ATIENZA RESIDENTIAL CARE

Official classification

Type A

Official code

87470(c)

Regulation authority

CCR

What the official deficiency says

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not having a completed plan available for view which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction Licensee to completed an infection control plan updated, and have it displatyed. Send a copy to LPA by POC date.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: 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 servicing extinguishers which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction Licensee to replace the extinguishers with news ones that have been purchased.

Official classification

Type A

Official code

87355(e)(4)

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: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above by allowing staff 1 at facility working which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction Licensee to immediatly remove staff 1 and obtain clearance prior to S1 working.

Official classification

Type A

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 record review, the licensee did not comply with the section cited above by not having for staff 1, S2, or S3 a current CPR completed or avialable for view which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction Licensee to ensure S2 and S3 or one staff per each shift complete a valid current CPR certification and maiantian it in file at all times at facility. Licensee to send confirmation to LPA by POC date.

Official classification

Type A

Official code

87555(b)(28)

Regulation authority

CCR

What the official deficiency says

(28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. 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 having food at the facility that was past the best used by date which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction Licensee to go through all of the food items stored at the facility and remove food items that are past the best used by dates.

Official classification

Type A

Official code

87506(b)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review , the licensee did not comply with the section cited above by not having a completed admission file for view, with all the required components to verfiy the facility is able to provide proper care for R1 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction Licensee to complete a record file for R1 inclduing admisison agremeent and the rewuiqred sigantures for the faiclity to provide services.

Official classification

Type A

Official code

87506(b)(15)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction LPA observed licensee to conduct the agreement while LPA was present. Licensee to complete and send a copy to LPA by POC date

Official classification

Type A

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 Based on record review, the licensee did not comply with the section cited above by allowing resident to move in by prior to forms being comepleted which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction Licensee to complete evaluation and send copy to LPA by POC date.

Official classification

Type A

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 Based on record review , the licensee did not comply with the section cited above by not having it comepleted for R4 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction Licensee to ensure it it signed by R4 or there representaive and send a copy to LPA by POC date.

Official classification

Type A

Official code

87507(g)

Regulation authority

CCR

What the official deficiency says

(g) Admission agreements shall specify the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not have a completed agrement for R1 and R4 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction Licensee to ensure it is complete and send a copy to LPA by POC

Official classification

Type A

Official code

87455(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) No resident shall be accepted or retained if any of the following apply: (2) The resident requires 24-hour, skilled nursing or intermediate care as specified in Health and Safety Code Sections 1569.72(a) and (a)(1). This requirement is not met as evidenced by: Deficient Practice Statement Based on record review , the licensee did not comply with the section cited above by not having documnetaion of the care needed to provide services, LPA observed resident be fully alert and in need of care for a colosotmy bag which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction Licensee to complete a preappraisal and obtain a copy of phyiscan records and maintain in file. Provide a copy to LPA by poc date.

Official classification

Type A

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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 having R1 and R4 with bed rails up with out a pysician order which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/19/2026 Plan of Correction Licensee to obtain physician orders for bed rail use or bring them down.

Official classification

Type B

Official code

87706(a)(1)(C)

Regulation authority

CCR

What the official deficiency says

(a) In addition to the requirements in Section 87705, Care of Persons with Dementia, licensees who advertise, promote, or otherwise hold themselves out as providing special care, programming, and/or environments for residents with dementia or related disorders shall meet the following requirements: (1) In addition to the requirements specified in Sections 87208, Plan of Operation, the licensee shall include in the plan of operation a brief narrative description addressing the following additional information: (C) Staff training describing the required training for direct care staff who provide dementia special care. At a minimum, the description shall include information on training to be provided, as specified in Health and Safety Code sections 1569.625 and 1569.626. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not having dementia care training conducted annually comeplted which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction Licensee to conduct dementia annual training with new staff. Submit sign in sheet of completion to LPA by POC date.

Official classification

Type B

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) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/28/2026 Plan of Correction Licensee to porivde a copy of current inurance to LPA by POC date.

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to construction or alterations, all facilities shall obtain a building permit. 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 having a curtain nailed to the cieling used to divide the dinning area which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction Licensee to remove curtain. Sned a copy to LPA by POC date.

