GRACE RETIREMENT VILLAGE

Official classification

Type B

Official code

87506(d)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records … (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement was not met as evidenced by: Based on interviews and documents, the licensee agreed to submit all requested documents by August 19, 2026, but as of August 26, 2026 has still not provided all requested documents, which poses a potential safety risk to persons in care.

Official plan of correction

Licensee stated they will submit the remaining documents to LPA by POC due date.

Deadline recorded: Aug 28, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator… This requirement was not met as evidenced by: Based on interviews and documents, the licensee does not have a certified administrator, which poses a potential safety risk to persons in care.

Official plan of correction

Licensee stated they will appoint a certified administrator and submit all required documents to LPA by POC due date.

Deadline recorded: Aug 10, 2026. 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

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met as evidenced by: Based on observation, the flooring in the first floor memory care and the third floor is cut, peeling, lifting, and shredding, which poses a potential safety risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

Licensee stated they are already working on fixing the floor and will submit proof that the floor has been repaired to LPA by POC due date.

Deadline recorded: Jul 21, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (e) For every … medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, … and a label on the medication This requirement was not met as evidenced by: Based on documents and admission, the licensee had a nurse administer IV bags to R1 and R2 that were not labeled as theirs and could have been a different formulation than that ordered, which poses a potential health risk to persons in care.

Official plan of correction

The licensee stated they will conduct medication training, including about this scenario, and submit proof to LPA by POC due date.

Deadline recorded: Apr 17, 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

(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, out of the 12 bathroom faucets tested, all were within range except Room 123 which tested at 122 degrees F, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2026 Plan of Correction Licensee stated they will adjust the temperature in this faucet and submit temperature logs 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 documents, S3's health screening is dated more than 6 months before their association date, S4 did not have a health screening in their file, and S9's health screening states they are positive for tuberculosis which S9 states is a mistake and S9's doctor stated over the phone they believe is a false positive and they will order a chest x-ray to confirm, which poses a potential health and safety to residents in care.

Official plan of correction

POC Due Date: 03/12/2026 Plan of Correction Licensee stated they will submit health screenings for these staff to LPA by POC due 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 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 documents, S5, S6, and S9 did not have records of their 40 hour initial training, which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2026 Plan of Correction Licensee stated they will review PIN 23-16-ASC and complete the training for these staff and submit proof to LPA by POC due 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 documents, S2, S3, S4, S7, and S8, did not have records of their 20 hour continuing training, which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2026 Plan of Correction Licensee stated they will review PIN 23-16-ASC and complete the training for these staff and submit proof to LPA by POC due date.

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, S4 and S5 did not have current first aid certificates in their files, which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2026 Plan of Correction Licensee stated they will ensure these staff have current first aid certificates and submit proof to LPA by POC due date.

Official classification

Type B

Official code

1569.626(a)(1)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on documents, the facility has a memory care unit but their training records indicate that no staff has received 12 hours of dementia initial training or 8 hours of dementia continuing training, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2026 Plan of Correction Licensee stated they will update their training protocols, conduct initial dementia training for all staff care staff, and submit proof to LPA by POC due date.

Official classification

Type B

Official code

87458(c)(7)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (7) A description of any known behavioral expression as defined in Section 87101, Definitions. This requirement is not met as evidenced by: Deficient Practice Statement Based on documents, the physician's reports for R1 through R10 are on the old form and do not include required information, such as descriptions of behavioral expressions, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2026 Plan of Correction Licensee stated they will review PIN 25-05-ASC, complete updated physician's reports based on the new form for these residents, and submit proof to LPA by POC due date.

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, the appraisals for R2, R6, R7, R8, R9, and R10 are more than a year old, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2026 Plan of Correction Licensee stated they will reappraise these residents and submit proof to LPA by POC due date.

Official classification

Type B

Official code

87507(c)

Regulation authority

CCR

What the official deficiency says

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by: Deficient Practice Statement Based on documents, the admission agreement in R2's file was blank, which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2026 Plan of Correction Licensee stated they will have R2 complete an admission agreement and submit proof to LPA by POC due date.

Official classification

Type B

Official code

1569.69(a)(1)

Regulation authority

HSC

What the official deficiency says

§1569.69 (a) … (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 16 hours of initial training. This training shall consist of eight hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and eight hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by: Deficient Practice Statement Based on documents, medication technician S8's medication training records do not document the number of hours or type of training and medication technician S9 had no medication training at the facility, which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2026 Plan of Correction Licensee stated they will ensure these staff have the required medication training and submit proof to LPA by POC due date.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services … (f) Basic services shall at a minimum include: (1) Care and supervision. This requirement was not met as evidenced by: Based on interview and documents, the licensee did not ensure R1 received care and supervision to meet their needs resulting in a second elopement in less than week, an altercation with police, and hospitalization, which poses an immediate safety risk to persons in care.

