HILLS OF HIGHLAND, THE

Official classification

Type A

Official code

87213

Regulation authority

CCR

What the official deficiency says

87213 Finances: The licensee shall have a financial plan.. shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency... This requirement was not evidenced by: Based on interviews conducted, the Licensee does not have a sufficient financial plan as the have an outstanding rent balance of $82,000.00. This poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that he will provide LPA a written financial plan on how they will address the outstanding rent balance. The Licensee agreed to provide LPA the written plan via email or fax by POC date.

Deadline recorded: Aug 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87207

Regulation authority

CCR

What the official deficiency says

87207 False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not evidenced by: Based on interviews and records reviewed, the Licensee made a false & misleading statement to the landlord of the property regarding an agreement with CDSS to expedite the facility license. This poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that he will review the regulation cited and will complete a statement of understanding. The Licensee agreed to provide LPA the statement via email or fax by POC due date.

Deadline recorded: Aug 31, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation: (e) Water supplies ..shall be maintained as follows: (2) Faucets .. shall deliver hot water. Hot water .. shall be maintained .. not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not evidenced by: Based on observations, the Licensee did not ensure that the facility's water was within regulatory requirements as the hot water temperature measured between 96.8 and 97.3 degrees Fahrenheit. This poses a potential health and safety risk to persons in care.

Official plan of correction

The Administrator stated that she will adjust the hot water temperature to be within regulatory requirements. The Administrator agreed to provide LPAs a hot water temperature log once the water has been adjusted and will provide LPAs the log via email of fax by POC due date.

Deadline recorded: Aug 31, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation: (e) Water supplies ..shall be maintained as follows: (2) Faucets .. shall deliver hot water. Hot water .. shall be maintained .. not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not evidenced by: Based on observations, the Licensee did not ensure that the facility's water was within regulatory requirements as the hot water temperature measured between 97.8 & 100.5 degrees Fahrenheit. This poses a potential health and safety risk to persons in care.

Official plan of correction

The Administrator stated that she will adjust the hot water temperature to be within regulatory requirements. The Administrator agreed to provide LPAs a hot water temperature log once the water has been adjusted and will provide LPAs the log via email of fax by POC due date.

Deadline recorded: Aug 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1568.39(e)

Regulation authority

HSC

What the official deficiency says

§1569.38 Posting of licensing reports; disclosure to new residents: (e) Upon providing the notice described in subdivision (b), the licensed residential care facility shall also post a written notice.. in the facility.. This requirement is not evidenced by: Based on observation, the Licensee did not ensure that a notice regarding the proceedings was posted at the facility as LPAs did not observe it during today's visit. Staff also corroborated that the notice has not been posted. This poses an immediate health and safety risk to persons in care.

Official plan of correction

The Administrator stated that she will post the notice of the proceeding in the facility. The Administrator agreed to provide LPAs proof of posting via email or fax by POC due date. LPAs will also conduct a follow up visit to confirm the notice has been posted.

Deadline recorded: Jul 6, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87213

Regulation authority

CCR

What the official deficiency says

87213 Finances: The licensee shall have a financial plan.. shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency... This requirement was not evidenced by: Based on interviews conducted, the Licensee does not have a sufficient financial plan as the have an outstanding rent balance of $65,500.00. This poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that he will provide LPAs a written financial plan on how they will address the outstanding rent balance. The Licensee agreed to provide LPA the written plan via email or fax by POC date.

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

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation: (e) Water supplies ..shall be maintained as follows: (2) Faucets .. shall deliver hot water. Hot water .. shall be maintained .. not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not evidenced by: Based on observation, the Licensee did not ensure that the facility's water was within regulatory requirements as the hot water temperature measured between 124.3 & 126.1 degrees Fahrenheit. This poses a potential health and safety risk to persons in care.

Official plan of correction

The Administrator stated that she will adjust the hot water temperature to be within regulatory requirements. The Administrator agreed to provide LPAs a hot water temperature log once the water has been adjusted and will provide LPAs the log via email of fax by POC due date.

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

Official classification

Type B

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 is not evidenced by: Based on observations, the Licensee did not ensure that the exterior was clean and safe since LPAs observed multiple items in the side yard. LPAs also observed the sideyard and backyard has not been cleaned or maintained. This poses a potential health and safety risk to persons in care.

Official plan of correction

The Administrator stated that she will arrange for the items to be disposed of and for the backyard and sideyard to be cleaned. LPAs will conduct a subsequent visit to ensure the exterior has been cleaned.