Official classification

Type B

Official code

87307(a)(3)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction Licensee to add the missing chairs while ensuring there is sufficient room for the residents

Official classification

Type B

Official code

87307(d)(5)

Regulation authority

CCR

What the official deficiency says

(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, 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.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction Licensee toadd night light to hallway

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. 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 correct size posted posted which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction Licensee to obtain correct size poster and post in the main area visible

Official classification

Type B

Official code

1569.618(c)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: 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 not having an updated staff schedule to provide that information which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction Licensee to create a staff schedule of the current staff and have a current LIC 500 posted and sned a copy of the LIC 500 to LPA by POC date

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction Licensee to ensure one staff in each shift is CPR certified to provide care.

Official classification

Type B

Official code

87413(a)(1)

Regulation authority

CCR

What the official deficiency says

(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. 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.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction Licensee to train and designate a staff that is qualified to perfom tasks.

Official classification

Type B

Official code

87415(a)

Regulation authority

CCR

What the official deficiency says

(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency: This requirement is not met as evidenced by: Deficient Practice Statement Based on 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.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction S3 had expired CPR as og Augsut 2, 2026.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on 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.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction S1, S2, and S3 did not have a health screen comeplted on file for view

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 Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction Licensee to ensure files are accessible at facility

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: 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.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction Licensee to ensure files are completed and maintained at faiclity for S1, S2 and S3.

Official classification

Type B

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. 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 inwhich poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction Licensee to completed their admnistrator certification

Official classification

Type B

Official code

87411(d)(3)

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: (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on 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.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction Licensee train new staff and record the training and maintain in file training completed.

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 Based on 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.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction Licensee to record the training completed date it and maintian in staff file

Official classification

Type B

Official code

1569.618(b)

Regulation authority

HSC

What the official deficiency says

(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, 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.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction Licensee to designate a substitute staff that meet qualifications that shall be on premises in leu of Administrator

Official classification

Type B

Official code

1569.267(d)

Regulation authority

HSC

What the official deficiency says

(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation record review , the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction Licensee to ensure continious annual trianning to all staff.

Official classification

Type B

Official code

1569.313

Regulation authority

HSC

What the official deficiency says

Each residential care facility for the elderly shall state, on its client information form or admission agreement, and on its patient’s rights form, the facility’s policy concerning family visits and other communication with resident clients and shall promptly post notice of its visiting policy at a location in the facility that is accessible to residents and families. The facility’s policy concerning family visits and communication shall be designed to encourage regular family involvement with the resident client and shall provide ample opportunities for family participation in activities at the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not having R1 and R4 not have a completed facility policy agreement which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction Licensee to ensure all residents files are completed with client patients rights

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 observation record review, the licensee did not comply with the section cited above not having current new staff trained which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction Licensee to provide training to current staff for each shift and maintain a record of comepleted training. Provide a copy to LPA by POC date

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 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.

Official plan of correction

POC Due Date: 09/01/2026 Plan of Correction Licensee to provide training to new staff and current staff for each shift and maintain a record of comepleted training. Provide a copy to LPA by POC date

Official classification

Type B

Official code

87469(a)

Regulation authority

CCR

What the official deficiency says

(a) Upon admission, a facility shall provide each resident, and representative or responsible person of each resident, with written information about the right to make decisions concerning medical care. This information shall include, but not be limited to, the Department's approved brochure entitled “Your Right To Make Decisions About Medical Treatment,” PUB 325, (3/12) and a copy of Sections 87469(b), (c) and (d) of the regulations. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type B

Official code

87705(b)(1)(A)

Regulation authority

CCR

What the official deficiency says

(b) Licensees shall be responsible for the following: (1) Ensuring staff receive the following training as part of the training requirements specified in Section 87208 Plan of Operation: (A) Dementia care, including, but not limited to, knowledge about hydration, nutrition, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living; This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

87555(b) The following food service requirements shall apply:(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food... shall not be accepted, used or retained. This requirement is not met as evidenced by: Based on observation, the licensee had expired non-perishable items. Licensee did not comply with the section cited above in not providing safe and of quality food to 4 out 4 residents which poses an potential health, safety and personal rights risk to persons in care.