Official plan of correction

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

Deadline recorded: Nov 20, 2025. 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) … (1) ... (D) Any incident which threatens the welfare, safety or health … unexplained absence of any resident. This requirement was not met as evidenced by: Based on interview and documents, the licensee did not report R1’s elopement on October 30, 2025, to the OCRO, which poses a potential safety risk to persons in care.

Official plan of correction

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

Deadline recorded: Nov 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87633(k)

Regulation authority

CCR

What the official deficiency says

87633 Hospice Care of Terminally Ill Residents … (k) The licensee shall maintain a record of dosages of medications that are centrally stored for each resident receiving hospice services in the facility. This requirement was not met as evidenced by: Based on documents and admission, the licensee did not ensure all the medications of R1, R2, and R3 were documented on their centrally stored medication records and medication administration records, which poses a potential health risk to persons in care.

Official plan of correction

The licensee stated they will ensure the centrally stored medication records and medication administration records for all residents contain all of their medications and submit proof to LPA by POC due date.

Deadline recorded: Nov 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(i)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (i) Prescription medications which are not… returned to the issuing pharmacy … which are otherwise to be disposed of shall be destroyed in the facility…This requirement was not met as evidenced by: Based on admission, the licensee did not timely dispose of or destroy expired medications, which poses a potential health risk to persons in care.

Official plan of correction

The licensee stated they will submit a medication destruction record documenting the destruction of the expired medications to LPA by POC due date.

Deadline recorded: Nov 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87631(a)(3)(B)

Regulation authority

CCR

What the official deficiency says

87631 Healing Wounds (a)… (3) Residents with a stage one or two pressure injury… (B) All aspects of care performed by the medical professional and facility staff shall be documented in the resident's file. This requirement was not met as evidenced by: Based on admission and documents, the licensee did not ensure R1’s wound care from their hospice care team, or the repositioning care of the facility’s own staff, was documented in R1’s file, which poses a potential health risk to persons in care.

Official plan of correction

The licensee stated they will create a protocol for reviewing hospice files for new diagnoses and treatment plans to ensure all requirements are met and submit proof to LPA by POC due date.

Deadline recorded: Nov 28, 2025. 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

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidenced by: Based on observation and interview, the licensee did not ensure the kitchen, first floor memory care, and second floor chapel were free of black mold, which poses a potential health risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

Licensee stated that they will clean, disinfect, and have the affected areas professionally confirmed to be mold free and submit proof to LPA by POC due date.

Deadline recorded: Sep 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

… all residential care facilities for the elderly … shall maintain liability insurance covering injury to residents and guests in the amount of at least ... ($1,000,000) per occurrence and ... ($3,000,000) in the total annual aggregate... This requirement was not met as evidenced by: Based on documents, the licensee did not maintain liability insurance covering injury to residents and guests in the amounts required due to sub-limits on injuries typical in this facility type, which poses an immediate personal rights risk to up to 93 persons in care.

Official plan of correction

Licensee stated they will obtain liability insurance that complies with Health & Safety Code section 1569.605 and submit proof to LPA by POC due date.

Deadline recorded: Jul 16, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

87208 Plan of Operation (a) … Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval… This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not notify LPA or obtain approval for a new memory care on the third floor not included in the facility’s plan of operation when the facility was licensed, which poses an immediate safety and personal rights risk to persons in care.

Official plan of correction

Licensee stated they will deactivate and permanently disassemble the delayed egress system on the third floor and will ensure all residents who need to be in a memory care are relocated to the first floor memory care and submit proof to LPA by POC due date.

Deadline recorded: Jun 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

… all residential care facilities for the elderly … shall maintain liability insurance covering injury to residents and guests in the amount of at least ... ($1,000,000) per occurrence and ... ($3,000,000) in the total annual aggregate... This requirement was not met as evidenced by: Based on documents, the licensee did not maintain liability insurance covering injury to residents and guests in the amounts required due to sub-limits on injuries typical in this facility type, which poses an immediate personal rights risk to up to 93 persons in care.

Official plan of correction

Licensee stated they will obtain liability insurance that complies with Health & Safety Code section 1569.605 and submit proof to LPA by POC due date.

