WHITTEN HEIGHTS ASSISTED LIVING AND MEMORY CARE

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights… (a) … (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on observations and interviews, the licensee did not ensure a safe and healthful environment by allowing R1 to smoke in their room near rooms with oxygen, which poses an immediate safety and personal rights risk to persons in care.CIVIL PENALTY ASSESSED

Official plan of correction

The licensee stated that R1 is already being moved closer to the designated smoking area and they will submit proof to LPA by 07/31/26. Licensee stated they will investigate the smoke smell near stairway 3 and provide a plan to address it to LPA by POC due date.

Deadline recorded: Jul 25, 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

(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 observations, there were multiple areas in the facility's two memory care units, especially Room 259, which smelled strongly of urine, which poses a potential health risk to persons in care. CIVIL PENALTY ASSESSED

Official plan of correction

POC Due Date: 05/19/2026 Plan of Correction Licensee stated they will adjust the housekeeping protocol to address the urine smell and submit proof to LPA by POC due date.

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, the water temperature tested at 122 degrees F in Room 122, 125 degrees in Room 347, and 124 degrees in room 341, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 05/19/2026 Plan of Correction Licensee stated the central boiler is set to 118 degrees F. Licensee stated they will make necessary adjustments, conduct temperature checks, and submit temperature logs 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, R6, and R9 are on the old form and do not contain required information, including behavioral expressions, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 05/19/2026 Plan of Correction Licensee stated they will obtain new physician's reports on the new form for these residents and submit proof to LPA by POC due date.

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, the facility has been conducting emergency disaster drills annually, and not quarterly as required, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 05/19/2026 Plan of Correction The licensee has recently conducted their annual emergency disaster drill earlier this month. Licensee stated they will create a plan and schedule to conduct emergency disaster drills quarterly and submit the plan to LPA by POC due date.

Official classification

Type A

Official code

87224(b)

Regulation authority

CCR

What the official deficiency says

87224 Eviction Procedures (b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit… This requirement was not met as evidenced by: Based on interviews, the licensee told R1 they would be evicted via 3-Day Eviction when the 3-Day Eviction was withdrawn by the licensee and not approved, which poses an immediate personal rights risk to persons in care.

Official plan of correction

Licensee stated that R1 is no longer a resident of the facility. Licensee stated they will review 87224 and submit a statement of understanding to LPA by POC due date.

Deadline recorded: Apr 4, 2026. 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

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 photographs, observations, and interviews, the licensee did not ensure dog feces are timely cleaned up in the central outdoor courtyard resulting in residents not being able to enjoy their outdoor space, which poses an immediate personal rights risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

During the inspection, the licensee had the dog feces cleaned up. Licensee stated they will submit a plan to ensure that residents with dogs clean up after their pets or, if they do not, that staff will make sure it is done by April 6, 2026.

Deadline recorded: Apr 4, 2026. 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

(a) Each licensee shall furnish to the licensing agency ...:(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. (D) Any incident which theatens... the welfare, safety or health of any resident... This requirement was not met as evidence by there was no incident report for R1's hospitalization in December 2023. This poses a potential health and safety risks to persons in care.

Official plan of correction

Administrator agrees to conduct in service regarding reporting requirements and provide proof to LPA by POC due date.

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

Official classification

Type A

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457.., shall be updated, in writing as frequently as necessary... This requirement was not met as evidence by there was no appraisal conducted for R1 and therefore facility cannot meet needs that are not identified. This poses an immediate health and safety risks to persons in care.

Official plan of correction

Adminstrator stated will conduct in service on appraisals and when to update based on change of condition.

Deadline recorded: Nov 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

(f) Basic services shall at a minimum include:(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications... This requirement was not met as evidence by R1 did not have a care plan for fall mitagation which resulted in resident sustaining multiple falls due to neglect. This poses an immediate health and safety risks to persons in care.

Official plan of correction

Administrator to conduct in service regarding fall risk/mitagation of falls and provide to LPA by POC due date.

Deadline recorded: Nov 19, 2025. 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

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 admission and observations, the licensee did not ensure two out of three elevators were functional and accessible, with one elevator being non-functional for over a year and another elevator being obstructed, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

During the inspection, the licensee cleared the obstructed elevator and LPA confirmed. Licensee stated they will repair the broken elevator or request approval to decommission it by POC due date.

