A TENDER TOUCH SENIOR LIVING LLC

Official classification

Type A

Official code

87465(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. (2) The exact dosage. 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 by dispensing dated medication from random dates/numbers rather than following the calendar days which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/18/2025 Plan of Correction Manager will complete medication training by a licensed pharmacist by POC date in addition thereafter wll train staff to dispnse medication accordignly.

Official classification

Type B

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 by not having the laundry detergents locked up which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/06/2025 Plan of Correction Manager will move cleaninig detergents to a locked area or lock the laundry door

Official classification

Type A

Official code

87309(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations, the licensee did not comply with the section cited above by not maintaining chemicals, cleaning supplies, and other poisons locked; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/22/2024 Plan of Correction During today's visit the house manager locked the chemicals and a locked was installed in the laundry room. No further action required.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Department.. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited above by staff #1(S1) working at the facility without a criminal record clearcance; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/22/2024 Plan of Correction The Licensee/Admistration shall submit a statement of understanding that no staff shall work at the facility until a criminal record clearance has been received.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations, the licensee did not comply with the section cited above by Staff #2 and #3, did not have documentation of required job training; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/13/2024 Plan of Correction The Licensee/Administrator shall submit to the licensing agency documentation of staff training as mentioned in the regulation cited by plan of correction date.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited above by S2 did not have documention of first aid/CPR 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: 12/13/2024 Plan of Correction The Licensee/Administrator shall submit to the licensing agency documentation of staff's first aid training by plan of correction date.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations, the licensee did not comply with the section cited above by not maintaining an updated resident medication list with dosages for R1 and R2; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/13/2024 Plan of Correction The Licensee/Administrator shall submit to the licensing agency an updated medication list by plan of correction date.

Official classification

Type B

Official code

87465

Regulation authority

CCR

What the official deficiency says

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 the medication for all residendent in care were taken out of the original packaging and placed in seperate containers which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide training to all staff members on the cited regulation and provide a written statement of understanding of the regulation signed by all staff members and forward to CCL by the POC date of 12/8/2023.

Official classification

Type A

Official code

87405(d)

Regulation authority

CCR

What the official deficiency says

(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above the licensee did not ensure that the facility files for the administrator were available for review at the time of the visit which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide CCL with a complete and current file with the administrator (Administrator’s Package) by the POC date of 12/8/2023. This information can be brought or mailed to the regional office.

Official classification

Type A

Official code

87405(d)(6)

Regulation authority

CCR

What the official deficiency says

(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (6) Have a high school diploma or equivalent, such as a General Education Development (GED) certificate. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above the licensee did not ensure that the facility files for the administrator were available for review at the time of the visit which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide CCL with a complete and current file with the administrator (Administrator’s Package) by the POC date of 12/8/2023. This information can be brought or mailed to the regional office.

Official classification

Type B

Official code

87412(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by: Deficient Practice Statement LPA requested the personnel files for the staff members and Teresita Espinoza stated that there were only four (4) staff members, and no files were available at the facility for review.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide copies of all staff members files with all required documents, trainings and certificates by the POC dates of 12/8/2023.

Official classification

Type B

Official code

1569.17(b)

Regulation authority

HSC

What the official deficiency says

(b) In addition to the applicant, the provisions of this section shall apply to criminal record clearances and exemptions for the following persons: This requirement is not met as evidenced by: Deficient Practice Statement LPA requested the personnel files for the staff members and Teresita Espinoza stated that there were only four (4) staff members, and no files were available at the facility for review.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide copies of all staff members files with all required documents, trainings and certificates by the POC dates of 12/8/2023.

Official classification

Type B

Official code

87411(d)

Regulation authority

CCR

What the official deficiency says

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by: Deficient Practice Statement LPA requested the personnel files for the staff members and Teresita Espinoza stated that there were only four (4) staff members, and no files were available at the facility for review.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide copies of all staff members files with all required documents, trainings and certificates by the POC dates of 12/8/2023.

Official classification

Type B

Official code

87412(c)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Deficient Practice Statement LPA requested the personnel files for the staff members and Teresita Espinoza stated that there were only four (4) staff members, and no files were available at the facility for review.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide copies of all staff members files with all required documents, trainings and certificates by the POC dates of 12/8/2023.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Deficient Practice Statement LPA requested the personnel files for the staff members and Teresita Espinoza stated that there were only four (4) staff members, and no files were available at the facility for review.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide copies of all staff members files with all required documents, trainings and certificates by the POC dates of 12/8/2023.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement LPA requested the personnel files for the staff members and Teresita Espinoza stated that there were only four (4) staff members, and no files were available at the facility for review.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide copies of all staff members files with all required documents, trainings and certificates by the POC dates of 12/8/2023.

Official classification

Type B

Official code

1569.626(a)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: This requirement is not met as evidenced by: Deficient Practice Statement LPA requested the personnel files for the staff members and Teresita Espinoza stated that there were only four (4) staff members, and no files were available at the facility for review.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide copies of all staff members files with all required documents, trainings and certificates by the POC dates of 12/8/2023.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Deficient Practice Statement During the annual visit LPA requested the files for the residents in care three (3) files were incomplete and two (2)residents files were not available at the facility.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide a complete file for all residents in care with all required documents by the POC dates of 12/8/2023.