Deadline recorded: Jun 12, 2025. 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 interviews and documents, the licensee did not report R1’s femur fracture to the OCRO, which poses a potential safety risk to persons in care.

Official plan of correction

Licensee stated they will create a protocol to ensure incidents are being properly reported and submit proof to LPA by POC due date.

Deadline recorded: Jun 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a)… (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not ensure R1 received proper wound assessment and care for their unstageable pressure injury, which poses an immediate health risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

Licensee stated they will retrain staff on repositioning, noticing skin conditions, and obtaining proper care for any noticed skin conditions and will submit proof to LPA by POC due date.

Deadline recorded: Jun 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87506(a)(b)

Regulation authority

CCR

What the official deficiency says

Resident Records 87506(a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. (b) Each resident’s record shall contain at least the following information. This requirement was not met as evidence by: files for R1-R5 only had the Physician Report (LIC602), Appraisal/Needs and Services Plan, Personal Rights and Admission Agreement.

Official plan of correction

Licensee to update the Resident Records and email LPA proof by POC due date. A written statement will be submitted by the Licensee/Administrator that the he/she understood the regulation and will comply. Each resident’s record shall contain at least the following information: Physician Report (LIC602), Appraisal/Needs and Services Plan, Personal Rights, Admission Agreement, I.D. and Emergency Information, Centrally Stored Medication Destruction Record, and Safeguards for Cash Resources.

Deadline recorded: Apr 23, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

87615 (a) Prohibited health conditions. Persons who require health services for or have a health condition including, but not limited to those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on observations, interviews, and record review, the licensee retained R1 who had prohibited health condition of unstageable pressure injury while in care at the facility. The licensee failed to seek a higher level of care for R1. This poses an immediate health, safety and/or personal rights risk to residents in care.

Official plan of correction

The administrator agreed to ensure all residents with prohibited conditions are not admitted or retained in the facility. The administrator shall conduct an in-service training on pressure injury prevention to all direct care staff. The administrator shall self-certify understanding and compliance to the section 87615(a)(1). POC shall be submitted to jenifer.tirre@dss.ca.gov by the POC due date.

Deadline recorded: Apr 17, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance… This requirement was not met as evidenced by: Based on admission and documents, the licensee did not ensure S4, S5, and S7 were background cleared prior to working at the facility, which poses an immediate safety risk to persons in case. CIVIL PENALTY ASSESSED.

Official plan of correction

Licensee stated that will either have these individuals background cleared or confirm they no longer work at the facility and submit proof to LPA by POC due date.

Deadline recorded: Mar 27, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee... This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not maintain personnel records for 4 staff, which poses a potential safety risk to persons in care.

Official plan of correction

Licensee stated that since October 2024, they have ensured that all staff have staff files. On February 25, 2025, LPA reviewed the staff roster and 10 staff files and confirmed. POC CLEARED.

Deadline recorded: Apr 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a)… (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not notify R1’s doctor or obtain a medical assessment after R1’s fall and did not obtain medical care for R1 in response to R1’s change of condition, which poses an immediate health risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

Licensee stated that they will retrain staff on obtaining medical assessments and care for residents following falls and changes of condition and will submit proof to LPA by POC due date.

Deadline recorded: Mar 27, 2025. 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) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by Based on documents and interviews, the licensee did not ensure R1 received assistance with medications by not giving them their prescribed medications for multiple days, which poses an immediate health risk to persons in care.

Official plan of correction

The licensee stated that they will retrain staff on ensuring residents receive their medications as prescribed and properly completing the Medication Administration Record and will submit proof to LPA by POC due date.

Deadline recorded: Mar 27, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care. (a) … (5) ... Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician. This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure R1 received assistance with medications by offering R1 oxygen and giving R1 Tylenol which were not prescribed, which poses an immediate health risk to persons in care.

Official plan of correction

The licensee stated that they will retrain staff on not giving residents medications that are not on their med lists and submit proof to LPA by POC due date.

Deadline recorded: Mar 27, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) … (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days … shall include the resident's name, age, sex and date of admission; date and nature of event… This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not provide a written report of R1’s fall to the OCRO or R1’s responsible party, which poses a potential health risk to persons in care.

Official plan of correction

Licensee stated that they will create a plan to ensure incidents are properly reported and will submit proof to LPA by POC due date.

Deadline recorded: Apr 9, 2025. 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

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidenced by: Based on observations, the licensee did not ensure 4 fire extinguishers were inspected within the last year, which poses a potential safety risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

Licensee stated that they will ensure all fire extinguishers in the facility have been serviced in the last year and submit proof to LPA by POC due date.