Deadline recorded: Aug 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(2) – 87468.1 Personal Rights… (a) … (2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidenced by: Based on observations, the licensee did not ensure residents were able to enjoy healthful and comfortable accommodations by not cleaning, repairing, or replacing multiple stained and torn furniture items, which poses a potential personal rights risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

Licensee stated that they will clean, repair, or replace the stained and torn furniture items and submit proof to LPA by POC due date.

Deadline recorded: Sep 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (d) … (2) The premises... shall provide a safe and healthful environment. This requirement was not met as evidenced by: Based on admission and observations, the licensee did not ensure messes in the third-floor memory care are cleaned appropriately and timely by not providing immediate access to appropriate cleaning chemicals to caregivers and allowing caregivers to leave messes for the housekeepers to clean up hours later, which poses a potential health risk to persons in care.

Official plan of correction

Licensee stated that they will create a protocol to ensure messes are addressed timely and properly, train staff on the protocol, and submit proof to LPA by POC due date.

Deadline recorded: Sep 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(11)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights … (a) … (11) To have their visitors… permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. This requirement was not met as evidenced by: Based on documents and admission, the licensee did not ensure R1 was able to enjoy the right of visitation by calling the police on W1 for staying past visiting hours, which poses an immediate personal rights risk to persons in care.

Official plan of correction

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

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

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights… (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 did not ensure residents were accorded dignity when multiple staff engaged in rudeness, mockery, and ignoring resident inquiries, which poses an immediate personal rights risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

Licensee stated that they will retrain staff on personal rights, create a system for identifying future instances of staff misconduct, and submit proof to LPA by POC due date.

Deadline recorded: Aug 1, 2025. 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 … Personal Rights … (a) … (8) To be free from …mental … abuse. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure residents were free from mental abuse when S1 yelled at them, which poses an immediate personal rights risk to persons in care.

Official plan of correction

Licensee stated that they will retrain staff on personal rights, create a system for identifying future instances of staff misconduct, and submit proof to LPA by POC due date.

Deadline recorded: Aug 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights… (a) … (2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidenced by: Based on admission and observations, the licensee did not ensure residents can safely and comfortably enjoy the facility by not properly enforcing the facility’s smoking rules resulting in verbal altercations between residents and visitors and R1, which poses an immediate personal rights risk to persons in care.

Official plan of correction

Licensee stated that they will take all measures to address R1’s violations of the house rules, including by moving forward with the eviction process, and submit proof to LPA by POC due date.

Deadline recorded: Aug 1, 2025. 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 documentation of a medical assessment, signed... and made within the last year. This requirement is not met as evidence by: Based on interviews, record review and observations, R1, R2, R3, R4 have not recieved an updated medical evaluation. R1's physican report is dated for 5/18/22, R2's physican report is dated for 3/28/23, R3's physican report is dated for 3/24/23 and R4's physican report is dated for 3/28/23. This poses an immediate Health and Safety risk to residents in care.

Official plan of correction

As a plan of correction (POC) facility agrees to schedule R1, R2, R3, and R4 appointments with their physican and will obtain an updated physican report and submit proof to assigned LPA on or by 7/25/24.

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

Official classification

Type A

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (c) The medical assessment shall include... (1) ...results of an examination for... (A) Communicable tuberculosis. This requirement is not met as evidence by: Based on interviews, record review and observations, R2 and R3 did not complete a tuberculosis screening. This poses an immediate Health and Safety risk to residents in care.

Official plan of correction

As a plan of correction (POC) facility agrees to schedule R2 and R3 appointments to complete a TB exam and submit proof to assigned LPA on or by 7/25/24.

Deadline recorded: Jul 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(A)(1)

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not being met as evidenced by: FR1 was evicted for being inappropriate with women after being accused of groping R1.

Official plan of correction

Plan of Correction: The resident was served with an eviction notice and FR1 moved out of the facility. FR1 voluntarily moved out on November 29, 2024. Eviction notice provide. No further action required.

Deadline recorded: May 23, 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 of the occurrence of any of the events specified in (A) through (D) below… This requirement was not met as evidenced by: Based on documents and admission, the licensee did not ensure multiple reportable incidents were reported as required, which poses a potential safety risk to persons in care.

Official plan of correction

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

Deadline recorded: May 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (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…This requirement was not met as evidenced by: Based on documents, the licensee did not ensure R2 was reappraised at least yearly, which poses a potential safety risk to persons in care.

Official plan of correction

Licensee stated they will submit a plan to ensure all residents are reassessed at least yearly to LPA by POC due date.

