JADE GUEST HOME

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) … (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on observation, the licensee did not ensure R1 was treated with dignity when staff spoke loudly towards R1 in an argumentative manner, which poses a potential personal rights risk to persons in care.

Official plan of correction

Licensee stated that they will retrain staff on deescalating tense situations and speaking to residents with dignity.

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

Official classification

Type B

Official code

1569.319(a)

Regulation authority

HSC

What the official deficiency says

§1569.319(a) A licensee of a facility that has internet service shall provide at least one internet access device… dedicated for resident use. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure residents have dedicated internet device access when the only device is also used as the facility phone needed by staff, which poses a potential personal rights risk to persons in care.

Official plan of correction

Licensee stated they will obtain an internet capable device dedicated for resident use and submit proof to LPA by POC due date.

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

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by LPA observed dead and alive roaches throughout facility kitchen including the refridgerator (photos taken). This poses an immediate health and safety risks to persons in care.

Official plan of correction

Administrator stated will clean out the refridgerator and kitchen and will contact exterminator and provide proof to LPA by POC due date.

Deadline recorded: May 21, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives...otther similar items which could pose a danger to residents are in locked storage... This requirement was not met as evidence by LPA observed unsecured laundry area with.. toxins and unsecured sharps under kitchen sink. This poses an immediate health and safety risks to persons in care.

Official plan of correction

Administrator corrected during visit .

Deadline recorded: May 21, 2026. 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

(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 was not met as evidence by unsecured medications were in refridgerator. (photos taken)

Official plan of correction

Administrator corrected during visit.

Deadline recorded: May 21, 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

(b) The following food service requirements shall apply:(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement was not met as evidence by expired pork and rotting vegetables were present in the refrigerator. (photos taken)

Official plan of correction

Administrator will clear refridgerator and replinish food supply by POC due date and provide proof to LPA.

Deadline recorded: May 21, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 (a) resident records. The licensee shall ensure that a separate, complete, & current record is maintained for each resident in the facility or in a central location available to staff and to licensing staff. This requirement is not being met as evidence by: Records for residents were not complete for R1 and R2. Records were missing required documents for Admission. This poses a potential risk, personal rights to the health and safety of residents in care.

Official plan of correction

Licensee to provide Dept. a signed statement acknowledging regulation as well as a signed statement from Licensee stating they will not admit residents without proper records & understanding they will be subject to citations if not met. Licensee to provide copy by POC date 4/15/26

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

Official classification

Type B

Official code

87412(f)(g)

Regulation authority

CCR

What the official deficiency says

87412(f) All personnel records shall be available to the licensing to inspect, audit, and copy upon demand during business hours.(g) All personnel records shall be maintained at facility & be available to the licensing for review. This requirement is not met as evidence by: Personnel Records are not available at facility for review or copy. This poses a potential risk, personal rights to the health and safety of residents in care.

Official plan of correction

Licensee to provide a signed statement understanding reg as well as securring copies of staff files in facility. Licensee stating in POC understanding they will be subject to citations if not met. Licensee to provide copy by POC date 4/15/26.

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

Official classification

Type B

Official code

87507(a)(1)(A)

Regulation authority

CCR

What the official deficiency says

The licensee shall complete an individual written Admission Agreement as defined in section 87101(a), with ea resident or rep, if any: text of the Admin agreement, including any attachments & modifications, shall be printed in black type of not less then 12 point on plain paper. This requirement is not being met as evidence by: Facility had two of four resident agreements modified with handwritten changes. This poses a potential risk, personal rights to the health and safety of residents in care.

Official plan of correction

Licensee to provide to Dept an updated Admission Agreement all typed & signed for Resident 3 who remains in facility. Licensee to provide in service for staff who handle Admission Agreements acknowledging regulations of facility admission agreement by POC due date 2/12/26

Deadline recorded: Feb 12, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(i)

Regulation authority

CCR

What the official deficiency says

**AMENDED REPORT** Safeguards for resident cash, personal property & valuables. Upon discharge of a resident ,all cash resources, personal property & valuables, of that resident...shall be surrendered to resident or responsible person. A signed receiprt shall be retained. Based on investigation this requirement was not met as evidenced by facility failed to transfer personal belongings in a timely manner. R1 has been out of facility since 6/30/25. This poses a potential health & safety risk to residents in care.

Official plan of correction

As plan of correction (POC) , Facility is to coordinate and transfer R1’s belongings with new facility. Facility to provide proof of transfer by having a signed document from facility representative by POC due date 9/23/25.

