof to LPA by POC due date.

Deadline recorded: Mar 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, water temperatures checked in various grooming areas of the facility measured above 120 degree F, the licensee did not comply with the section cited above in 75 out of 75 residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/09/2024 Plan of Correction *Staff adjusted facility water broiler. This clears 24hr correction* Licensee will re-train staff on this regulation. Proof of re-training must be received by 12/13/2024, via email to LPA Ramirez.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, disinfectants and cleaning solutions were found accessible in resident bathroom, the licensee did not comply with the section cited above in 1 out of 75 residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/09/2024 Plan of Correction *Staff removed disinfectants and cleaning solutions from resident bathroom. This clears 24HR correction.* Licensee will re-train staff on this regulation. Proof of re-training must be received by 12/13/2024, via email to LPA Ramirez.

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, S1,S2 and S3 did not complete required 20 annual training hours, the licensee did not comply with the section cited above in 3 out of 4 personnel records reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/13/2024 Plan of Correction Licensee will re-train staff on this regulation and send proof of re-training by 12/13/24 to LPA Ramirez via email.

Official classification

Type B

Official code

87412(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (1) The following staff training and orientation shall be documented: (A) For staff who assist with personal activities of daily living, there shall be documentation of at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter in one or more of the content areas as specified in Section 87411(c)(2). This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, S1 and S2 personnel records did not document initial training within four weeks of employment,the licensee did not comply with the section cited above in 2 out of 4 staff records reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/13/2024 Plan of Correction Licensee will re-train staff on this regulation and send proof of re-training by 12/13/24 to LPA Ramirez via email.

Official classification

Type B

Official code

87507(f)

Regulation authority

CCR

What the official deficiency says

Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement... This regulation was not met as evidenced by: Based on interviews conducted and file reviews the facility failed to follow their non-smoking policy as documented per facility's Admission Agreement. This poses a potential risk to resident’s health and safety while in care.

Official plan of correction

Licensee/Administrator agrees to read regulation and sign a statement of understanding and forward proof to LPA by POC due date.

Deadline recorded: Apr 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not provide required assistance with medications to one out of eight residents, which poses a potential health risk to persons in care.

Official plan of correction

Licensee stated they create a list of all residents storing and handling their own medications, review the residents’ Physician’s Reports to ensure they are able to handle their own medications, and submit proof to LPA by POC due date.

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

Official classification

Type B

Official code

00000

Regulation authority

CCR

What the official deficiency says

This page was amended due to this second citation being created in error.

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

Official classification

Type B

Official code

87507(f)

Regulation authority

CCR

What the official deficiency says

Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement... This regulation was not met as evidenced by: Based on interviews conducted and file reviews the facility failed to follow their non-smoking policy as documented per facility's Admission Agreement. This poses a potential risk to resident’s health and safety while in care.

Official plan of correction

Licensee/Administrator agrees to read regulation and sign a statement of understanding and forward proof to LPA by POC due date.

Deadline recorded: Jan 4, 2024. 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 for the elderly shall have all of the following personal rights: (...) (3) To be free from (...) other actions of a punitive nature, such as (...) interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: Based on evidence reviewed and interviews conducted, there were two documented instances of staff disregarding verbal requests to go back to bed. This constitutes an immediate risk to the health, safety or personal rights of residents in care.

Official plan of correction

Licensee to provide a statement indicating its plan to retrain all staff members on the applicable rights of residents in care by the plan of corrections due date.

Deadline recorded: Dec 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(6)

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (...) (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement is not met as evidenced by: Based on interviews conducted, it was determined that facility staff was locking R1's room at night regardless of the resident's agreement or not. This constitutes an immediate risk to the health, safety or personal rights of residents in care.

Official plan of correction

Licensee to provide a statement indicating its plan to retrain all staff members on the applicable rights of residents in care and measures to ensure no resident is locked without their consent by the plan of corrections due date.

Deadline recorded: Dec 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(i)(1)

Regulation authority

CCR

What the official deficiency says

(1) All facilities licensed for 16 or more (...) shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff (...) (C) Identify the specific resident living unit. This requirement is not met as evidenced by: Based on interviews conducted, the facility spend several days with a completely inoperant call system in October 2023. This constitutes a potential risk to the health, safety and personal rights of residents in care

Official plan of correction

The call system was verified to be fully operational during the follow-up investigation visit and the deficiency was cleared at that time.

Deadline recorded: Dec 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87470(a)(1)

Regulation authority

CCR

What the official deficiency says

87470 Infection Control Requirements (a) A licensee shall ensure that infection control practices are maintained as follows: (1) All staff and volunteers shall perform hand hygiene.This requirement is not met as evidenced by: Based on evidence reviewed, it was determined that adequate hand hygiene measures had not been followed after staff handled bodily fluids and/or provided incontinence care to a resident with a urostomy. This constitutes a potential risk to the health, safety and personal rights of residents in care,

Official plan of correction

Licensee to provide a statement indicating its plan to retrain all staff members on adequate hand hygiene by the plan of corrections due date.

Deadline recorded: Jan 10, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)

Regulation authority

CCR

What the official deficiency says

87464(f): " Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code [meaning] the facility assumes responsibility for (...) ongoing assistance with activities of daily living without which the resident’s physical health (...) would be endangered. This requirement is not met as evidenced by: Based on interviews and records reviewed, facility failed to provide adequate supervision. This posed an immediate risk to the health and safety of individuals in care.

Official plan of correction

Licensee to assess reporting procedure and shift incident logs to ensure proper response is provided to residents' needs. Facility to provide in-service training and certify assessment has been conducted.

Deadline recorded: Mar 17, 2023. A deadline is not proof that correction was completed.