Official plan of correction

Licensee shall be responsible for the regular inspection of the food pantry, including the timely removal and proper disposal of all expired food products and the replenishment of nonperishable food supplies sufficient for one week supply and submit proof of restock by POC date.

Deadline recorded: Sep 22, 2025. 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 ...This requirement is not met as evidenced by: Based on observation, LPA observed inside the facility a hole in the hallway wall adjacent to the garage door entrance which poses an potential health, safety and personal rights risk to persons in care.

Official plan of correction

Licensee will repair the hole and submit proof by POC date.

Deadline recorded: Oct 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)(5)

Regulation authority

CCR

What the official deficiency says

87465(h)The following requirements...(2) Centrally stored medicines shall be kept in a safe and locked...(5)Each resident's medication shall be stored... No medications shall be transferred...This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by making medications accessible to 4 out of 4 residents which poses an immediate health, safety and personal rights risk to persons in care.

Official plan of correction

Licensee will conduct an in-serivce training to all staff to ensure an understanding of the regulation cited. In addition, licensee will provide a statement of acknowledgement from all participents involved in the training.

Deadline recorded: Sep 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87755(a)

Regulation authority

CCR

What the official deficiency says

87775(a) Any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter and inspect the entire premise of any place providing services at any time, with or without advance notice..this requirement is not met as evidenced by: The licensee did not comply with the section cited above by not allowing LPA entry into the facility, which poses and immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

The Licensee/Administrator shall review the regulation cited and submit a statement of the understanding of the regulation cited by POC due date.

Deadline recorded: Sep 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(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 observation, interview and record review, the licensee did not comply with the section cited above by not tracking the medication administered to each client in care which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/28/2025 Plan of Correction Licensee will submit an in house pharmacy approved medication training signed by all staff and a statement of understanding that licensee should follow the regulation 87465(a)(6)

Official classification

Type A

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 documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. 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 by not ensuring the Resident 1 (R1) and resident 2 (R2) had a current physican report which includes the tuberculosis (TB) results which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/28/2025 Plan of Correction Licensee will submit the date of physician appointment to LPA Conchas for resident 1 (R1) and resident 2 (R2) by plan of correction (POC) due date. Licensee to submit the completed physicians report that includes the tuberculosis (TB) report test result cleared to LPA upon completion.

Official classification

Type B

Official code

87465(a)(8)(A)

Regulation authority

CCR

What the official deficiency says

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. This requirement is not met as evidenced by: Deficient Practice Statement Based onobservation, interview, and record review, the licensee did not comply with the section cited above by not having a First Aid Manual avaliable upon request which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2025 Plan of Correction Licensee will submit a picture of the first aid manual that was purchased by the licensee on plan of opration (POC) due date.

Official classification

Type B

Official code

1569.695(a)(2)

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: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. 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 by not ensuring the facility has the 72hour Emergency food supply available which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2025 Plan of Correction Licensee to submit a picture of the 72 hour emergency food supply (grab and go bin) on plan of operation (POC) due date.

Official classification

Type A

Official code

87411(g)(1)

Regulation authority

CCR

What the official deficiency says

(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or.. This requirement was not met as evidence by: Based on interviews with staff #1, LPA's Farlow and Conchas determined that the licensee did not obtain S! criminal backgorund clearnace prior to employment which poses an immeddiate health, safety and personal rights risk to residents in care.Deficiency will be issued

Official plan of correction

Staff immediately was removed from facility. The licensee has agreed to obtain background clearance for S1 before allowing S1 to work at the facility and provide proof to LPA of S1 association/ clearance.

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

Official classification

Type A

Official code

87465(h)(2)(i)

Regulation authority

CCR

What the official deficiency says

87465(h)(2) Centrally stored medication... locked in place that is not accessible to persons other than employees responsible.... (i)Prescription or medication which are not taken with resident upon termination of service...to be disposed of and destroyed by facility...not a resident. Based on LPA's records review and observation, the licensee did not ensure all residents medication was centrally stored and kept safe and locked away and inaccessible to residents in care. LPA's also observed expired medications still in facility as well as medications from previous residents not centrally stored and locked and inaccessible to residents in care.