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

Official classification

Type A

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, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. During the tour LPAs observed knives and scissors in an unlocked kitchen drawer. Per caregiver she locks the knives in the staff bedroom at night.

Official plan of correction

POC Due Date: 11/22/2024 Plan of Correction During the visit Licensee locked the knives in a locked cabinet located under the kitchen sink.

Official classification

Type B

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA observed a shower chair; however LPA did not observe a non-skid floor mat in two of two restrooms.

Official plan of correction

POC Due Date: 11/28/2024 Plan of Correction Licensee to provide non-skid mats for the restrooms and email LPA proof by POC due date.

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPAs observed a Comex bleach powder cleaner and a liquid bleach cleaner on the first restroom, next to the living room. Chemicals were observed to be unlocked.

Official plan of correction

POC Due Date: 11/28/2024 Plan of Correction During the visit Licensee moved the chemicals to a locked cabinet under the kitchen sink.

Official classification

Type B

Official code

87464(d)

Regulation authority

CCR

What the official deficiency says

(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. 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 which poses a potential health, safety or personal rights risk to persons in care. Per preplacement appraisal dated 10/21/23 under Services Needed it states that Resident 1 (R1) needs help with medication. LPA observed that PM Buspirone 5mg and PRN Hydrocodone-Acetamin were out of pills.

Official plan of correction

POC Due Date: 11/22/2024 Plan of Correction Licensee to follow-up on the R1 medications refills and email proof to LPA by POC due date.

Official classification

Type B

Official code

87506(b)(2)

Regulation authority

CCR

What the official deficiency says

Resident Records. 87506(b)Each resident’s record shall contain at least the following information: (2) Social Security number. Based on record review, Licensee did not comply with the section cited above due to one resident's file not having a social security number documented.

Official plan of correction

Facility staff stated they will ensure all resident files contain all of the information required by Title 22 867506(b) by the assigned POC due date. Facility staff stated all resident files will be accessible for review upon request.

Deadline recorded: Oct 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(9)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9) To have communications to the licensee from their representatives answered promptly and appropriately. Based on interviews conducted, the Licensee did not comply with the section cited above due to the Ombudsman's request for records not being fulfilled and no further communication regarding the request being made.

Official plan of correction

Administrator stated they will conduct an in-service training with staff on record requests and fulfilling them. AD stated they will document the topics covered, staff attending, date/time of the training. AD stated they will send the above documentation to LPA via email by the assigned POC due date.

Deadline recorded: Oct 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(5)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply:(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met as evidence by 1 out of 2 staff was not aware of Residents 1 special diet. This poses a possible health and safety risk to persons in care.

Official plan of correction

Licensee agreed to provide in service to staff on renal diets and other possible diets that residents may have. Licensee agreed to keep a log of groceries purchased to prepare meals and provide proof to LPA by POC due date.

Deadline recorded: Mar 11, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operations: (a )The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requriement was not met as evidence by the facility had multple rodent traps, but the present of rodent droppings were still visble. This poses an immediate health and safety risk to persons in care.

Official plan of correction

Administrator has provided LPA with pest control contract which is for pest control to visit facility quaterly and as needed. Retained copy on file.

Deadline recorded: Apr 26, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(h)

Regulation authority

CCR

What the official deficiency says

87303 (h) Emergency lighting shall be maintained. At a minimum this shall include flashlights, or other battery powered lighting, readily available in appropriate areas accessible to residents and staff. Open-flame lights shall not be used. This requirement is not met as evidence by Administrator stated that the facility utilizes hallway and bathroom lights on at night. Facility does not have emergency lighting set up.

Official plan of correction

Administrator to distrubute emergency lighting to appropiate areas.

Deadline recorded: May 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(3)(B)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (3) Equipment and supplies necessary for personal care ... shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: B) Bedroom furniture, which shall include, for each resident,.. a lamp, or lights sufficient for reading... This requirement was not met as evidence by 2 out of 3 residents bedrooms have missing light bulbs. This poses a potential risk to persons in care.

Official plan of correction

Administrator has since replaced ceiling fan/lights.

Deadline recorded: May 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: LPA and LPM observed rodents and pest present in facility along with rodent droppings. This poses an immediate health risk to persons in care.

Official plan of correction

Licensee agrees to set up daily cleaning schedule and seal all openings into the home. Licensee to provide proof by POC due date 11/14/2022.

Deadline recorded: Nov 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidence by: LPA observed discarded bike and paintings obsturcting walkway along side of house. LPA and LPM observed screws coming out of ground along other side patiowalkway which poses a potential health and safety risk to persons in care.

