Facility condition and maintenanceType A
- 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, interview, and record review, the licensee did not comply with the section cited above in three out of three bathroom sinks. Hot water temperature measured in Bathroom #1 at 129.0 degrees F, Bathroom#2 at 126.8 degrees F, and bathroom #3 at 127.9 degrees F. This poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/18/2025 Plan of Correction Licensee stated they will fix the temperature to be within regulation and send proof of a photo measuring the temperature being in range and keep a water log that measures the water temperature every 2 hours for a 24 hour period to CCLD via email to edward.kim@dss.ca.gov by POC due date December 18, 2025.
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 observation, interview, and record review, the licensee did not comply with the section cited above. LPA observed R1's latest appraisal was dated July 24, 2024, R2's latest appraisal was dated September 19, 2023, R3's latest appraisal was dated November 2, 2023, R4's latest appraisal was dated August 28, 2024, and R5's latest appraisal was dated November 21, 2024 This poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/31/2025 Plan of Correction Licensee states they will send updated reappraisals for R1, R2, R3, R4, and R5 to CCLD via email to edward.kim@dss.ca.gov by POC due date December 31, 2025.
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, interview, and record review, the licensee did not comply with the section cited above. LPA observed last emergency drill on file available during the visit was conducted on May 20, 2025, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/31/2025 Plan of Correction Licensee states they will send a current emergency drill for this quarter and send a tentative schedule of emergency drills for 2026 to CCLD via email to edward.kim@dss.ca.gov by POC due date December 31, 2025.