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

Official classification

Type A

Official code

87213

Regulation authority

CCR

What the official deficiency says

87213 Finances: The licensee shall have a financial plan.. shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency... This requirement was not evidenced by: Based on interviews conducted, the Licensee does not have a sufficient financial plan as the have an outstanding rent balance of $59.500.00 This poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that he will provide LPA a written financial plan on how they will address the outstanding rent balance. The Licensee agreed to provide LPA the written plan via email or fax by POC date.

Deadline recorded: Jun 18, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation: (e) Water supplies ..shall be maintained as follows: (2) Faucets .. shall deliver hot water. Hot water .. shall be maintained .. not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not evidenced by: Based on observation, the Licensee did not ensure that the facility's water was within regulatory requirements as the hot water temperature measured between 131.9 & 132.2 degrees Fahrenheit. This poses a potential health and safety risk to persons in care.

Official plan of correction

The Licensee stated that he will adjust the hot water temperature to be within regulatory requirements. The Licensee agreed to provide LPA a hot water temperature log once the water has been adjusted and will provide LPA the log via email of fax by POC due date.

Deadline recorded: Jun 26, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation: (e) Water supplies ..shall be maintained as follows: (2) Faucets .. shall deliver hot water. Hot water .. shall be maintained .. not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not evidenced by: Based on observation, the Licensee did not ensure that the facility had water as the facility's water was shut off. There are no residents in care, but the Licensee is planning on relocating residents back into the home next month. This poses a potential health and safety risk to persons in care.

Official plan of correction

The Licensee agreed to pay the remaining balance for the facility's water bill to restore the water. The Licensee agreed to provide LPA proof of payment via email or fax by POC date.

Deadline recorded: Jun 8, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87213

Regulation authority

CCR

What the official deficiency says

87213 Finances: The licensee shall have a financial plan.. shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency... This requirement was not evidenced by: Based on observation and records reviewed, the Licensee did not provide all the requested documents to Community Care Licensing as requested. The Licensee has also not resolved previous staff wage issues. This poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that he will provide LPA the requested documents and will submit a plan on how he will address the owed wages to staff. The Licensee agreed to provide LPA the written plan via email or fax by POC date.

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

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. Based on observation, the Licensee did not ensure that all fire extinguishers at the facility were serviced annually, which violates State Fire Marshal regulations. This poses a potential health and safety risk to persons in care.

Official plan of correction

The Licensee stated that he will service all fire extinguishers in order to comply with State Fire Marshal regulations. The Licensee agreed to provide LPA provide of fire extinguishers being serviced via email or fax by POC date.

Deadline recorded: May 8, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87213

Regulation authority

CCR

What the official deficiency says

87213 Finances: The licensee shall have a financial plan.. shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency... This requirement was not evidenced by: Based on observation and records reviewed, the Licensee did not provide all the requested documents to Community Care Licensing as requested. The Licensee has also not resolved previous staff wage issues. This poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that he will provide LPA the requested documents and will submit a plan on how he will address the owed wages to staff. The Licensee agreed to provide LPA the written plan via email or fax by POC date.

Deadline recorded: Apr 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows (2)Faucets used by residents .. shall be maintained to .. not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not evidenced by: Based on observation, the Licensee did not ensure the hot water temperature was within regulatory requirements as LPA measured the resident bathrooms to be between 128.3 and 129.9 degrees Fahrenheit. This poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Administrator agreed to adjust the hot water temperature to be within regulatory requirements. LPA will conduct a follow up visit to measure the hot water temperature to ensure it is within regulatory requirements.

Deadline recorded: Apr 13, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87213

Regulation authority

CCR

What the official deficiency says

87213 Finances: The licensee shall have a financial plan.. shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency... This requirement was not evidenced by: Based on observation and records reviewed, the Licensee did not provide all the requested documents to Community Care Licensing as agreed upon. Additionally, the Licensee did not ensure staff have been paid on schedule. This poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that they will provide a written plan to LPA on when they will submit the requested documents on how they will address the owed wages of staff. The Licensee agreed to provide LPA the written plan via email or fax by POC date.

Deadline recorded: Mar 10, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87213

Regulation authority

CCR

What the official deficiency says

87213 Finances: The licensee shall have a financial plan.. shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency... This requirement was not evidenced by: Based on observation and records reviewed, the Licensee did not provide all the requested documents to Community Care Licensing as agreed upon. Additionally, the Licensee did not ensure staff have been paid on schedule. This poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that they will provide a written plan to LPA on when they will submit the requested documents on how they will address the owed wages of staff. The Licensee agreed to provide LPA the written plan via email or fax by POC date.

