QUEENS HOME 3

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (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 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observations made the licnesee did not comply with the cited above in 1 out of 5 bathrooms. The water temperature measured at 133.5 in staff bathroom which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 12/19/2025 Plan of Correction Licensee posted warning signs regarding hot water temperature. Licensee stated will adjust water temperature and provide proof to LPA by POC due date.

Official classification

Type A

Official code

87463(h)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations and records reviewed the licensee did not comply with the cited above in 1 out of 12 residents. R9 did not have an updated medical assessment. This poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 12/19/2025 Plan of Correction Licensee to get updated LIC 602 and provide proof to LPA by POC due date.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations and records reviewed the Licensee did not comply with the cited as R9 had full bed rails and is not on hospice. This poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 12/18/2025 Plan of Correction Licensee removed full bed rail during visit. Licensee has an order for half rails and will obtain half rails and provide proof to LPA by POC due date.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed Licensee did not comply with the cited above in 5 out of 6 staff files reviewed. 6 staff file reviewd was Administrators. The staff training did not include times of trainings provided and the topics of restricted health conditions and postural supports were not covered. This poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 12/30/2025 Plan of Correction Licensee to provide updated times of current trainings and include at least 4 hours of postural supports and restricted health conditions and provide proof to LPA by POC due date.

Official classification

Type B

Official code

87555(b)(23)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations made licensee did not comply with the cited above as there were expired seasonings in Unit A. This poses a potential risk to persons in care.

Official plan of correction

POC Due Date: 12/17/2025 Plan of Correction Corrected during visit.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). Health and Safety Code section 1569.2(c) provides: (c) " Care and supervision " means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with.., or personal care. This requirement was not met as evidenced by: Three staff members including Licensee Maghbouleh, confirmed R1 was left unattended, resulting in the resident falling and sustaining skin tears to both arms and bruising to the forehead. This poses a threat to the health, safety, and personal rights of residents in care.

Official plan of correction

Administrator Maghbouleh stated the regulation will be reviewed by all Administrators and the Licensee. A signed statement of acknowledgement and understanding will be provided for each Administrator and the Licensee, for a total of four statements of acknowledgement. POC is by 4:00pm on the POC due date.

Deadline recorded: Sep 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(1)

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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: On April 14, 2024, a caregiver was recorded on video handling R1 in a rough manner. While being changed, R1 was carelessly flipped over by one of the caregivers. Multiple individuals, including Licensee Maghbouleh confirmed the now former caregiver’s actions captured on video. This poses a threat to the health, safety, and personal rights of residents in care.

Official plan of correction

Administrator Maghbouleh stated the regulation will be reviewed by himself, and all primary caregivers. A signed statement of acknowledgement and understanding will be provided for each primary caregiver.If all staff can not review the regulation with the licensee and sign a statement of acknowledgement and understanding. Licensee will be given no more than three business days to submit all signed statements.

Deadline recorded: Sep 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by: The facility failed to accurately report R1’s falls and injuries to R1’s responsible person. The facility also failed to accurately report R1’s fall and injuries to the department. The incident report with no date contains false information and there’s no incident report for R1 from Queens Home 3 in the departments data base for all incident and death reports. This poses a potential threat to the health, safety, and personal rights of residents

Official plan of correction

Administrator Maghbouleh stated himself, and the other Administrator(s) and the licensee will read and review the regulation section on Reporting Requirements and send a signed statement of acknowledgement and understanding for each administrator and the licensee. AD Maghbouleh will conduct and in-service training for all staff members on reporting requirements and email the sign in sheet for all staff in attendance, and share with the department who the primary person and a secondary person responsible for sending all incident reports to the department in a timely fashion. POC is due Friday, September 5, 2025, by 1:00pm.

Deadline recorded: Sep 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

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 being met as evidenced by: Three staff members, including AD, admitted to making false claims to the department during the course of a complaint investigation. This a potential threat to the health, safety, and personal rights of residents

Official plan of correction

Administrator Maghbouleh stated all administrators, the licensee, and all primary caregivers will read and review regulation section 87207 False Claims. Administrator Maghbouleh stated everyone will sign their statement of acknowledgment and understanding once completed. POC will be emailed to LPA Haley by 4:00pm on the POC due date.

Deadline recorded: Sep 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.269(a)

Regulation authority

HSC

What the official deficiency says

1569.269(a) Residents of residential care facilities for the elderly shall have all of the following rights: (21) To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. The licensee did not comply with the section cited above because the investigation revealed, the facility exceeded two days to get the requested documents sent out.

Official plan of correction

The facility fulfilled the request on August 16, 2024, therefore the plan of correction has been fulfilled before the time of this visit. LPA provided a clear letter with this deficiency.

Deadline recorded: Oct 31, 2024. A deadline is not proof that correction was completed.