Official plan of correction

The Licensee has agreed to ensure all centrally stored medication is kept in a safe and locked place that is inaccessible to residents in care by POC date 6/6/25. All none current residents medications be properly dispose of by 6/19/25.

Deadline recorded: Jun 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(d)

Regulation authority

CCR

What the official deficiency says

All residents 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. Based On LPA's observation and record review licensee did not have updated client files which were missing pertinent documents missing signature on admission agreement, Physician Report, Needs and Service plan and Emergency contact.

Official plan of correction

Licensee agrees to update client files by POC date.

Deadline recorded: Jun 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)(c)(g)

Regulation authority

CCR

What the official deficiency says

Licensee shall ensure the personnel records are maintained on the licensee, administrator and each employee... (c)Licensee shall maintain in the personnel records verification of required staff training and orientation.(g) All personnel records... for review Based On LPA's observation and record review licensee did not have updated staff files which were missing Personnel records, health screening report, Criminal record report, verification of training

Official plan of correction

Licensee agrees to update client files by POC date.

Deadline recorded: Jun 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

Except as specified in subsection (b)the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches tools, sharp objects... locked storage. Based on LPA's observations sharps, knives and chemicals were seen in pantry, garage and bathroom unlocked, not secured and accessible to clients.

Official plan of correction

Licensee agrees to secure and maintain all sharps, knives, and chemicals in a safe secure locked area innacessible to residents by POC date.

Deadline recorded: Jun 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

Resident Records 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 was not met as evidenced by: During time of visit, Administrator confirmed the records for resident #1 were at a different location and not available for review.

Official plan of correction

Administrator to provide LPA with a hard copy of resident #1's file for physical review at Licensing office by POC date.

Deadline recorded: Dec 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(20)

Regulation authority

CCR

What the official deficiency says

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer .... This requirement was not met as evidenced by: Per Licensee/Administrator Armstrong and Resident #5 (R5) responsible party stated written notice of transfer was not given to them only verbal notification which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to provide written notification of the transfer of R5 being moved to a new location in Redlands CA. Licensee has also agreed to provide written statement of understanding of the cited regulation by the POC date of 11/15/2024.

Deadline recorded: Nov 15, 2024. 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

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. LPAs Brown and Allen observed Resident #1 (R1) and Resident #3 (R3) Admission Agreement do not have the required signature and signature date of R1 and R3 or their Representative.

Official plan of correction

The licensee has agreed to provided signed admissions agrements that must be signed by their responsible parties for R1 and R3.

Deadline recorded: Nov 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87457(a)(1)

Regulation authority

CCR

What the official deficiency says

(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. (1) Sufficient information about the facility and its services shall be provided to enable all persons involved in the placement to make an informed decision regarding admission. LPAs Brown and Allen observed that R3 does not have the required Preplacement Appraisal as evidenced of incomplete Preplacement Appraisal (LIC603) in R3 file.

Official plan of correction

The licensee has agreed to provide the required preplacement appraisal (lic603) for R3 along with a written statement of understanding of the cited regulation by the POC date of 11/15/2024

Deadline recorded: Nov 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (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 was not met as evidenced by: LPAs Brown and Allen observed that R3 does not have the required record of dosages of medications that are centrally stored which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to provide all residents required record of dosages of medications that are centrally stored and provide a written statement of regulations by the POC date of 11/7/2024.

Deadline recorded: Nov 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(c)(4)(A)

Regulation authority

CCR

What the official deficiency says

c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415,..This requirement was not met as evidenced by: LPAs Brown and Allen observed that the facility does not have a staff scheduled to work the night shift, awake and on duty as required for facility with dementia residents which poses an immediate health, safety or personal rights risk to persons in care

Official plan of correction

The licensee has agreed to to schedule a staff to work the night shift and submit an updated staff schedule or Personnel report (LIC500) showing a staff scheduled to work the night shift to LPA Allen on POC due date of 11/7/2024.

Deadline recorded: Nov 7, 2024. 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. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following...:This requirement was not met as evidenced by: LPAs Brown and Allen observed that staffs at the facility are not assisting R1, Resident #2 (R2) and R3 with their self-administered medications per their physician’s order as there’s no record at the facility that indicated they are assisting R1. R2 and R3 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to provide updated record of dispensing medications to each resident in care by the poc date of 11/07/2024

Deadline recorded: Nov 7, 2024. 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 LPAs Brown and Allen observed that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do not have the required initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to provide proof of enrollment/registration for required annual training for all staff members. Licensee has also agreed to provide proof of training signed by all staff members once completed.

