Hazardous items and storageType A
- 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, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above due to cleaning supplies and insecticides found in an unlocked garage, staff room, and staff restroom which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/28/2026 Plan of Correction Licensee stated they will complete a Statement of Understanding and submit to LPA by POC due date. Licensee will also conduct an in-service training, proof will be sent to LPA by August 17,2026 . Licensee also stated a key will be left for staff use to lock the garage when licensee is not here.
Medication handling and storageType A
- 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 is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above due to medications being found in staff bedroom and unlcoked garage which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/28/2026 Plan of Correction Licensee stated they will complete a Statement of Understanding and submit to LPA by POC due date. Licensee will also conduct an in-service training, proof will be sent to LPA by August 17, 2026 .
Licensing and administrationType B
- Official classification
- Type B
- Official code
- 1569.319(a)
- Regulation authority
- HSC
What the official deficiency says
(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above due to the facility not providing residents with an internet device which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/17/2026 Plan of Correction Licensee to provide facility device by POC due date. Picture to be sent to LPA via email.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(d)
- Regulation authority
- HSC
What the official deficiency says
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. 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 due to Emergency DIsaster Plan being incomplete and not being reviewed annually which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/17/2026 Plan of Correction Licensee to complete and sign Emergency Disaster Plan and sent to LPA via email by POC due date.