Deadline recorded: May 22, 2025. 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 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision… This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure R2 received care and supervision for their aggressive behavior resulting in R1’s injury, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED

Official plan of correction

The licensee stated they reassess R2 and create a care plan for their aggression and will review their roster, identify residents with aggressive behavior, and create care plans to address those aggressive behaviors, and submit proof to LPA by POC due date.

Deadline recorded: May 9, 2025. 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 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision… This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure one resident received care and supervision by having to wait approximately one hour for assistance with using the bathroom due to short staffing, which poses an immediate health risk to persons in care.

Official plan of correction

The licensee stated they will create a plan to ensure staff call-outs are properly covered and submit proof to LPA by POC due date.

Deadline recorded: Apr 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights… (a) … (2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidenced by: Based on observations and interviews, the licensee did not ensure residents are able to safely and comfortably enjoy the facility by not properly enforcing the facility’s smoking rules, which poses a potential personal rights risk to persons in care. CIVIL PENALTY ASSESSED for repeated violation.

Official plan of correction

Administrator stated that the facility will move forward with the eviction of R1 and will provide the eviction notice to LPAs Cho and Haddad via email by POC due date.

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

Official classification

Type B

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 one resident received assistance with medications when the facility ran out of supply and provided a doctor-prescribed alternative, which poses a potential health risk to persons in care.

Official plan of correction

The licensee stated they will submit a plan to ensure residents’ medications are refilled timely to LPA by POC due date. CIVIL PENALTIES ASSESSED

Deadline recorded: Apr 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.17(c)(1)(A)

Regulation authority

HSC

What the official deficiency says

(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on Guardian records and admission, the licensee did not ensure staff VERONICA DIAZ VILLEGAS was background cleared prior to working at the facility for multiple years and that staff Dolores L Gonzalez was associated prior to working at the facility for multiple months, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

POC Due Date: 03/26/2025 Plan of Correction During the inspection, the licensee removed both staff from the facility and LPA confirmed. Licensee stated they will background clear and associate both staff prior to allowing them to return to the facility.

Official classification

Type B

Official code

1569.618(b)

Regulation authority

HSC

What the official deficiency says

(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on documents and admission, the current administrator's administrator certificate lapsed on February 5, 2025, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 04/22/2025 Plan of Correction Licensee stated they will have the administrator renew their administrator's certificate and submit proof to LPA by POC due date.

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 documents, the staff files for 5 out of 10 staff did not have health screenings, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 04/22/2025 Plan of Correction Licensee stated they will find or obtain health screenings for all 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, the licensee did not maintain complete records for annual training requirements for 10 out of 10 staff, which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 04/22/2025 Plan of Correction Licensee stated they will ensure all staff are trained as required and submit proof to LPA by POC due date.

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, it has been more than three months since the facility's last emergency disaster drill, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 04/22/2025 Plan of Correction Licensee stated they will conduct an emergency disaster drill immediately, submit proof to LPA by POC due date, and ensure emergency disaster drills are conducted quarterly moving forward.

Official classification

Type B

Official code

87632(a)(4)

Regulation authority

CCR

What the official deficiency says

a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency....(4) A statement by the licensee that an agreement with the hospice agency will be entered into regarding the care plan for the terminally ill resident... ... to be accepted and/or retained in the facility. (4)The agreement with hospice shall design and provide for the care, services, and necessary medical intervention related to the terminal illness.. This requirement was not met as evidence by R1's hospice records were not available.

Official plan of correction

COO agrees to retain all hospice records and to hold a meeting with hospice for R1

Deadline recorded: Feb 26, 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

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 req is not being met as evidenced by: Based on observation, Licensee failed to ensure facility is in good repair. LPA observed noted items on LIC 9099. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee to repair/ replace noted items and forward proof to LPA by POC due date.

Deadline recorded: Feb 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

(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 was not met as evidence by facility had an AC unit on the 3rd floor that is still in disrepair as of 2/14/2025. Civil Penalty assessed

Official plan of correction

Administrator agrees to remove AC unit in 3rd floor tv room and provide proof to LPA by POC due date.

Deadline recorded: Feb 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights… (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 and observation, the licensee did not ensure residents are encouraged to wear shoes and that staff do not make fun of residents, which poses an immediate personal rights risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

Licensee stated that they will address the facility’s dress code with residents in violation, retrain staff on treating residents with dignity and respect, and submit proof to LPA by POC due date.

