ORANGE COUNTY CARE HOME II

Official classification

Type B

Official code

87224(d)(1)

Regulation authority

CCR

What the official deficiency says

Per CCR 87224(d)(1) The notice to quit shall include the following information: (B) Resources available to assist in identifying alternative housing and care options (...). This requirement was not met as evidenced by: Based on records reviewed, the notice served to R1's responsible party did not include the necessary elements detailed in Title 22. This constitutes a potential risk to the health, safety and personal rights of individuals in care.

Official plan of correction

Licensee reviewed Section 87224 on Eviction Procedures and verbalized understanding the requirements. Deficiency cleared during the visit.

Deadline recorded: Jan 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

Per CCR 87466: " 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. " This requirement is not met as evidenced by: Based on records and interviews, it was evidenced that a discrepancy between R1's medical assessment and their functional capabilities was not flagged and brought to their physician's attention. This constitutes a potential risk to health, safety and personal rights of residents in care.

Official plan of correction

Licensee requested an immediate reassessment which concluded that the resident was able to attend outside medical appointments with the assistance of the taxi driver. Report provided to licensing staff on 06/25/2025. Deficiency cleared.

Deadline recorded: Jan 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87628(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. 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 using insulin self-injection has been assessed to be unable to manage injections in their physician report. This discrepancy poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/19/2026 Plan of Correction Licensee notified the resident's responsible party to flag the discrepancy and request an update of the resident's form LIC602A during an appointment scheduled on the day of the visit. Proof of corrected assessment to be provided to licensing staff before the plan of corrections due date.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465(a)(4) – Incidental Medical and Dental CareFacility staff shall assist residents with self-administration of prescription medications as needed ... shall be given in accordance with the physician’s instructions. Based on interviews and records review, the facility failed to follow physician instructions for (R1)despite clear instructions to administer only Lantus prior to R1's fasting laboratory appointment. This posed an immediate health and safety risk to resident in care.

Official plan of correction

Administrator shall retrain all staff on medication administration requirements, emphasizing that medications must be administered strictly according to physician instructions. Administrator shall also implement procedures for staff to double-verify physician orders prior to administering insulin. Documentation of training and verification procedures shall be submitted to by POC due date

Deadline recorded: Sep 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(i)

Regulation authority

CCR

What the official deficiency says

87465 … (i) Prescription medications which … are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record… This requirement was not met as evidenced by: Based on admission, the licensee destroyed R1’s 20MG Atorvastatin in February 2025 but did not keep a record, which poses a potential health risk to persons in care.

Official plan of correction

Licensee stated they will conduct staff training on properly destroying medications and documenting the destruction and will submit proof to LPA by POC due date.

Deadline recorded: Aug 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) … (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on documents and admission, the licensee received multiple doses of the same medication for R1 but did not address this issue with R1’s family, doctor, or pharmacy, which poses a potential health risk to persons in care.

Official plan of correction

Licensee stated they will conduct staff training on reviewing medications received for accuracy and potential issues and will submit proof to LPA by POC date.

Deadline recorded: Aug 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

87468 Personal Rights… (c) Licensees shall prominently post (2) … (A) … the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) … 20 " x 26 " in size and be posted in the main entryway of the facility… Based on observation, the licensee did not ensure the PUB 475 was the correct size and in the entryway of the facility, which poses a potential personal rights risk to persons in care.

Official plan of correction

The licensee has already posted a proper sized PUB 475 in the main entryway of the facility and LPA confirmed. POC CLEARED.

Deadline recorded: Jul 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(f)(1)

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: Deficient Practice Statement Based on observation conducted during the facility visit, the licensee did not comply with the section cited above in one instance of supplements being left accessible in the room of a resident. The resident is not diagnosed with dementia but other residents are, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/26/2024 Plan of Correction Licensee will secure supplements and ointments (such as Voltarene and Calmoseptine) with the rest of the facility's medication central storage.

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

Per the Calfornia Code of Regulations Section 87465(h)(5): " The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. " This requirement is not met as evidenced by: Deficient Practice Statement Based on observation conducted during a tour of the physical plant and an interview with the administrator, the licensee did not comply with the section cited above as medication has been prepared in advance until February 28, 2024. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/26/2024 Plan of Correction Licensee will update staff training on medication dispensation and ensure that pre-pouring does not occur for periods of over 24 hours. Proof of training to be provided to LPA before the Plan of Corrections due date.

Official classification

Type B

Official code

87608(a)

Regulation authority

CCR

What the official deficiency says

Per CCR Section 87608(a) on Postural Supports: " 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. (...) (5)(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record reviewed during the facility visit, the licensee did not comply with the section cited above in three instances. Two residents have beds with half rails with no physician order and one bed is equipped with full rails in spite of the resident not being on hospice. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/26/2024 Plan of Correction Licensee will get the unused full rails removed and obtain physician orders for the half rails seen in use in the facility. A copy of the orders will be provided to the Department before the plan of corrections due date.

Official classification

Type A

Official code

87625(b)(2)

Regulation authority

CCR

What the official deficiency says

CCR Section 87625(b)(2) on Managed Incontinence states that " (...) the licensee shall be responsible for (...) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night " . This requirement is not met as evidenced by: Based on interviews conducted and records reviewed, facility staff had adopted the practice of stacking diapers at night rather than conduct routine checks. This poses an immediate risk to the health, safety and personal rights of residents in care.

Official plan of correction

Licensee to provide statement that updated policies and training will be conducted regarding nightly care for incontinent residents.

Deadline recorded: Jan 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.2(c)

Regulation authority

HSC

What the official deficiency says

Per the Health & Safety Code: " (c) " Care and supervision " means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, or welfare would be endangered. (...) This requirement is not met as evidenced by: Based on interviews conducted, no routine checks of the resident's hygiene were implented after it became evident that nightly incontinence was present. This poses an immediate to the health, safety and personal rights of residents in care.

Official plan of correction

Licensee to provide statement that updated policies and training will be conducted regarding nightly care for incontinent residents.

Deadline recorded: Jan 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Deficient Practice Statement Type A 02/28/2022 CCR 87465(h)(2) Incidental Medical and Dental Care Services. Centrally stored medications shall be kept in a safe locked place that is not accessible to persons ther than employees responsible for the supervision of the medication. This requirement is not met as evidenced by: LPAs observed 24hr supply of prepared medication being stored in an unlocked drawer.

Official plan of correction

POC Due Date: 03/11/2022 Plan of Correction Administrator will provide LPA with proof of the deficient lock being replaced.