QUALITY SENIOR LIVING

Official classification

Type B

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire Saftey All facilites 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 met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as fire extinguishers was observed to not have an updated service tag, or a recent purchase reciept which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 04/13/2026 Plan of Correction Administrator will schedule an appointment with fire department to have fire extinguishers serviced or purchase new fire extinguishers and send a receipt as proof to LPA prior to P.O.C due date.

Official classification

Type B

Official code

87412(c)(2)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: (A) Trainer’s full name; (B)Subject(s) covered in the training; (C) Date(s) of attendance; and (D) Number of training hours per subject 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 one of two staff records not having documented training. which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/13/2026 Plan of Correction Administrator will provide and document correct training for staff members and document them correctly. Administrator will send proof via email to LPA prior to P.O.C due date.

Official classification

Type B

Official code

87633(a)(2)

Regulation authority

CCR

What the official deficiency says

Per CCR 87633(a)(2):The licensee shall be permitted to accept or retain residents (...) to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met:(...) (2)The licensee remains in substantial compliance with the requirements of this section. This requirement is not met as evidenced by: The current waiver in place has a capacity of two residents while three current residents are receiving hospice care. This constitutes a potential risk to the health, safety and personal rights of individuals in care.

Official plan of correction

Licensee stated they would re-submit a request to increase the hospice capacity under the waiver that had previously been submitted to the Department.

Deadline recorded: Feb 12, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. During a tour of the kitchen, LPA observed that the lock on the kitchen cabinet where knives and sharps are being stored was inoperable making them accessible to residents in care.

Official plan of correction

POC Due Date: 03/07/2025 Plan of Correction A caregiver removed the knives and sharps from the cabinet during the visit and placed them in the garage. POC cleared at time of visit.

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 record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. During file review, LPA observed that the facility has not completed any emergency disaster drills.

Official plan of correction

POC Due Date: 03/07/2025 Plan of Correction AD agreed to complete an emergency disaster drill. AD will submit proof of the emergency disaster drill to LPA via email or fax by POC date.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based oncrecord review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During staff file review, LPA observed that 0 out of the 3 care giving staff do not have a valid CPR training card on file.

Official plan of correction

POC Due Date: 03/20/2025 Plan of Correction AD agreed to have all staff complete CPR training. AD wil submit proof of a valid CPR training card to LPA via email or fax by POC 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 record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During staff file review, LPA observed that Staff #1 (S1), Staff #2 (S2), and Staff #3 (S3) did not complete the required annual training for the year of 2024.

Official plan of correction

POC Due Date: 03/20/2025 Plan of Correction AD agreed to have all staff complete the required annual training. AD will submit proof of training completion to LPA via email or fax by POC date.

Official classification

Type B

Official code

87456(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. 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 which poses/posed a potential health, safety or personal rights risk to persons in care. During resident file review, LPA observed that the facility did not have a Pre-admission appraisal on file for Resident #1 (R1), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5).

Official plan of correction

POC Due Date: 03/20/2025 Plan of Correction AD agreed to complete a Preappraisal for R1, R3, R4, and R5. AD will submit the completed Preappraisals for all four residents to LPA via email or fax by POC date.

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 documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. 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 which poses/posed a potential health, safety or personal rights risk to persons in care. During resident file review, LPA observed that the facility did not have a Medical Assessment on file for Resident #4 (R4) and Resident #5 (R5).

Official plan of correction

POC Due Date: 03/20/2025 Plan of Correction AD agreed to get a Medical Assessment for R4 and R5. AD will submit the Medical Assessment's for R4 and R5 to LPA via email or fax by POC 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 record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. During resident file review, LPA observed the facility did not have a Reappraisal on file for Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5).

Official plan of correction

POC Due Date: 03/20/2025 Plan of Correction AD agreed to complete Reappraisals for R1, R2, R3, R4, and R5. AD will submit the completed Reappraisals for all five residents to LPA via email or fax by POC date.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: the magnetic lock securing the drawer contaning knives and sharp instruments is broken and not functional, as observed by LPAs during the visit. Deficient Practice Statement Based on this observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/25/2022 Plan of Correction A replacement lock or new locked storage for sharp instruments and other dangerous items has to be procured and installed instead of the defective magnetic lock currently in place.