Deadline recorded: Feb 26, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87213

Regulation authority

CCR

What the official deficiency says

87213 Finances: The licensee shall have a financial plan.. shall maintain adequate financial records; and shall submit such financial reports as may be required upon the written request of the licensing agency... This requirement was not evidenced by: Based on observation and records reviewed, the Licensee did not provide all the requested documents to Community Care Licensing as agreed upon. Additionally, the Licensee did not ensure staff have been paid on schedule. This poses an immedate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that they will provide a written plan to LPA on when they will submit the requested documents on how they will address the owed wages of staff. The Licensee agreed to provide LPA the written plan via email or fax by POC date.

Deadline recorded: Feb 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87156(a)

Regulation authority

CCR

What the official deficiency says

87156 Licensing Fees: (a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. This requirement was not evidenced by: Based on observation and records reviewed, the Licensee did not pay the facility's annual fees for 2025 depsite previous reminders. This poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that he will pay the facility's annual fees. The Licensee agreed to provide LPA proof of payment via email or fax by POC date.

Deadline recorded: Feb 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General: (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirment was not evidenced by: Based on observation and records reviewed, the Licensee did not ensure that five staff had received the proper intiial or annual training. This poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that he will have the five staff complete the required training. The Licensee agreed to provide LPA proof of the training for the five staff via email or fax by POC date.

Deadline recorded: Feb 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(b)(17)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records: (b) Each resident’s record shall contain at least the following information: (17) Documents and information required by the following: This requirement was not evidenced by: Based on observations and records reviewed, the Licensee did not ensure that three resident records were complete. This poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that he will conduct an in service training with staff regarding proper documentation in record files. The Licensee agreed to provide LPA proof of training via email or fax by POC date.

Deadline recorded: Feb 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties: (a) All facilities shall have a.. certified administrator... and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility ... This requirment was not evidenced by: Based on records reviewed and interviewed conducted, the Licensee did not ensure the Administrator was present at the facility a sufficient amount of hours to ensure compliance. This poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that he will create a plan on how he will ensure an Administrator is present at the facility a sufficient amount of hours to remain in compliance. The Licensee agreed to provide the plan to LPA via email or fax by POC date.

Deadline recorded: Feb 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

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 evidenced by: Based on observations, the Licensee did not ensure the facility was in good repair as LPA noted a light not operational, paint peeling, the yards being overgrown, and outdoor furniture to be in disrepair. This poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that he will make the necessary repairs to the facility. LPA will conduct a subsequent visit to ensure that all repairs have been made.

Deadline recorded: Feb 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87213

Regulation authority

CCR

What the official deficiency says

87213 Finances: The licensee shall have a financial plan... that assures sufficient resources to meet operating costs for care of residents... This requirement was not evidenced by: Based on observations, interviews, and records reviewed, the Licensee does not have an adequate financial plan to meet the needs of the residents. The facility has an outstanding rent balance, water was shut off due to non-payments, staff have not received full wages or were not paid on time. This poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that he will create a financial plan to ensure the needs of the residents and of the facility are met. The Licensee agreed to provide LPA the financial plan via email or fax by POC date.

Deadline recorded: Feb 6, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

87208 Plan of Operation: (a)The licensee shall have and maintain a current, written definitive plan of operation for the facility. .. and may be cited for not doing so ... This requirement was not evidenced by: Based on interviews conducted, the Licensee did not ensure staff followed the facility's plan of operation since staff did not ensure visistors signed into the vistor log. This poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that he will conduct an in service training with staff regarding the vistor log policy. The Licensee agreed to provide LPA proof of training via email or fax by POC date.

Deadline recorded: Feb 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility..(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not evidenced by: Based on observations and records reviewed, the Licensee did not ensure the medication administration records for two residents were completely accurately. This poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that he will conduct an in service training with staff regarding the proper documentation of resident's medication administration records. The Licensee agreed to provide LPA proof of the training via email or fax by POC date.

Deadline recorded: Feb 6, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87205(a)

Regulation authority

CCR

What the official deficiency says

87205 Accountability of Licensee Governing Body: (a) The licensee.. shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations... This requirment was not evidenced by: Based on observations, interviews, and records reviewed, the Licensee has not provided sufficient supervision as the facility is in disrepair, in financial distress, and does not have an Administrator present a sufficient amount of hours. This poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee stated that he will complete a statement understanding the regulaion and will commit to provide enough supervision over the facility. The Licensee agreed to provide the statement to LPA via email or fax by POC date.