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

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights… (a) … (2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidenced by: Based on interviews and observations, the licensee did not ensure residents are able to safety and comfortably enjoy their rooms and interior spaces of the facility by not properly enforcing the facility’s smoking rules, which poses an immediate personal rights risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

Licensee stated that they will create a list of residents violating the facility’s smoking rules, take action against these residents, document the actions taken on the list, and submit proof to LPA by POC due date.

Deadline recorded: Jan 16, 2025. 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

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 interviews, the licensee did not ensure the facility was safe and sanitary when R1’s room was infested with roaches, which poses an immediate health risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

Licensee stated that they relocated R1 and are addressing the infestation in R1’s room with a professional exterminator. Licensee stated they will create a plan to address future infestations and submit proof to LPA by POC due date.

Deadline recorded: Dec 10, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87219(f)

Regulation authority

CCR

What the official deficiency says

87219 Planned Activities(f)In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities,...The program of activities shall be written, planned in advance, kept up-to-date, and made available to all residents. This requirement was not met as evidence by: Based on interviews and records reviewed the facility does not have a full-time Activities Director. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Per Licensee a Plan of Action to have a full-time Activities Director will be develop. Licensee to email 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. 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: LPA observed ripped couches with brown and black discoloration, LPA observed that the wood floor is broken and missing parts of the tiles, LPA observed chipped tables, tables missing paint and chairs with ripped plastic covers, LPA observed that the baseboards throughout the facility are chipped and have brown and/or black discoloration and on the first floor LPA observed that the dryer is missing the top cover which exposes the flame. This poses a potential health, safety or personal rights risk to persons in care

Official plan of correction

Licensee to repair the floor, tables, chairs, couches, baseboards, dryer, washer and elevator. Licensee to email LPA proof by POC due date.

Deadline recorded: Nov 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by: Based on interviews and record review, the black dog became a tripping harzard for R1 causing R1 to trip and fall on 10/06/24 which poses a potential Safety Risk to persons in care.

Official plan of correction

Administrator stated that the facility will post signs requiring all pets to be leashed or in a carrier at all times and will submit proof of the signs and an Acknowledgement of Understanding of the said regulation to LPA via email by POC due date.

Deadline recorded: Oct 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not being met as evidenced by: Interview confirmation and observation that revealed Resident 1 smokes cigarettes inside their room. This poses a potential health and safety risk to residents in care.

Official plan of correction

The licensee stated a formal meeting will be conducted with Resident 1. The house rules will be presented for R1 to sign and acknowledge, and R1 will be given a final warning regarding smoking inside the room. Licensee will email LPA Haley the copy of the House Rules signed by R1, and a copy of the Final Warning Notice presented to R1 with the residents signature by 1:00PM on the POC due date.

Deadline recorded: Oct 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

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 the medications for 5 out of 5 residents were documented on the MAR as being given as prescribed, which poses a potential health risk to persons in care.

Official plan of correction

Licensee stated that they will create a procedure for ensuring the MAR is completed properly and will train medication technicians on the procedure and submit proof to LPA by POC due date.

Deadline recorded: Sep 26, 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

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision ... for the safety and well-being of residents, employees and visitors. This req is not being met as evidenced by: Based on observation and interviews conducted, the Licensee failed to ensure facility is clean and sanitary. LPA observed cockroaches and ants in resident rooms. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee to exterminate noted resident rooms and forward proof to LPA by POC due date.

Deadline recorded: Jun 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not being met as evidenced by: Interview confirmation and observation that confirm Resident 1 smokes cigarettes in their room. This poses a potential health and safety risk to residents in care.

Official plan of correction

Chief Operating Officer (COO) Faye Shen agrees to develop and implement a plan to address residents who fail to follow facility rules and continue to smoke in their room and other areas of the facility where smoking is prohibited. COO Shen will email LPA Haley a copy of the plan by the POC due date, April 19, 2024 at 1:00PM.

Deadline recorded: Apr 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(g)(4)

Regulation authority

CCR

What the official deficiency says

87507 Admission Agreements … (g) Admission agreements shall specify the following: (4) Modification conditions, including the requirement for the provision of at least 60 days prior written notice to the resident of any rate or rate structure change... This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not provide at least 60 days’ notice of a rate change to residents, which poses a potential personal rights risk to persons in care.

Official plan of correction

Licensee stated they will create a new notice of rate change specifying the amount of the increase, the reason, and a general description of the additional costs, and will give the notice to each resident and mail it to each responsible party at least 60 days prior to the effective date and will provide proof to LPA by POC due date.