Deadline recorded: Nov 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(c)(3)(A)

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 for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia .... This requirement was not met as evidenced by:PAs Brown and Allen observed that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do not have the required dementia care training in hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to provide proof of enrollment/registration for required annual training for all staff members. Licensee has also agreed to provide proof of training signed by all staff members once completed.

Deadline recorded: Nov 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(c)(3)(b)

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 for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff....This requirement was not met as evidenced by: LPAs Brown and Allen observed that Staff #2 (S2), Staff #3 (S3), Staff #4 (S4) and Staff #5 (S5) do not have the required dementia care training in Recognizing the effects of medications commonly used to treat the symptoms of dementia.which poses an immediate health, safety or personal rights risk to persons in care

Official plan of correction

The licensee has agreed to provide proof of enrollment/registration for required annual training for all staff members. Licensee has also agreed to provide proof of training signed by all staff members once completed.

Deadline recorded: Nov 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.695(e)(2)

Regulation authority

HSC

What the official deficiency says

HSC 1569.695 Other Provisions (e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.This requirement was not met as evidenced by: LPAs Brown and Allen observed that Resident #3 (R3) does not have the required Needs and Services Plan maintained in R3 file.

Official plan of correction

The licensee has agreed to provide a completed copy of R3 current appraisal of resident needs and services plan for resident 3.

Deadline recorded: Nov 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(g)(2)

Regulation authority

CCR

What the official deficiency says

General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)...This requirement was not met as evidenced by: Based on interview with Staff #2 (S2), LPAs Brown and Allen determined that the Licensee did not ensure that Staff #3 (S3) criminal background clearance was transferred to the facility prior to employment which poses a potential and personal rights risks to residents in care.

Official plan of correction

The licensee has agreed to ensure that all staff members are cleared and associated to the facility by providing proof of S3 associated through guardian.

Deadline recorded: Nov 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

HSC 1569.695 Other Provisions (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... 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 not conducting the required fire and eathquake drill at least quarterly which poses a potential health, safety or personal rights risk to persons in care

Official plan of correction

The licensee has agreed to conduct the required fire and eathquake drill at least on a quarterly basis and provide proof of current fire and earthquake drill by the POC date of 11/15/2024.

Deadline recorded: Nov 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.695(d)

Regulation authority

HSC

What the official deficiency says

HSC 1569.695 Other Provisions (d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation ....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 not ensuring that the emergency disaster plan was reviewed annually and signed by the Administrator or Licensee which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to provide LPA a current emergency disaster plan that is required to be updated annually and signed by the administrator and provide a copy by the POC date of 11/15/2024.

Deadline recorded: Nov 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87219(a)(1)

Regulation authority

CCR

What the official deficiency says

CCR 87219 Planned Activities (a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participa-tion in planned activities. The activities made available shall include: (1) Socialization...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 not ensuring that there's planned activities at the facility for the socialization of residents and not just watching television at the living room which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to provide a schedule of planned activities at the facility for the socialization of residents in care. The licensee has agreed to provide a copy of planned activites by the POC date of 11/15/2024.

Deadline recorded: Nov 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

(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, staff, and others who may...This requirement was not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above by using the family room area as the sleeping area for Resident #3 (R3) and the staff, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to relocate resident #3 back into bedroom #3 and provide proof that R3 was moved back into the room.