Deadline recorded: Feb 6, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

87457 Pre-Admission Appraisal: (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs... This requirement was not evidenced by: Based on observations and records reviewed, the Licensee did not ensure there was a Pre-Admission Appraisal on file for Resident #1 (R1). This poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Administrator stated that he will complete a Pre-Admission Appraisal for R1. The Adminstrator agreed to provide LPA the Pre-Admission Appraisal for R1 via email or fax by POC date.

Deadline recorded: Feb 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals: (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... This requirement was not evidenced by: Based on records reviewed, the Licensee did not ensure there was a Reappraisal on file for Resident #1 (R1) and that the Reappraisal for Resident #2 (R2) was updated as frequently as necessary. This poses a potential health, safety, & personal rights risk.

Official plan of correction

The Administrator stated that he will complete Reappraisals for R1 and R2. The Administrator agreed to provide LPA the Reappraisals for R1 and R2 via email or fax by POC date.

Deadline recorded: Feb 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87459(a)

Regulation authority

CCR

What the official deficiency says

87459 Functional Capabilities: (a) The facility shall assess the person's need for personal assistance and care by determining his/her ability to perform specified activities of daily living. Such activities shall include, but not be limited to.. This requirement was not evidenced by: Based on observations and records reviewed, the Licensee did not ensure that there were functional capability assessments on file for the three residents of the facility. This poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Administrator stated that he will complete functional capability assessments for all three residents. The Administrator agreed to provide the functional capability assessments for all three residents via email or fax by POC date.

Deadline recorded: Feb 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(c)

Regulation authority

CCR

What the official deficiency says

87507 Admission Agreements: (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative.. This requirement was not evidenced by: Based on observation and record review, the Licensee did not ensure that Resident #1 (R1) Admission Agreement was signed by a facility representative. This poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Administrator stated that he will sign R1's Admission Agreement. The Administrator agreed to provide the signed copy of R1's Admission Agreement via email or fax by POC date.

Deadline recorded: Feb 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation: (e) Water supplies ..shall be maintained as follows: (2) Faucets .. shall deliver hot water. Hot water .. shall be maintained .. not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not evidenced by: Based on observation, the Licensee did not ensure the facility had water as the facility was experiencing a water shutoff upon LPA's arrival. The facility remained without water for the duration of the visit. This poses and immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee agreed to paid the outstanding balance for the facility's water bill to restore the water. The Licensee agreed to provide LPA proof of payment via email or fax by POC date.

Deadline recorded: Feb 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Criminal Record Clearance: (e) All individuals subject to a criminal record review ..shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement was not evidenced by: Based on observation and record review, the Licensee did not ensure all staff had a criminal record clearance as one care giving staff present during the visit, Staff #4 (S4) was not background cleared. This poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Administrator stated that he will contact Guardian regarding S4's status. The Administrator stated that he will provide LPA a written plan once Guardian is contacted to ensure S4 has a criminal record clearance. The Administrator will provide the written plan to LPA via email or fax by POC date.

Deadline recorded: Feb 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87755(c)

Regulation authority

CCR

What the official deficiency says

87755 Authority of the Licensing Agency: (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours.... This requirement is not evidenced by: The Licensees did not submit the requested documents for all sixteen licensed facility's by the due date as agreed upon during the annual inspection conducted on November 4, 2025. This poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensees agreed to submit the requested documents for all sixteen licensed facility's to LPA by POC date.

Deadline recorded: Dec 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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 an immediate health, safety or personal rights risk to persons in care. LPAs observed the Licensees do not currently have liability insurance for the facility. LPAs observed the Licensees did not renew their liability insurance after it expired on April 26, 2025.

Official plan of correction

POC Due Date: 11/05/2025 Plan of Correction The Licensees stated that they are in the process of renewing the liability insurance for the facility. The Licensees stated that they will provide LPA proof of liability insurance once it has been obtained. The Licensees agreed to provide LPA the liability insurance via email or fax by POC date.

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 comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPAs observed there was no Reappraisal on file for Resident #3 (R3). LPAs also observed that the Reappraisals on file for Resident #2 (R2), Resident #4 (R4), and Resident #5 (R5) were outdated.

Official plan of correction

POC Due Date: 11/28/2025 Plan of Correction The Licensees stated that they will complete the Reappraisals for all four residents. The Licensees stated that they will provide the completed Reappraisals for all four residents to LPA via email or fax by POC date.