Official classification

Type B

Official code

87456(a)

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: This requirement is not met as evidenced by: Deficient Practice Statement During the annual visit LPA requested the files for the residents in care three (3) files were incomplete and two (2)residents files were not available at the facility.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide a complete file for all residents in care with all required documents by the POC dates of 12/8/2023.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Deficient Practice Statement During the annual visit LPA requested the files for the residents in care three (3) files were incomplete and two (2)residents files were not available at the facility.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide a complete file for all residents in care with all required documents by the POC dates of 12/8/2023.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Deficient Practice Statement During the annual visit LPA requested the files for the residents in care three (3) files were incomplete and two (2)residents files were not available at the facility.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide a complete file for all residents in care with all required documents by the POC dates of 12/8/2023.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: This requirement is not met as evidenced by: Deficient Practice Statement LPA requested the personnel files for the staff members and Teresita Espinoza stated that there were only four (4) staff members, and no files were available at the facility for review.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide a complete file for all residents in care with all required documents by the POC dates of 12/8/2023.

Official classification

Type B

Official code

87467(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. This requirement is not met as evidenced by: Deficient Practice Statement LPA requested the personnel files for the staff members and Teresita Espinoza stated that there were only four (4) staff members, and no files were available at the facility for review.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide a complete file for all residents in care with all required documents by the POC dates of 12/8/2023.

Official classification

Type B

Official code

87507(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement is not met as evidenced by: Deficient Practice Statement LPA requested the personnel files for the staff members and Teresita Espinoza stated that there were only four (4) staff members, and no files were available at the facility for review.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide a complete file for all residents in care with all required documents by the POC dates of 12/8/2023.

Official classification

Type B

Official code

87508(b)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information: This requirement is not met as evidenced by: Deficient Practice Statement LPA requested the personnel files for the staff members and Teresita Espinoza stated that there were only four (4) staff members, and no files were available at the facility for review.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide a complete file for all residents in care with all required documents by the POC dates of 12/8/2023.

Official classification

Type B

Official code

1569.695(a)

Regulation authority

HSC

What the official deficiency says

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by: Deficient Practice Statement LPA requested the personnel files for the staff members and Teresita Espinoza stated that there were only four (4) staff members, and no files were available at the facility for review.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide complete files for all staff members with all required documents by the POC dates of 12/8/2023.

Official classification

Type B

Official code

87212(b)

Regulation authority

CCR

What the official deficiency says

(b) The plan shall be subject to review by the Department and shall include: This requirement is not met as evidenced by: Deficient Practice Statement LPA requested the personnel files for the staff members and Teresita Espinoza stated that there were only four (4) staff members, and no files were available at the facility for review.

Official plan of correction

POC Due Date: 12/08/2023 Plan of Correction The licensee has agreed to provide complete files for all staff members with all required documents by the POC dates of 12/8/2023.

Official classification

Type A

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible... (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually...This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by not having annual medical assessment and a reappraisal done at least annually for R1 which pose immediate health, safety and personal rights risk to resident in care.

Official plan of correction

Licensee stated to submit signed Statement of Understanding on CCR 87705(c)(5) to LPA Brown by POC due date.

Deadline recorded: Feb 23, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87457(a)

Regulation authority

CCR

What the official deficiency says

87457 Pre-Admission Appraisal – General (a) Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions. This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by not having a completed Pre-Admission Appraisal for R1 which pose potential health, safety and personal rights risk to resident in care.

Official plan of correction

Licensee stated to submit signed Statement of Understanding on CCR 87457(a) to LPA Brown by POC due date.

Deadline recorded: Mar 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working...(1) Obtain a California clearance... This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by allowing Staff #4 (S4) to work at the facility without criminal background clearance since 08/01/2021 which pose immediate health, safety and personal rights risk to resident in care.

Official plan of correction

Licensee stated to submit Signed Statemanet of Understanding on CCR 87355(e)(1) to LPA Brown by POC due date. Licensee confirmed S4 was granted criminal background clearance last 09/07/2022. POC cleared.

Deadline recorded: Feb 23, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355. Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing, or volunteering in a licensed facility:(1) Obtain a California clearance or a criminal record..This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above by allowing S1 to work at the facility for one (1) day without a criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to read regulation 87355 entirely and send LPA self-certify letter that the regulation was read and understood. The licensee has agreed to remove S1 from the facility and not allow S1 to work at the facility until S1 has a criminal background clearance. POC is due 12/14/2023

Deadline recorded: Jan 14, 2023. 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

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency... This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by not submitting Special Incident Report (SIR) that R3 had a wound on right arm while hospice staff is giving R3 a shower. This pose potential health, safety and personal rights risk to resident in care.

Official plan of correction

Licensee stated to train all staff on CCR 87211(a)(1) and submit proof of Staff Training Log to LPA Brown by POC due date. Licensee will submit Signed Statement of Understanding on CCR 87211(a)(1) to LPA Brown by POC due date.

Deadline recorded: Jan 3, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents… This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by placing an audio surveillance device in R3, R2 and R1’s bedroom without R3, R2 and R1’s responsible party’s consent which poses potential health, safety and personal rights risk to residents in care.

Official plan of correction

Licensee stated to train all staff on CCR 87307(a) and will submit Training Log to LPA Brown by POC due date. Licensee will submit a Statement of Understanding on CCR 87307(a) to LPA Brown by POC due date.

Deadline recorded: Jan 3, 2023. A deadline is not proof that correction was completed.