Deadline recorded: Nov 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(g)(1)

Regulation authority

CCR

What the official deficiency says

(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or..This requirement was not met as evidenced by: Based on interview with Staff #2 (S2) and Staff #4 (S4), LPAs Brown and Allen determined that the Licensee did not obtain S4 criminal background clearance prior to employment which poses an immediate health, safety and personal rights risk to residents in care. Deficiency will be issued

Official plan of correction

Licensee has agreed to obtain a background clearance for S4 before allowing s4 to work at the facility and provide proof to LPA Allen of association/clearance,

Deadline recorded: Nov 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87777(a)(1)(g)

Regulation authority

CCR

What the official deficiency says

(a) The Department may prohibit an individual from serving as a board of directors, executive director, or officer; being employed or allowed in a licensed facility as specified in Health and Safety Code Sections 1569.58 and 1569.59. Health and Safety Code Section 1569.58 reads in part:.. (g) A licensee's failure to comply with the department's exclusion order after being notified of the order shall be grounds for disciplining the licensee pursuant to Section 1569.50.This requirement was not met as evidenced by: Based on LPAs and interviews with Caroline Armstrong and resident S1 has been allowed at the facility on 11/3/2024 after receiving an exclusion letter.

Official plan of correction

The licensee is required to disassociate Adam Baron from gardian and must not allow him into any home licensed by Department of Social Services by the POC date of 11/7/2024.

Deadline recorded: Nov 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

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 (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 evidence by.. Based on observations and record review the licensee didn't comply with the section above by not ensuring that staff 1, 3, 4.and 5 did not have appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

Official plan of correction

The licensee stated that she will have all staff members trained/registered with the required first aid training and provide proof of training/certification on the plan of correction by the POC date of 11/7/2024

Deadline recorded: Nov 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.this requirement is not met as evidenced by... Based on observation interview and record review the licessee did not comply with the cited section above by not ensuring that staff 4,3,and 5 have the required health screening report maintained in s3,s4 and s5 files which poses an immediate health,saftey ,and personal rights risk to residents in care.

Official plan of correction

Licensee has stated to obtain S3,4,and 5 medical appointment to complete the required health screening report and submit proof to LPA Allen by the by the POC date of 11/7/2024.

Deadline recorded: Nov 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87412(a)(12)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General .this requirement is not met as evidenced by Based on observation interview and record review the licessee did not comply with the cited section above by not ensuring that staff 4,3,and 5 have the required Tuberculousis (TB) test and TB test results maintained in s3,s4 and s5 files which poses an immediate health,saftey ,and personal rights risk to residents in care.

Official plan of correction

Licensee has stated to obtain S3,4,and 5 medical appointment to complete the required Tuberculousis (TB) report and submit proof to LPA Allen by the by the POC date of 11/7/2024.

Deadline recorded: Nov 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant ...... This requirement is not met as evidenced by: Based on LPA observation,and interviews, the licensee did not comply with the section cited above LPA observed R1 in bedroom #3 which was is not cleared by the fire department for non-ambulatory residents.

Official plan of correction

The licensee has agreed to relocate the resident in bedroom #3 to a bedroom that has been approved by fire marshalls.

Deadline recorded: Oct 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

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: Based on LPA observation,and interviews, the licensee did not comply with the section cited above LPA request facility files for R1,R2,R3 and R4 that could not be provided or was incomplete for review.

Official plan of correction

The licensee has agreed to provide a complete files R1, R2,R3 and R4.

Deadline recorded: Oct 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (h) All personnel records shall be retained for at least three (3) years following termination of employment....This requirement is not met as evidenced by: During the visit LPA Allen requested personnel files that could not be provided.

Official plan of correction

The licensee has agreed to provide a complete file for all staff members eligible to work at the facility by the POC date.

Deadline recorded: Oct 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)

Regulation authority

CCR

What the official deficiency says

(a)-(b)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 ...... This requirement is not met as evidenced by:LPA requested the special incident report (SIR) for R1 that could not be provided during visit.

Official plan of correction

The licenss has agreed to provide SIR for the death of R1 by the POC date.

Deadline recorded: Oct 1, 2024. A deadline is not proof that correction was completed.

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. LPA reviewed the files of the residents in care and each residents file were incomplete,invalid information or could not be located. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations,interview, record review, the licensee did not comply with the section cited above the licensee did not ensure that the residents files were not complete with information, invalid information and could not be located. This poses a potential health and saftey concern for the residents in care.

