Health conditions and treatmentsType A
- Official classification
- Type A
- Official code
- 87618(b)(3)(B)
- Regulation authority
- CCR
What the official deficiency says
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation licensee did not comply with the cited above as there is not a " No Smoking- Oxygen In use " posted in facility with a resident that is utilizing oxygen. This poses an immediate health and safety risk to persons in care.
Official plan of correction
POC Due Date: 10/11/2025 Plan of Correction Administrator corrected during visit.
Health conditions and treatmentsType A
- Official classification
- Type A
- Official code
- 87628(a)
- Regulation authority
- CCR
What the official deficiency says
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and records reviewed the licensee did not comply with the following in 2 out of 2 resident that receive insulin as they are not self administering injections and are not getting injections by a skilled professional. This poses an immediate health and safety risk to persons in care.
Official plan of correction
POC Due Date: 10/11/2025 Plan of Correction Administrator stated will administer insulin to both residents as she is a Nurse Practioner (licensed viewed by LPA. Administrator stated will contact R1's physician for updated orders for insulin to orally. Administrator stated will submit an exception for Resident 2 to LPA by POC due date.
Health conditions and treatmentsType A
- Official classification
- Type A
- Official code
- 87606(c)
- Regulation authority
- CCR
What the official deficiency says
(c) To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance. This requirement is not met as evidenced by: Deficient Practice Statement Based on obseveration and record review the licensee did not comply with the regulation above as Resident 1 (R1) resides in a room that is not cleared for bedridden resident. This poses an immediate health and safety risk to persons in care.
Official plan of correction
POC Due Date: 10/17/2025 Plan of Correction Administrator stated will get updated physicians report for R1 to state non-ambulatory as Administrator stated R1 is not bedridden. Licensee agreed if physicians report is not udpdated will move R1 from bedroom 2 to bedroom 3.
Facility condition and maintenanceType A
- Official classification
- Type A
- Official code
- 87303(e)(2)
- Regulation authority
- CCR
What the official deficiency says
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Deficient Practice Statement This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above in 3 out of 4 sinks as temperature read 97.3, 102.2, and 104.3 which poses a potential health and safety risk to persons in care.
Official plan of correction
POC Due Date: 10/11/2025 Plan of Correction Administrator agreed to adjust water heater and provide proof to LPA that water temperatures are within range. Administrator agreed to conduct quarterly water temperature checks and retain document for review.
Facility condition and maintenanceType B
- Official classification
- Type B
- 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 is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the regulation cited above as the facility has cobwebs in multple locations including: hallway cabinet where linens are stored, laundry area in behind washer/dryer and in kitchen cabinent on left hand of stove. LPA also observed screens in bathroom #2 and #3 to be in disrepair.This poses a potential health and safety risk to persons in care.
Official plan of correction
POC Due Date: 10/16/2025 Plan of Correction Licensee to clean faciltiy and replace screens in bathrooms and provide proof to LPA by POC due date.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695
- 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 and records reviewed the licensee did not comply with the cited above as there is no record of emergency drills conducted in 2025. This poses a pontential health and safety risks to persons in care.
Official plan of correction
POC Due Date: 10/16/2025 Plan of Correction Administrator agreed to conduct emergency drills and provide 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 cited above as LPA Mendivil observed unsecured medications in refrigerator. This poses an immediate health and safety risk to persons in care.
Official plan of correction
POC Due Date: 10/11/2025 Plan of Correction Administrator corrected during visit.