RESPIT MANOR MISSION VIEJO

Official classification

Type A

Official code

87355(e)(2-3)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (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: (2) Obtain a California clearance...(3) Request a transfer of a criminal record clearance... This requrement was not met as evidenced by: Based on observation and record review, a transfer of criminal record clearance for S1 and fingerpring clearance for S2 were not met. S2 was previously fingerprint cleared and was separated on 5/7/26 which poses an immediate Health, Safety, and/or Personal Rights risk to persons in care.

Official plan of correction

Admin stated proof of fingerprint clearance and/or transfer request will be forwarded to LPA via email by POC due date.

Deadline recorded: Aug 14, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(A)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... (A) Death of any resident from any cause regardless of where the death occurred... This requirement was not met as evidenced by: Based on record review and the Department's system, there was no record of a death report for R1 which poses a potential Health, Safety, and/or Personal Rights risk to persons in care.

Official plan of correction

Admin will forward a death report for R1 to LPA via email by POC due date.

Deadline recorded: Aug 17, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements (b) The following food service requirements shall apply: (8) All food shall be of good quality. [...]. This requirement was not met as evidenced by: Based on observations and interviews, the licensee did not ensure that all expired foods stored at the facility were disposed of, which poses an immediate health and safety risk to persons in care.

Official plan of correction

Staff disposed of food item immediately during the visit. Deficiency cleared during the visit. Licensee agrees to review all perishable and non-perishable food items on a weekly basis and dispose of any items that have exceeded the expiration dates. Licensee will provide training to all staff regarding the Title 22 regulation 87555 General Food Service Requirements and will provide proof of the training to LPA by POC due date.

Deadline recorded: Apr 15, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (2) The exact dosage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation record review, the medication Furosemide 20mg tablet for Resident #3 has an extra pill in the bubblepack, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2026 Plan of Correction The Licensee will train all caregivers and provide proof to CCLD by Plan of Correction due date via email or fax.

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 observation and record review, the licensee did not have an updated Appraisal/Needs and Services plan for three out of three residents, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2026 Plan of Correction The Licensee will obtain updated Appraisal/Needs and Services plans for all residents in care and provide proof to CCLD via email by Plan of Correction 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 observation, interview, and record review, the licensee did not have a quarterly emergency drill this year which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2026 Plan of Correction The Licensee will ensure all staff have an emergency drill this quarter and document the date, time, all employees involved, and provide a signed copy to CCLD by the Plan of Correction due date.

Official classification

Type B

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire Safety All facilities 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 and record review, the fire extinguisher was purchased on July 1, 2024 which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/31/2026 Plan of Correction The Licensee will purchase a new fire extinguisher or have current fire extinguisher tagged for this year and provide proof to CCLD by Plan of Correction due date.

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) 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, the licensee did not comply with the section cited above in one of four residents (R1) which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 07/26/2024 Plan of Correction Licensee agrees to complete medication management training by POC date and provide proof to LPA

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 and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in two of four residents in care poses/posed a potential health risk to persons in care.

Official plan of correction

POC Due Date: 07/26/2024 Plan of Correction Licensee agrees to provide resident with an medical assessment and provide LPA proof by POC date.

Official classification

Type B

Official code

87467(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviews, the licensee did not comply with the section cited above in four of four residents which posespersonal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/26/2024 Plan of Correction Licensee agrees to provide proof of needs and service plan to LPA via email.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in one of four residents which poses a posed a potential health risk to persons in care.

Official plan of correction

POC Due Date: 07/26/2024 Plan of Correction Licensee agrees to provide proof of updated medication assessment to LPA by POC date.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (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: (2) Request a transfer of a criminal record clearance... This requirement was not met as evidenced by: Based on observation, interviews, and record review, S1 was not associated at the time of the visit which poses an immediate Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Administrator stated they will request in writing to associate S1 and to provide proof of access to Guardian, and to submit an Acknowledgement of Understanding of the said deficiency to LPA via email by POC due date.

Deadline recorded: Jun 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(g)(5)(A)

Regulation authority

CCR

What the official deficiency says

87507 Admission Agreements (g) Admission agreements shall specify the following: (5) Refund conditions. (A) Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652. This requirement was not met as evidenced by: Based on interviews and record review, facility did not issue a refund for R1 for part of March 2024 and the entire month for April 2024 which poses a potential Personal Rights risk to persons in care.

Official plan of correction

Administrator stated that they will issue the refund of $4500 and ensure that the $1000 that was issued is withdrawn and will provide proof of reimbursement in the amount of $5500 to LPA via email by POC due date.

Deadline recorded: Jun 30, 2024. A deadline is not proof that correction was completed.