Medication handling and storageType A
- Official classification
- Type A
- Official code
- 87465(c)(2)
- Regulation authority
- CCR
What the official deficiency says
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the facility is not administrating medication according to the physician's directions which poses an immediate health and safety risk to persons in care.
Official plan of correction
POC Due Date: 12/27/2025 Plan of Correction AD stated he will obtain current physician's orders and updated medications. AD to provide proof to LPA.
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 LPA observation, one burner on the stove in non-operational which poses a potential health and safety risk to persons in care.
Official plan of correction
POC Due Date: 01/09/2026 Plan of Correction AD stated the burner will be repaired or replaced and will provide proof to LPA
Licensing and administrationType B
- Official classification
- Type B
- Official code
- 1569.618(c)(3)
- Regulation authority
- HSC
What the official deficiency says
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the only staff member working a shift does not have proof of CPR training which poses a potential health and safety risk to persons in care.
Official plan of correction
POC Due Date: 01/09/2026 Plan of Correction AD stated he will provide CRP certification to LPA.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(a)(11)
- Regulation authority
- CCR
What the official deficiency says
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, one staff member did not have evidence of a health screening which poses a potential health and safety risk to persons in care.
Official plan of correction
POC Due Date: 01/09/2026 Plan of Correction AD stated he will provide health screening to LPA
Staffing, personnel, and trainingType B
- 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, one staff member did not have evidence of training which poses a potential health and safety risk to persons in care.
Official plan of correction
POC Due Date: 01/09/2026 Plan of Correction AD stated he will provide proof to LPA
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(a)(6)
- Regulation authority
- CCR
What the official deficiency says
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the facility does not have a centrally stored medication and destruction record for five out of five residents which poses a potential health and safety risk to persons in care.
Official plan of correction
POC Due Date: 01/09/2026 Plan of Correction AD stated he will provide copies to LPA
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 record review and interview, the facility does not have documented records of disaster drills which poses a potential health and safety risk to persons in care.
Official plan of correction
POC Due Date: 01/09/2026 Plan of Correction AD stated he will provide a disaster drill to LPA