Deadline recorded: Apr 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance… This requirement was not met as evidenced by: Based on admission and documents, the licensee did not ensure staff Sung Ae Byun and Carlota Olguin were background cleared prior to working at the facility, which poses an immediate safety risk to persons in case. CIVIL PENALTY ASSESSED.

Official plan of correction

During the inspection, the licensee removed both staff from the facility and LPA confirmed. Licensee stated they will have both staff background cleared, submit proof to LPA by POC due date, and ensure these staff are not allowed back to the facility until they are background cleared.

Deadline recorded: Mar 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on Guardian records and interview, S1 is background cleared but is not associated to the facility and has been working at the facility for a long time, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 03/11/2025 Plan of Correction Licensee stated they will associate S1 to the facility and submit proof to LPA by POC due date.

Official classification

Type B

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on documents, the facility has been allowing R1 to store and administer their own medications, but R1's physician's report indicates R1 is not able to store or administer their own medications, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 03/11/2025 Plan of Correction Licensee stated they will immediately begin handling R1's medications, will review all residents who handle their own medications to ensure they are able to do so, and will submit an updated list of all residents handling their own medications along with their physician's reports 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 evidenced by: Deficient Practice Statement Based on observation, the facility's fire extinguishers have not been inspected since 2023, which poses a potential safety risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

POC Due Date: 03/11/2025 Plan of Correction Licensee stated they will service or purchase new fire extinguishers and submit proof to LPA by POC due date.

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) … (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews, the licensee does not ensure memory care residents’ dignity when they are kept in only diapers and a shirt overnight, which poses an immediate personal rights risk to persons in care.

Official plan of correction

Licensee stated that they will provide an explanation as to why they were engaged in this practice, train all care staff to ensure residents are fully clothed at all times, and submit proof to LPA by POC due date.

Deadline recorded: Nov 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance… This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not S1 was background cleared prior to working at the facility for at least 5 days, which poses an immediate safety risk to persons in case. CIVIL PENALTY ASSESSED.

Official plan of correction

Licensee stated that they will have S1 background cleared and submit proof to LPA by POC due date.

Deadline recorded: Nov 7, 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

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidenced by: Based on observation and interviews, the licensee did not ensure the memory care unit was free for mild bad odors, which poses a potential personal rights risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

Licensee stated that they will create a housekeeping protocol to address the mild bad odors in the memory care unit, train housekeeping staff on the protocol, and submit proof to LPA by POC due date.

Deadline recorded: Nov 20, 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

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidenced by: Based on observation, the licensee did not ensure resident rooms 104, 112, 113, 114, and 116 were free of black mold, which poses a potential health risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

Licensee stated that they will clean and disinfect resident rooms 104, 112, 113, 114, and 116 and all other areas of the building that have molds and will submit proof to LPA by POC due date.

Deadline recorded: Nov 11, 2024. 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

(e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility(2)Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement was not met as evidenced by, through record review LPA observed Staff 1 has a background clearance but is not associated to the facility. This poses an immediate health and safety and personal rights risk to residents in care.

Official plan of correction

Licensee agrees to associate Staff 1 to the facility and to submit a statement that they have read and understand the regulation 87355 Criminal Record Clearance. Licensee agrees to forward proof of correction to LPA.

Deadline recorded: Oct 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not being met as evidenced by: LPA observed Resident 1's room, 233 did not have a smoke detector. This poses an immediate Health and safety risk to residents in care.

Official plan of correction

Licensee agrees to have a smoke detector installed in each resident room.

Deadline recorded: Oct 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87415(a)(5)

Regulation authority

CCR

What the official deficiency says

In facilities required to have a signal system, specified in Section 87303, Maintenance Operation, at least one night staff person shall be located to enable immediate response to the signal system. If the signal system is visual only, that person shall be awake. This requirement is not being met as evidenced by record review and interviews verified the facility does not have a staff person monitoring the signal system to provide immediate response. This poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Licensee agrees to schedule a minimum of 3 staff members between the hours of 10:00 pm to 6:00 am everyday. Licensee to forward proof to LPA.

Deadline recorded: Oct 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not being met as evidenced by, LPA observed 49 boxes of cereal stored in the kitchen that have expired. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agrees to discard all expired food. Licensee agrees to train staff on CCR 87555 General Food Service Requirements and to submit proof of training to LPA.

