Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87208(a)(12)
- Regulation authority
- CCR
What the official deficiency says
(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above as the Infection Control form provided during the 2024 annual visit was never reviewed or filled which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 10/10/2025 Plan of Correction Licensee will prepare an Infection Control Plan using the form LIC9282 provided and submit it to LPA before the plan of corrections due date.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(a)(2)
- Regulation authority
- HSC
What the official deficiency says
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above as the form LIC610E provided during the 2024 annual was not used to generate an updated Emergency and Disaster Plan meeting the regulatory requirements. This poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 10/10/2025 Plan of Correction Licensee states they will complete form LIC610E and submit it to licensing staff before the plan of corrections due date.
Fire safety and emergency preparednessType B
- 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 interview and record review, the licensee did not comply with the section cited above as only one drill is conducted yearly and is additionally not documented, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 10/10/2025 Plan of Correction Licensee stated they would conduct one quarterly drill and provide a schedule for the next three quarterly drills before the plan of corrections due date.
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 observation, interview and record review, the licensee did not comply with the section cited above as one resident is using half-rails while facility staff does not have a physician order on file. This poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 10/10/2025 Plan of Correction Licensee stated they would reach out to the resident's hospice provider to request the required documentation and provide it to licensing staff before the plan of corrections due date.