Facility condition and maintenanceType B
- 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 facility's fire extinguisher has not been serviced or replaced in over a year, which poses a potential safety risk to persons in care.
Official plan of correction
POC Due Date: 03/05/2026 Plan of Correction Licensee stated they will have the fire extinguisher replaced or inspected and submit proof to LPA by POC due date.
Incident reportingType B
- Official classification
- Type B
- Official code
- 87211(h)
- Regulation authority
- CCR
What the official deficiency says
87211 Reporting Requirements … (h) Any change in the chief corporate officer of an organization, corporation or association shall be reported to the licensing agency in writing within fifteen (15) working days following such change. This requirement is not met as evidenced by: Deficient Practice Statement Based on admission, the licensee had a change in corporate structure more than 15 business days ago which was not reported to the Department, which poses a potential personal rights risk to persons in care.
Official plan of correction
POC Due Date: 03/05/2026 Plan of Correction Licensee stated they will submit documentation regarding the original state of the licensee corporation, the changes made, the date the changes were made, and a new LIC309 to LPA by POC due date.
Staffing, personnel, and trainingType B
- 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 records, S2 does not have a health screening, which poses a potential safety risk to persons in care.
Official plan of correction
POC Due Date: 03/05/2026 Plan of Correction Licensee stated they will obtain a health screening for S2 and submit proof to LPA by POC due date.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(c)(1)
- Regulation authority
- CCR
What the official deficiency says
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on documents, S2 did not have a current first aid certificate at the facility, which poses a potential safety risk to persons in care.
Official plan of correction
POC Due Date: 03/05/2026 Plan of Correction Licensee stated they will submit proof of first aid training for S2 POC due date.
Admission, assessment, and evictionType B
- 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, R2's appraisal has not been updated in over a year, which poses a potential safety risk to persons in care.
Official plan of correction
POC Due Date: 03/05/2026 Plan of Correction Licensee stated they will reappraise R2 and submit proof to LPA by POC due date.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(f)(1)
- Regulation authority
- HSC
What the official deficiency says
(1) An evacuation chair at each stairwell, on or before July 1, 2019. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and admission, the facility has two stories but does not have an evacuation chair, which poses a potential safety risk to persons in care.
Official plan of correction
POC Due Date: 03/05/2026 Plan of Correction Licensee stated they will obtain an evacuation chair and submit a photograph of the chair at the facility to LPA by POC due date.