SIGNATURE LIVING ON CAMELIA AVENUE

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 review, the licensee did not comply with the section cited above in 2 of 2 staff, S1 and S1, not having 20 hours annual training on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/16/2025 Plan of Correction Licensee will submit proof of training to CCL by the POC date of 12/16/25

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 interview and records, the licensee did not comply with the section cited above in staff training was not completed quarterly which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/09/2025 Plan of Correction Licensee will submit proof of all staff participation in a drill and a statement for planned upcoming drills for 2026 by the POC date of 12/9/25.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed.This requirement was not met for R1 based on records and interviews. This posed a potential risk to R1.

Official plan of correction

At this visit, LPA observed that R1 is receiving medications as prescribed. POC cleared by visit.

Deadline recorded: Oct 23, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(7)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements (b) (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement was not met for R1 based on records and interviews. This posed a potential risk to R1.

Official plan of correction

At this visit, LPA observed that R1 is receiving required and preferred foods as prescribed. POC cleared by visit.

Deadline recorded: Oct 23, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625

Regulation authority

CCR

What the official deficiency says

Managed Incontinence (b)(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met based on statements by resident and staff. This posed a potential risk to R1.

Official plan of correction

The licensee has corrected this situation by instituting scheduling changes to ensure adequate number of qualified staff are present for resident needs. This POC is cleared by this visit.

Deadline recorded: May 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.695(b)

Regulation authority

HSC

What the official deficiency says

(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with this section based on 2 of 2 staff records that did not have training on the facility's emergency and disaster plan. This posed a potential risk to residents

Official plan of correction

POC Due Date: 11/06/2024 Plan of Correction Licensee will submit proof of all current care stafftarining on the facility's emergency procedures by the POC date of 11/6/24

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 interview and record, the licensee did not comply with the section cited above in quarterly emergency drills have not been recored which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/06/2024 Plan of Correction Proof of drills including all caregivers during the shifts for which they regularly work will be submitted by the POC date of 11/06/24.

Official classification

Type B

Official code

87211(a)

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)(D)ny incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview the licensee did not comply with the section cited above infor R4's recent incident and hospitalization which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/30/2024 Plan of Correction Licensee will submit a procedure and accountable staff to ensure all reportable incidents are reported timely by the POC date of 10/30/24

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met based on records review which showed R1 was admitted to the facility with stage IV injuries. This posed an immediate risk to resident health and safety.

Official plan of correction

R1 is currently stable and receiving appropriate care. Licensee will submit proof of scheduled training for preappraisals and prohibitted conditions to CCL by the POC date of 1/22/24. Scheduled training must be completed within 30 days from this date.

Deadline recorded: Jan 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility…by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met based on records review and statements that found R1 had recommendations for wound care that were not arranged for by the licensee. This posed an immediate risk to the resident. Civil Penalties are applied.

Official plan of correction

R1 is currently stable and receiving appropriate care. Licensee will develop procedures to address, staff knowledge of resident conditions, staff observation for changes to known conditions and response, up to call to 9-1-1, when resident conditions need medical care. Procedure will include staff training. Procedure to be submitted by the POC date of 1/22/24.

Deadline recorded: Jan 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87631(a)(1)

Regulation authority

CCR

What the official deficiency says

Healing Wounds (a), the licensee shall be permitted to accept or retain a resident who has a healing wound under the following circumstances: (1) When care is performed by or under the supervision of an appropriately skilled professional. This requirement was not met based on records review and interviews. This posed and immediate risk to the resident.

Official plan of correction

Licensee will submit a wound care plan for R1, which includes but is not limited to: Staging of R1's current wounds, schedule for home health, training of caregivers, reposition schedule if ordered and a communication system to record wound care performed at every home health visit. This POC is due 12/15/23 by 5PM.

Deadline recorded: Dec 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation of temperature taken, the licensee did not comply with the section cited above in 2 of 2 resident bathrooms temperature measured at 126' F which poses/posed a potential health, safety or personal rights risk, due to their ambulatory status, to persons in care.

Official plan of correction

POC Due Date: 12/06/2023 Plan of Correction Licensee will adjust water temperature and test log which shows 2 consecutive temperatures between 105-120' F, to CCL by the POC date of 12/6/23.

Official classification

Type B

Official code

87456(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in 2 out of 6 residents not have apraisals or care plans on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2023 Plan of Correction Licensee will submit copies of appraisals for R5 and R6 by the POC date of 12/6/23.

Official classification

Type B

Official code

87507(c)

Regulation authority

CCR

What the official deficiency says

(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 no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in 2] out of 6 resident files R5 and R6 did not have admission agreements on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2023 Plan of Correction Licensee will submit proof of admission agreements for identified residents by the POC date of 12/6/23.