Deadline recorded: Oct 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

Per CCR Section 87705(f)(2) on the Care of Persons with Dementia: " The following shall be stored inaccessible to residents with dementia: (...) toxic substances such as (...) cleaning supplies and disinfectants " . This requirement is not met as evidenced by: Based on observation conducted during the visit, cleaning supplies and potential toxic substances were left unattended in the memory care unit. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.

Official plan of correction

Licensee will replace the current cleaning carts with lockable carts that enable staff to ensure cleaning products are out of reach of residents in care.

Deadline recorded: Oct 3, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

Per CCR Section 87303(a): " The facility shall be clean, safe, sanitary and in good repair at all times. " This requirement is not met as evidenced by: Based on observation, the presence of a makeshift table balanced on refrigerator, with a broken glass cover constitutes an immediate risk to the health, safety and personal rights of individuals in care.

Official plan of correction

Licensee stated they would proceed to the immediate removal of the dangerous item.

Deadline recorded: Oct 3, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department… This requirement was not met as evidenced by: Based on observation, documents, and admission, the licensee was not following its approved fire clearance because 2 out of 3 delayed egress doors were not functioning as required and the facility has been keeping the west delayed egress door open, which poses an immediate safety risk to persons in care.

Official plan of correction

Licensee states that a pricing proposal and scheduled appointment will be made before end of business day. This is a repeat/continuation of the initial deficiency cited on August 18, 2024. No additional immediate civil penalty cited at this time.

Deadline recorded: Sep 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department… This requirement was not met as evidenced by: Based on observation, documents, and admission, the licensee was not following its approved fire clearance because 2 out of 3 delayed egress doors were not functioning as required and the facility has been keeping the west delayed egress door open, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

Licensee stated they will immediately repair the main delayed egress door and the west delayed egress door by POC due date and will take all required and allowable measures to address the risk of residents wandering from the outside courtyard.

Deadline recorded: Aug 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.69(a)(1)

Regulation authority

HSC

What the official deficiency says

§ 1569.69(a) … (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training... This requirement was not met as evidenced by: Based on documents, the licensee did not ensure S1 and S2 had documented medication technician training, which poses a potential health risk to persons in care.

Official plan of correction

Licensee stated they will have S1 and S2 complete the required medication technician or properly document the training they already received and submit proof to LPA by POC due date.

Deadline recorded: May 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. This requirement was not met as evidenced by: Based on documents, the licensee did not ensure an administrator with an active administrator’s certificate was properly designated, which poses a potential safety risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

Licensee stated they will submit the necessary documents to designate a qualified administrator to LPA by POC due date.

Deadline recorded: May 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Deficient Practice Statement Based on documents, R1 moved in on 01/13/24 but the facility still does not have a Physician's Report for R1, which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 04/10/2024 Plan of Correction During the inspection, the facility obtained the Physician's Report dated 02/28/24 for R1. Licensee stated that in the future they will obtain Physician's Reports before admission.

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 documents and Administrator's admission, the facility has not been conducting emergency disaster drills, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 04/10/2024 Plan of Correction Licensee stated they will conduct an emergency disaster drill and submit proof to LPA by POC due date and will conduct them quarterly in the future.

Official classification

Type B

Official code

87156(a)

Regulation authority

CCR

What the official deficiency says

87156 Licensing Fees (a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. This requirement was not met as evidenced by: Deficient Practice Statement Based on documents, the licensee did not ensure their licensing fees were paid and has a past-due balance, which poses a potential risk to persons in care.

Official plan of correction

POC Due Date: 04/24/2024 Plan of Correction Licensee stated they will pay the fees and submit proof to LPA by POC due date.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This regulation was not met as evidenced by: On May 21, 2023, R1 eloped from the facility and was transported to the hospital unbeknownst to the facility This poses an immediate risk to resident’s health and safety.

Official plan of correction

Per Administrator Assistant facility will conduct an in-house training with all staff. Administrator Assistant to email proof to LPA by POC due date.

Deadline recorded: Dec 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

Administrator Qualifications and Duties. …When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section… This regulation was not met as evidenced by: Licensee failed to have a qualified designated substitute when Administrator was not in the facility on 8/24/23 as evidenced by Department staff observations and comments made by Administrator. This poses a potential risk to residents health and safety while in care.

Official plan of correction

Licensee to update Designation of Facility Responsibility (LIC308). Licensee to email updated LIC308 to LPA by POC due date.

