Fire safety and emergency preparednessType A
- Official classification
- Type A
- Official code
- 1569.695(c)
- Regulation authority
- HSC
What the official deficiency says
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above, there is no record of a any disaster drill being conducted which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 04/29/2026 Plan of Correction Licensee agrees to conduct a disaster drill and to document the drill in accordance with the regulation above. Licensee agrees to submit proof to the LPA by the POC due date.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(a)(11)
- Regulation authority
- CCR
What the official deficiency says
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 1 out of 2 staff files, Staff 1 (S1) did not have a completed health screening, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/08/2026 Plan of Correction Licensee agrees to have a completed health screening completed and documented for Staff 1 (S1) and to submit proof to LPA by the POC due date.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87457(c)
- Regulation authority
- CCR
What the official deficiency says
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 1 out of 4 resident files, Resident 1 (R1) did not have a completed pre-appraisal, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/08/2026 Plan of Correction Licensee agrees to complete a pre-appraisal for R1 by the POC due date and to submit proof to the LPA by the POC due date.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(a)
- Regulation authority
- CCR
What the official deficiency says
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 1 out of 4 resident files, Resident 1 (R1) did not have a completed reappraisal/care plan which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/08/2026 Plan of Correction Licensee agrees to complete a appraisal/care plan for Resident 1 (R1) by the POC due date and to submit the appraisal/care plan to the LPA.
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87608(a)(3)
- Regulation authority
- CCR
What the official deficiency says
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above, Resident 1 (R1) has bed rails and does not a doctor's orders for bed rails in their file which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 05/08/2026 Plan of Correction Licensee agrees to remove the bed rails or to obtain a doctor's order for bed rails. Licensee to submit proof of correction to the LPA by the POC due date.