Allegations4 substantiated · 1 unsubstantiated · 1 unfounded · 3 cited
Basic services and supervisionType A
- Official classification
- Type A
- Official code
- 87464(f)
- Regulation authority
- CCR
What the official deficiency says
(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and [...] 1569.2(c). This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure R1 received care and supervision, as a result R1 suffered multiple injuries because of falls, which poses an immediate health and safety risk to persons in care.
Official plan of correction
Licensee agrees to train all staff on CCR 87464 and will submit a written plan within 24hrs to schedule staff training and will follow up to provide the proof of training to LPA by March 31, 2026.
Deadline recorded: Mar 20, 2026. A deadline is not proof that correction was completed.
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(g)
- Regulation authority
- CCR
What the official deficiency says
(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified [...]. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not call 911 when R1’s leg was lodged between the bedrails on October 1, 2025, resulting in bruising, which poses an immediate health and safety risk to persons in care.
Official plan of correction
Licensee agrees to submit a written plan within 24hrs to schedule all staff training and will follow up to provide the proof of training to LPA by March 31, 2026.
Deadline recorded: Mar 20, 2026. A deadline is not proof that correction was completed.
Dementia careType A
- Official classification
- Type A
- Official code
- 87705(2)
- Regulation authority
- CCR
What the official deficiency says
For facilities with fewer than 16 residents, ensuring there is at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal, or observation, to require awake night supervision. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not have an awake night staff person on duty even though R1 was observed to engage in wandering and lacks hazard awareness.
Official plan of correction
Licensee agrees to adhere to CCR 87705 and to sign a statement of understanding and submit proof to LPA within 24hrs by March 20, 2026. Licensee will submit a written plan to LPA regarding awake staff supervision for residents who are wanderers or in need of supervision at night. This is due by March 31, 2026.
Deadline recorded: Mar 20, 2026. A deadline is not proof that correction was completed.