Deadline recorded: Dec 27, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87755(b)

Regulation authority

CCR

What the official deficiency says

Inspection Authority of the Licensing Agency. The licensee shall ensure that provisions are made for private interviews with any resident or any staff member... This regulation was not met as evidenced by: Licensee failed to ensure provisions were made for private interviews with staff on 8/24/23 as evidenced by Administrator’s statements. This poses a potential risk to residents’ personal rights 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: Dec 27, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87469(c)(1)

Regulation authority

CCR

What the official deficiency says

Advanced Directives and Requests Regarding Resuscitative Measures. Immediately telephone 9-1-1, present the advance directive and/or request regarding resuscitative measures form to the responding emergency medical personnel… This regulation was not met as evidenced by: Licensee failed to ensure records were made available to emergency personnel as evidenced by records being locked inaccessible to staff. This poses a potential risk to resident’s health and safety while in care.

Official plan of correction

Per Administrator Assistant the facility will develop a Plan of Action to ensure resident records are available to emergency personnel upon request. Administrator Assistant to email proof to LPA by POC due date.

Deadline recorded: Dec 27, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464(f)(1) Basic Services. Basic services shall at a minimum include: Care and supervision…This requirement was not met as evidence by: Licensee failed to ensure R1 was receiving care and supervision which resulted in R1 sustaining a burn from an unknown cause while in the care of the facility as evidence by interviews conducted and hospital records reviewed. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Per Administrator Assistant facility will conduct an in-house training with all staff. Administrator Assistant to email proof to LPA by POC due date.

Deadline recorded: Dec 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87456(a)

Regulation authority

CCR

What the official deficiency says

(a) Evaluation of Suitability for Admission. Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8:..conduct an interview…perform a pre-admission appraisal…obtain and evaluate a recent medical assessment…This regulation was not met as evidenced by: Based on interviews conducted and records reviewed the Licensee did not evaluate R1 for suitability prior to accepting them. This poses an immediate risk to resident’s health and safety.

Official plan of correction

Per Administrator Assistant the facility will develop a Plan of Action to evaluate residents suitability prior to being admitted to the facility. Administrator Assistant to email proof to LPA by POC due date.

Deadline recorded: Nov 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(h)(1)

Regulation authority

CCR

What the official deficiency says

Administrator- Qualifications and Duties. The administrator shall have the responsibility to: Administer the facility in accordance with these regulations and established policy… This regulation was not met as evidenced by: Based on interviews conducted and records reviewed the Licensee did not ensure the facility was following regulatory and policy regarding acceptance and retention due to failure to evaluate R1 for suitability prior to accepting them and providing required supervision. This poses an immediate risk to resident’s health and safety.

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: Nov 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87207

Regulation authority

CCR

What the official deficiency says

False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This regulation was not met as evidence by: Based on interviews conducted and records reviewed the Licensee provided false statements to the Department by stating they had not received R1’s paperwork prior to being admitted and was dropped off at the facility blindly without Licensee consent. Statements were proven to be false. This poses an immediate risk to resident’s safety.

Official plan of correction

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

Deadline recorded: Nov 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

Resident Records. The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility…This regulation was not met as evidence by: Based on interviews conducted and records reviewed the Licensee did not maintain a complete record for R1 as evidenced by incomplete appraisal and unsigned physician report. This poses a potential risk to resident’s health and safety.

Official plan of correction

Per Administrator Assistant the facility will develop a Plan of Action to have current and complete Resident Records. Administrator Assistant to email proof to LPA by POC due date.

Deadline recorded: Nov 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

Basic Services (f)Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This regulation was not met as evidence by: Based on interviews conducted and records reviewed the Licensee did not provide care and supervision to R1 resulting in R1 eloping from the facility and dying. Prior to being admitted the facility was made aware of R1’s exit seeking behaviors and still chose to admit R1 to the facility. This poses an immediate risk to health risk to residents in care. An immediate civil penalty of $500 is being assessed.

Official plan of correction

Per Administrator Assistant facility will develop a Plan of Action to prevent future elopements and will conduct an in-house training with staff. Administrator Assistant to email proof to LPA by POC due date.

Deadline recorded: Nov 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87207

Regulation authority

CCR

What the official deficiency says

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidence by: Based on LPA’s observation, records obtained and interviews, it was revealed that the doctor indicated on R1, R2, R3, R4, R5, and R6 physician's report denied of evaluating the residents and stated that the physician signature was falsified. This poses an immediate health and safety risk to residents in care.

Official plan of correction

As a POC, licensee stated that no employee or officer of a licensee will make or disseminate any false or misleading statement or documents. The Licensee stated all staff will be trained on ethical conduct and truthful reporting and will submit proof to assigned LPA on or by 11/3/23.