Official plan of correction

POC Due Date: 07/30/2024 Plan of Correction The licensee has agreed to xxxxx

Official classification

Type B

Official code

87156(a)(e)

Regulation authority

CCR

What the official deficiency says

(a) An application fee adjusted by facility and capacity shall be charged by the department for the issuance of a license to operate a residential care facility for the elderly. After initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license. (e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews,and record review the licensee did not comply with the section cited above the licensee has been informed of past due facility fee's which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2024 Plan of Correction The licensee has agreed to xxxxx

Official classification

Type A

Official code

87204

Regulation authority

CCR

What the official deficiency says

(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation,interview, and record review the licensee did not comply with the section cited above LPA observed R1 in bedroom #3 which was is cleared by the fire department for non-ambulatory residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2024 Plan of Correction The licensee has agreed to xxxxxx

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review the licensee did not comply with the section cited above the licensee has not complied with the fire clearance request made by the City of Beaumont fire Marshal dated May 10,2022 listing five (5) non-compliant orders issued which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2024 Plan of Correction The licensee has agreed to xxxxx

Official classification

Type A

Official code

87516(a)(e)

Regulation authority

CCR

What the official deficiency says

(a) An application fee adjusted by facility and capacity shall be charged by the department for the issuance of a license to operate a residential care facility for the elderly. After initial licensure, a fee shall be charged by the department annually on each anniversary of the effective date of the license. (e) The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review the licensee did not comply with the section cited above the licensee has not paid the past due annual fee's. which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2024 Plan of Correction The licensee has agreed to pay the annual fees in full by the poc date of 8/1/2024.

Official classification

Type A

Official code

87777(1)(g)

Regulation authority

CCR

What the official deficiency says

87777- Exclusions (1) Health and Safety Code Section 1569.58 reads in part: (g) A licensee's failure to comply with the department's exclusion order after being notified of the order shall be grounds for disciplining the licensee pursuant to Section 1569.50.This requirement is not met as evidenced by: Based on observation, interview and document review, the licensee failed to comply with the immediate exclusion order issued on 6/3/2024 which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to contact the excluded individuals responsible parties for relocation of Adam Barone and she will write a statement of understanding of the immediate exclusion letter issued on 6/3/2024 and the regulation cited she was cited for on 7/19/2024.

Deadline recorded: Jul 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269(a)(5)

Regulation authority

HSC

What the official deficiency says

(a) Residents of residential care...shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings...this requirement is not met as evidence by: Licensee/Administrator did not comply with regulation cited above by staff#1's inappropriate conduct in the presence of residents and Licensing Agency representative when poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator shall conduct inservice training with staff on the regulation cited and submit proof of training by POC due date.

Deadline recorded: Dec 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not as evidenced by: Licensee did not comply with section cited by S1 and S2 did not have personal telephone numbers, education and/or employment history on file for review; which is a potential health, safety, or personal rights rights to residents in care.

Official plan of correction

Licensee shall submit to the licensing agency proof of missing documentation and/or employee application by POC due date.

Deadline recorded: Jan 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (1)The following...shall be documented:(A)For staff who assist with personal activities of daily living, there shall be documentation of at least ten hours of initial training within the first four weeks of employment, and at least four hours of training annually thereafter...this requirement is not met as evidenced by: Licensee/Administrator did not comply with regulation cited above by hours of training for both S1 and S2 were not maintained in facility files; which poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

Licensee/Administrator shall submit to the licensing agency proof of staff training hours for licensing review.

Deadline recorded: Jan 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a-b)

Regulation authority

CCR

What the official deficiency says

87211- Reporting Requirements Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: 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 This requirement is not met as evidenced by: Caroline Armstrong or staff did not report that resident 1 left the facility without staff members knowledge.

Official plan of correction

Caroline Armstrong will provide training to all staff members regarding reporting requirments and has agreed to provide a written statement of understanding of the cited regulations by the POC date of 9/12/2023 before the close of business.

Deadline recorded: Sep 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(c)(3)(A)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia ... (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training ... (A) Dementia care including, but not limited to... 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 providing the appropriate Dementia training to S2 as required which pose immediate Health and Safety risk to the resident in care.

Official plan of correction

Licensee stated to submit Signed Statement of Understanding on CCR 87705(c)(3)(A) to LPA Brown by POC due date.

Deadline recorded: Dec 1, 2022. 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) of R1's falls to CCLD ASC. This poses a potential Health and Safety risk to the 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: Dec 7, 2022. A deadline is not proof that correction was completed.