Deadline recorded: Apr 9, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by; On December 3, 2023 facility staff wore a sweatshirt " hoodie " that said, " F - U " on it. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee agrees to train staff on personal rights of all residents CCR 87468.1 and to instruct all staff not to wear offensive clothing while working. Licensee to submit proof of training to LPA by POC due date.

Deadline recorded: Mar 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes... or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by, the facility did not notify R1's responsible party of the bruise on their right arm. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee agrees to train facility staff on all reporting requirements CCR 87211 and the proper observation of residents CCR 87466 and to submit proof of training to LPA by POC due date.

Deadline recorded: Mar 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.695(f)(1)

Regulation authority

HSC

What the official deficiency says

(f) A facility shall have both of the following in place:(1) An evacuation chair at each stairwell, on or before July 1, 2019. This requirement is not being met as evidenced by... LPA observed that none of the 4 stairwells in the facility had an evacuation chair. This poses an immediate Health and Safety risk to residents in care.

Official plan of correction

Licensee states that the facility will order and install an evacuation chair at each stairwell in the facility. LIcensee to forward proof to LPA by POC due date.

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

Official classification

Type B

Official code

1569.269

Regulation authority

HSC

What the official deficiency says

Residents of residential care facilities for the elderly shall have all of the following rights: To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided...This requirement is not being met as evidenced by: Based on interview and record review, Licensee failed to ensure R1's records were provided as requested. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee to provide the full and complete file to responsible party/ law office and forward proof to LPA by POC due date.

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

Official classification

Type A

Official code

87468.2(a)(26)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ... residents ... shall have all of the following personal rights: (26) To manage their financial affairs... This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not ensure R1 was able to manage their financial affairs by withdrawing money from R1's bank account without authorization, which poses an immediate personal rights risk to persons in care.

Official plan of correction

The licensee stated that W2 reimbursed R1 for the back owed rent, an agreement was reached with W2 regarding the amount R1 would pay going forward, and the licensee obtained a credit card authorization in this amount. Licensee agreed to submit proof to LPA by POC due date. Licensee stated they understand not to charge residents without a credit card authorization in the future.

Deadline recorded: Jun 22, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(i)(1)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (i) … (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit… This requirement was not met as evidenced by: Based on interviews, facility staff did not respond to R1’s call light in a timely manner, which poses an immediately health and safety risk to residents in care.

Official plan of correction

During the inspection, facility maintenance staff checked on the call system in R1’s room and confirmed it is working properly. Licensee stated they will continue conducting monthly checks for technical issues with the call system and will begin keeping records of these checks. Licensee stated they will train all staff to report any issues with the call system to the Administrator in the future.

Deadline recorded: Apr 16, 2022. 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 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision… This requirement was not met as evidenced by: Based on interviews and documents, the facility did not provide R1 the care and supervision they required as evidenced by R1’s multiple attacks on residents/staff and the injuries R1 also sustained in some altercations, which poses an immediate safety and personal rights risk to persons in care.

Official plan of correction

Licensee states that R1 is being relocated to a facility that can meet R1’s needs on 10/7/21. Licensee states they will submit proof and details of relocation to LPA by 10/8/21. Licensee states that if R1 has not been relocated by 10/15/21, Licensee will immediately begin the process to evict and relocate R1 to a facility that can meet R1’s needs and submit a status update to LPA by 10/22/21.

Deadline recorded: Oct 7, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. … This requirement was not met as evidenced by: Based on interviews and documents, the facility did not reappraise R1’s care needs for two (2) years despite R1’s change of condition and increased aggression which began in late 2019, which poses an immediate safety and personal rights risk to persons in care.

Official plan of correction

Licensee previously provided updated reassessments for R1 to LPA.

Deadline recorded: Oct 7, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services: … (d) …: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not met as evidenced by: Based on observation, the licensee did not ensure carpets were free from fall hazards including tears, holes, gaps, and mounds on all 3 floors, which poses a potential health safety risk to residents in care.

Official plan of correction

Licensee states they will submit photographs of affected carpets to LPA by COB tomorrow, repair or replace the affected carpets, and submit photographic proof to LPA by POC due date.

Deadline recorded: Oct 13, 2021. 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 carpets were free from stains and possible mold on all 3 floors, which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee states they will submit photographs of affected carpets to LPA by COB tomorrow, repair or replace the affected carpets, and submit photographic proof to LPA by POC due date.

Deadline recorded: Oct 13, 2021. A deadline is not proof that correction was completed.