Deadline recorded: Nov 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician... This requirement is not met as evidence by: Based on the reviewed documents obtained, interviews conducted, and direct admission from the indicated physician on the reports, facility did not obtain a physician report and medical evaluation for R1, R2, R3, R4, R5, and R6. This poses an immediate health and safety risk to residents in care.

Official plan of correction

As a POC, licensee stated that all physician reports for residents will be obtained and an assessment will be conducted by the physician prior to admission. Licensee will provide an in-service to all staff regarding the regulation cited and will submit proof to assigned LPA on or by 11/3/23.

Deadline recorded: Nov 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464(f)(1) Basic Services (f) Basic services shall... include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Based on the documents obtained and interviews conducted, the facility did not obtain a proper medical evaluation for the resident, therefore was unaware of the care and supervision the resident needed, resulting into the resident wandering out of the facility and sustaining injuries. This poses an immediate health and safety risk to residents in care.

Official plan of correction

As a plan of correction (POC), facility is to conduct an in-service training to all staff regarding the regulation cited and will submit proof to assigned LPA on or by 11/3/2023.

Deadline recorded: Nov 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

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. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care... This requirement is not met as evidence by: Per Unusual Incident/Injury Report (UIIR) dated 05/02/22 on 05/01/22 at 11:49 AM R1 left the facility unassisted. Per Physician Report (LIC602A) R1 is not Able to Leave Facility Unassisted.

Official plan of correction

Per Administrator Assistant the facility will be using agengy staff as needed, facility will be offering overtime as needed and facility will develop a Plan of Action to have sufficient personnel at all times. Administrator Assistant to email proof to LPA by POC due date.

Deadline recorded: Nov 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidence by: Three of three UIIRs reviewed by LPA indicate that the residents left the facility unassisted. Therefore, the facility neglected the residents’ care and supervision as it was unsafe for all three residents to leave the facility unassisted.

Official plan of correction

Licensee to submit a written plan to ensure basic services including care and supervision are provided to residents in care at all times by POC due date.

Deadline recorded: Sep 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation. 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 regulation was not met as evidence by: Based on LPA’s observations, Licensee failed to keep the facility safe and sanitary as evidence by Broken glass observed unattended on the ground in Memory Care Unit and feces smeared on the wall. Both were observed accessible to dementia residents. This poses an immediate risk to the health and safety of residents in care.

Official plan of correction

The Licensee will clean up broken glass immediately and provide photos as proof of cleaned walls by POC due date.

Deadline recorded: Sep 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(h)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia. Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. This regulation was not met as evidence by: Based on LPA’s observations, Licensee failed to ensure that facility gate which led to back lot had a functioning self-closing latch. This poses an immediate risk to the safety of residents in care.

Official plan of correction

The Licensee will secure self-closing latch on fence door by POC due date.

Deadline recorded: Sep 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

all residential care facilities for the elderly … shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee health and safety. The requirement was not met as evidence by Licensee did not provide requested full liability insurance policy. This poses a potential threat.

Official plan of correction

Licensee to provide copy of full policy for liability insurance by POC due date.

Deadline recorded: Sep 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician... This requirement is not met as evidence by: Based on LPA's interviews, observations and record reviews, facility failed to obtain physician reports for R1, R2, R3, and R4, This poses an immediate health and safety risk to residents in care.

Official plan of correction

As a plan of correction, licensee will organize resident files and obtain updated physican reports for the residents listed and will provide proof to LPA on or by 8/24/23.

Deadline recorded: Aug 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to... Section 87468.1...residents...shall have all of the following personal rights: (1) To have reasonable level of personal privacy...communications, telephone conversations... This requirement is not met as evidence by: Based on LPA's tour, interviews, observations and records reviews, facility took possession of a total of 6 resident's cellphones and placed it in a plastic container located in the staff office. This poses a potential health and safety risk to residents in care.

Official plan of correction

As plan of correction, licensee will return resident cellphones to the rightful owner and will review the section citied and provide understanding to assigned LPA on or by 8/28/23.

Deadline recorded: Aug 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(c)(1)

Regulation authority

CCR

What the official deficiency says

c) All information and records obtained from or regarding residents shall be confidential.(1) ... The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not met as evidence by facility has not provided requestor with documents and has not shown proof to LPA.

Official plan of correction

Licensee to communicate with requestor and provide documents to requestor by POC due date.

Deadline recorded: Aug 7, 2023. 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. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care... This requirement is not met as evidence by: Per Unusual Incident/Injury Report (UIIR) dated 05/02/22 on 05/01/22 at 11:49 AM R1 left the facility unassisted. Per Physician Report (LIC602A) R1 is not Able to Leave Facility Unassisted.

