GOOD SAMARITAN II

Official classification

Type A

Official code

87506(e)

Regulation authority

CCR

What the official deficiency says

Per CCR 87506(e) on Resident Records, " 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: Based on interviews and records reviewed, resident records for R1 have been lost (...) following the resident's discharge from the facility in April 2025. Facility staff is unable to locate the recors at this time in order to provide them to the resident's responsible party upon request. This constitutes an immedicate risk to the health, safety and personal rights of individuals in care.

Official plan of correction

Licensee stated their awareness of the applicable regulations and would submit a statement in writing by the plan of corrections due date.

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

Official classification

Type B

Official code

87468.2(a)(19)

Regulation authority

CCR

What the official deficiency says

Per CCR 87468.2(a)(19): " residents in (...) shall have all of the following personal rights: To have prompt access to review all of their records and to purchase photocopies of their records. (...) records shall be provided within two (2) business days " . This requirement is not met as evidenced by: The initial request for request was made on May 21, 2025. As of the present visit, records have not been provided to R1's responsible party in full, which constitutes a potential risk to the health, safety and personal rights of individuals in care.

Official plan of correction

Licensee will continue efforts to locate the records and ensure that they are provided to the responsible party as soon as possible. Proof of submission to be submitted to LPA before the plan of corrections due date.

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

Official classification

Type A

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 records reviewed, the licensee did not comply with the section cited above as two caregivers on staff are not associated to the licensed location. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/10/2025 Plan of Correction Licensee will request a transfer of the current criminal record clearances for both staff members. Immediate civil penalty assessed.

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 interview and records review, the licensee did not comply with the section cited above as annual training for both caregivers is incomplete or partially documented only, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/20/2025 Plan of Correction Licensee will ensure current staff members meet all initial and annual training requirements as listed above. Proof of completion to be submitted to LPA before the plan of corrections due date.

Official classification

Type B

Official code

1569.69(a)(2)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 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 observation and record reviews, the licensee did not comply with the section cited above as multiple madatory training required are not found to be documented adequately. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/20/2025 Plan of Correction Licensee will ensure current staff members meet all initial and annual training requirements as listed above. Proof of completion to be submitted to LPA before the plan of corrections due date.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by: Deficient Practice Statement Based on resident records reviewed, the licensee did not comply with the section cited above as one resident's physician report does not indicate their potential tuberculosis status upon admission, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/20/2025 Plan of Correction Licensee will obtain an updated physician report indicating the resident's tuberculosis status and provide a copy to LPA before the plan of corrections 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 resident record reviews, the licensee did not comply with the section cited above as multiple residents do not have a pre-admission appraisal on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/20/2025 Plan of Correction Licensee will document two recent admissions with adequate pre-admission appraisals and provide copies to LPA before the plan of corrections 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 records reviewed, the licensee did not comply with the section cited above as admission agreements are yet to have been completed and filed for two residents after more than seven days following their admission, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/20/2025 Plan of Correction Licensee will obtain the required, signed and dated admission agreements and provide copies to LPA prior to the plan of corrections due date.

Official classification

Type B

Official code

1569.695(b)

Regulation authority

HSC

What the official deficiency says

(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement is not met as evidenced by: Deficient Practice Statement Based on staff records reviewed, the licensee did not comply with the section cited above as two caregivers' files did not document that they had adequately received fire/emergency training upon hire and annually thereafter. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/20/2025 Plan of Correction Fire/emergency training to be provided and/or documented. Proof of attendance to be provided to LPA before the plan of corrections 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 interviews and record review, the licensee did not comply with the section cited above as quarterly drills are not adequately documented which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/20/2025 Plan of Correction Additional drills to be scheduled quarterly as required. Documentation to be provided to LPA.

Official classification

Type A

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 records reviewed and interview conducted, the licensee did not comply with the section cited above as one staff member was found to not be associated to this licensed location in Guardian which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/27/2024 Plan of Correction Licensee will submit a clearance transfer request and provide proof of association to LPA.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation conducted during the tour of the physical plant, the licensee did not comply with the section cited above as prepared medication for the same day's lunch was found to be stored in an unlocked drawer rather than the secure central storage which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/27/2024 Plan of Correction Medication were placed in the secure and locked drawer during the visit. Deficiency cleared during the visit.