Official plan of correction

Licensee agrees to remove obstructions from walkways and provide picture proof of corrections by POC due date of 11/14/2022.

Deadline recorded: Nov 14, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(b)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (b) All window screens shall be clean and maintained in good repair. This is evidence by missing screen in facility ktichen slider, which poses a potential health and safety risk to persons in care.

Official plan of correction

Licensee agrees to repair/replace broken and missing screens and provide proof of correction by POC due date of 11/14/2022.

Deadline recorded: Nov 14, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

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 regulation was not met as evidence by: Based on observation smoke alarm in kitchen is nonoperational and fire door leading to resident bedrooms is proped open, this poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.

Official plan of correction

Licensee agrees to repair non-operational smoke alarms by POC due date of 11/01/2022

Deadline recorded: Nov 1, 2022. 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

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked....This regulation was not met as evidence by: Based on observation LPA observed an unlocked medication cabinet in facility hallway.This poses an immediate health and safety risk to persons in care.

Official plan of correction

Licensee agrees to set training date for all staff regarding medication management/storing by 11/01/2022. Training is to be completed by no later than 11/14/2022 and proof of training to be sent to LPA by 11/14/2022.

Deadline recorded: Nov 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: Based on medication reviewed for Resident 1 and Resident 2 medications records failed to document date medication started and medications missed. It remains unclear if medications are being given as prescribed. This poses an immediate health and safety risk to persons in care.

Official plan of correction

Licensee agrees to review all resident's medication and update record keeping. License to provide copies of updated records to LPA by COB 11/01/2022.

Deadline recorded: Nov 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87705(f) relative to the Care of Persons with Dementia indicates that: " The following shall be stored inaccessible to residents with dementia: (...) nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances " This requirement is not met as evidenced by: LPA observed cleanings solutions left unsecured in the cabinet under the sink.

Official plan of correction

Licensee will ensure that all potentially dangerous items are stored securely within the next 24 hours.

Deadline recorded: Oct 18, 2022. 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

The California Code of Regulations Section 87465(h)(2) relative to Incidental Medical and Dental Care indicates that: " 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: LPA observed that staff present had left the door to the medication closet unlocked while conducting the inspection visit. Caregiver states that they only lock the medication " when they sleep " . Deficient Practice Statement Based on observation and interviews conducted during the visit, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/17/2022 Plan of Correction Licensee will ensure that centrally stored medication remain locked and secure at all times.

Official classification

Type A

Official code

87705(f)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87705(f) relative to the Care of Persons with Dementia indicates that: " 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). (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. " This requirement is not met as evidenced by: LPA observed sharp instruments, cleanings solutions, insecticide and/or rodenticide and nutritional supplements left unsecured throughout the physical plant. Deficient Practice Statement Based on observation made during the inspection visit, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/17/2022 Plan of Correction Licensee will ensure the safe and secure storage of all the identified objects and substances by the Plan of Correction due date.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87506(a) relative to Resident Records indicates that " The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. " This requirement is not met as evidenced by: Licensing staff requested residents files during the inspection visit. Caregiver was only able to provide three files out of six residents observed at the facility. Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/28/2022 Plan of Correction Licensee will ensure that a complete and current record is present and available for each individual in care before the Plan of Corrections due date.

Official classification

Type B

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87303(a)(1) pertaining to Maintenance and Operation states that: " The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. " This requirement is not met as evidenced by: LPA observed footsteps marking the floor throughout the resident bathroom. The commode in the visitor bathroom is also noted to be non-functional. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/28/2022 Plan of Correction Licensee will ensure that the floor in the two bathroonms is kept clean, safe and sanitary and that the two commodes are functional before the Plan of Corrections due date.

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87468.1(a)(1) relative to Personal Rights of Residents in All Facilities indicates that: " Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. " This requirement is not met as evidenced by: LPA observed one resident with no items of clothing on the top part of their body, using a bedsheet to cover up during the inspection visit. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/17/2022 Plan of Correction By the plan of corrections due date, the licensee will ensure that the right to dignity of all the individuals in care at the facility are accorded.

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 87355(e) on Criminal Record Clearance states that " All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working (...) in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department or Request a transfer of a criminal record clearance as specified in Section 87355(c) or Request and be approved for a transfer of a criminal record exemption. This requirement is not met as evidenced by: One staff member present is neither cleared nor associated to the facility in Guardian. Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/14/2022 Plan of Correction Licensee will immediately remove staff member from the facility and ensure that they are not scheduled to work at the facility until they have received the required background clearance and been associated to the facility in Guardian.