Official plan of correction

Per AD the facility has been hiring more staff. Licensee to provide an updated Personnel Report (LIC500) by POC due date.

Deadline recorded: Aug 11, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) All information and records obtained from or regarding residents shall be confidential.(1) ... The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not met as evidence by the facility has not provided requested documents or contacted requestor for an extension. This poses a risk to persons in care.

Official plan of correction

Licensee to provide requested documents to requestor by POC due date.

Deadline recorded: Jul 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(e)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87506(e) on Resident Records states that " Original records (...) shall be retained for a minimum of three (3) years following termination of service to the resident. " This requirement is not met as evidenced by: The records requested by LPA Saborit-Guasch were unsuccessfully searched by facility staff who was eventually unable to provide them altogether. This poses a potential risk to the health, safety and personal rights of individuals in care.

Official plan of correction

Licensee to train all staff handling resident records of the necessity to maintain complete and accurate records for every person admitted and retain them at the facility for a minimum of three years following termination of service to the resident. A copy of the training's curriculum and attendance will be provided to LPA before the Plan of Correction's due date of August 3, 2023.

Deadline recorded: Aug 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.312

Regulation authority

HSC

What the official deficiency says

Health and Safety Code section 1569.312 provides that every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety. Based on interviews conducted, this requirement is not being met as evidenced by the fact that resident R1 was able to leave the facility unattended in spite of being admitted to the secure memory care unit.

Official plan of correction

Licensee to provide updated training on the importance of securing all ways of ingress and egress into the memory care unit.

Deadline recorded: Jun 23, 2023. 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

California Code of Regulations Section 87303(a) on Maintenance and Operation states that: " The facility shall be clean, safe, sanitary and in good repair at all times. " Based on observation conducted at the facility, this requirement is not met as evidenced by: Floor material in the memory care unit bunches up in places and creases up, thus creating a fall hazard.

Official plan of correction

Licensee to ensure that the flooring in all areas of the facility is safe and in good repair.

Deadline recorded: Jun 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87608(a)(3) states that: " A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. " This requirement is not met as evidenced by: Based on records reviewed, observation conducted and interviews, it was determined that half bed rails were in place without a physician report at the time of the fall incident on 01/18/2023. This constitutes a potential risk to the health, safety and personal rights of individuals in care.

Official plan of correction

Licensee will obtain physician order for postural support for resident R1 and submit it to LPA before the Plan of Corrections due date.

Deadline recorded: Apr 26, 2023. 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

The California Code of Regulations Section 87211(a)(1)(B) on Reporting Requirements states that: " A written report shall be submitted (...) within seven days (...) [for] Any serious injury (...) occurring while the resident is under facility supervision. " This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, it was determined that licensee failed to submit an incident report prior to the facility inspection on 01/28/2023. This constitutes a potential risk to the health, safety and personal rights of individuals in care.

Official plan of correction

Licensee provided a late report during the facility visit in January, the deficiency is therefore cleared.

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

Official classification

Type B

Official code

87506(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) All information and records obtained from or regarding residents shall be confidential.(1) ... The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This was not met as evidenced by the facility not providing documents after a formal request was made. This poses a potential risk to persons in care.

Official plan of correction

Administrator to provide requested documents by POC due date and forward proof to LPA.

Deadline recorded: Mar 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights … (a) In addition to the … (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure R1 was free from neglect, punishment, and physical abuse when a staff member tied R1 to their wheelchair, which poses an immediate personal rights and safety risk to residents in care.

Official plan of correction

Licensee stated they already trained all caregivers never to tie residents to wheelchairs and to report any such incidents. Licensee provided proof to LPA during the inspection. Licensee stated they will train all other employees never to tie residents to wheelchairs and to report any such incidents and to provide proof of training to LPA within 5 days of POC due date.

Deadline recorded: Sep 15, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

Fire Safety- All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement was not met as evidenced by: LPA and Licensee observed a wheelchair laying on its side blocking an exit gate door on the outside of the first floor by Memory Care. Gate door was also tied with a cloth at the top. This posed an immediate health and safety risk to residents in care.

Official plan of correction

Administrator states the staff will be trained in Fire Safety, Evacuation and Resident Rights. Administrator agrees to ensure the facility exits will not be blocked for any reason. Administrator to forward proof of correction by POC due date.

Deadline recorded: May 18, 2022. A deadline is not proof that correction was completed.