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, the licensee did not comply with the section cited above. LPA observed unsecured toxins and knives in unsecured cupboards in kitchen which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/26/2026 Plan of Correction Licensee secured knives during the visit. Please secure toxins and forward proof to LPA by POC due date.
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, the licensee did not comply with the section cited above. LPA observed unsecured staff medications in the laundry room which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/26/2026 Plan of Correction Licensee to secure medications and forward proof to LPA by POC due date.
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87307(e)(1)(A)
- Regulation authority
- CCR
What the official deficiency says
(e) The licensee shall supervise residents as needed and as determined by the resident's appraisal pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to or when there is use of the following items: (1) Ranges, ovens, heaters, fireplaces, wood stoves, inserts, and other heating devices. (A) Heating devices shall have protective mechanisms or other measures to prevent access to the device, or to make it inoperable when not in use, in order to reduce the risk of burns or fire. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPA observed facility cook top does not have protective mechanisms which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/08/2026 Plan of Correction Licensee to obtain protective mechanisms and forward proof to LPA by POC due date.
Fire safety and emergency preparednessType B
- 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 record review, the licensee did not comply with the section cited above. Facility does not have documented quarterly drills which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/08/2026 Plan of Correction Licensee to conduct drill and forward proof to LPA by POC due date.
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87608(a)(3)
- Regulation authority
- CCR
What the official deficiency says
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. 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. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in three out of five residents without a physician order for bed rails which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/08/2026 Plan of Correction Licensee obtained 1 order during visit. Please obtain the other orders and forward proof to LPA by POC due date.
Staffing, personnel, and trainingType A
- Official classification
- Type A
- Official code
- 87411(h)
- Regulation authority
- CCR
What the official deficiency says
All services requiring specialized skills shall be performed by personnel qualified by training or experience in accordance with recognized professional standards. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in two out of two residents with parameter medication orders and staff are not licensed professionals which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/26/2026 Plan of Correction Licensee to obtain non-parameter orders for residents #2 and 4 and forward proof to LPA by POC due date.