WESTMINSTER VILLA

Official classification

Type A

Official code

87309(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in LPAs observing the housekeeping closet where chemicals are store to be unlocked and accessible which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/03/2026 Plan of Correction LPAs observed the housekeeping closet to be locked and made inaccessible. Licensee stated they will do an inservice with staff and send to LPA by POC due date.

Official classification

Type A

Official code

87555(b)(21)

Regulation authority

CCR

What the official deficiency says

(21) Freezers of adequate size shall be maintained at a temperature of 0 degree F (-17.7 degree C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degree F. (4 degree C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in LPAs observing the fridge to be 50 degrees F and the freezer being 10 degrees F which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/03/2026 Plan of Correction Licensee stated they will have their maintenance supervisor repair the fridge and freezer and send proof of temperatures at 0 and 40 degrees F 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 record review, the licensee did not comply with the section cited above in 1 of 6 staff not having a health screening with a TB test on file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/23/2026 Plan of Correction Licensee stated they will obtain a health screening with a TB test for staff and send to LPA by POC due date.

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 is not met as evidence by: During the visit on 2/5/26, 5/8/26 and 5/15/26 LPA tour the facility and observed that the main elevator next to the front desk is broken. This poses a potential health, safety, and personal rights risk to people in care.

Official plan of correction

Per AD, the elevator will be replace in Mid June. Licensee to email LPA documentation confirming the elevator repair has been completed.

Deadline recorded: Jun 15, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)(6)

Regulation authority

CCR

What the official deficiency says

(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer. This requirement is not met as evidenced by: Deficient Practice Statement Based on AAD interview and record review, the licensee did not comply with the section cited above in four of four staff files, which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2024 Plan of Correction AAD stated that for on-the-job training, documentation will consist of a statement or notation, made by the trainer, of the content covered in the training and proof provided to LPA via email by POC date.

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... who assist residents with personal activities of daily living to receive appropriate training... A staff member shall complete 20 hours, including six hours specific to dementia care... four hours specific to postural supports, restricted health conditions, and hospice care... 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 additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Deficient Practice Statement Based on AAD interview and record review, the licensee did not comply with the section cited above in three of four staff files which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2024 Plan of Correction AAD stated they will document hands-on shadowing training completed and a copy provided to LPA via email by POC date.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

Per the California Code of Regulations Section 87303(e)(2) " Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. " This requirement is not met as evidenced by: Based on observation and interviews conducted at the facility, an unspecified number of units are confirmed to have no access to hot water or limited intermittent access based on the use made in other parts of the facility. This constitutes a potential risk to the health, safety and personal risks of individuals in care.

Official plan of correction

Licensee has already initiated action to repair the facility's dysfunctional water heater and will confirm that the required repairs have been conducted and hot water service been restored before the plan of correction due date.

Deadline recorded: Feb 1, 2024. 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

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 being met as evidenced by: Based on interview and observation, Licensee failed to ensure facility is safe and in good repair. Elevator in facility is inoperable and R1's room does not have an emergency pull cord. This poses a potential health and safety risk to residents in care.

Official plan of correction

licensee to repair/ replace elevator as well as install emergency pull cord in resident's room. Licensee to forward proof to LPA by POC due date.

Deadline recorded: May 16, 2022. A deadline is not proof that correction was completed.