EASTVALE SENIOR HOME CARE II

Official classification

Type A

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. 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 ensuring Resident #3 (R3) medication was properly labeled, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction Administrator stated to receive request physician to prescribed R3 the two medications that were not labled and send proof to LPA Hernandez by Plan of Correction (POC) due date.

Official classification

Type A

Official code

87465(d)(3)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. 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 ensuring Resident #2 (R2) and Resident #3 (R3) PRN medication was properly documented, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/30/2026 Plan of Correction Administrator stated to go over with facility staff the appropriate way to properly document all PRN medications. POC will be cleared.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. 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 ensuring a reapprasial was completed for Resident #1 and Resident #3, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/15/2026 Plan of Correction Administrator stated to submit reapprasials for R1 and R3 to LPA by Plan of Correction (POC) due date.

Official classification

Type B

Official code

1569.695(e)(2)

Regulation authority

HSC

What the official deficiency says

(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 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 ensuring R1 and R3 have a completed needs and services plan which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/15/2026 Plan of Correction Administrator stated to submit needs and services plan for R1 and R3 to LPA by POC due date.

Official classification

Type B

Official code

87633(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department. 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 ensuring a hospice care waiver increase was sent and approved by licensing department which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2026 Plan of Correction Administrator stated to submit a hospice care waiver increase to LPA by POC due date.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operate Facilities (a) In addition to the rights listed... (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient... This requirement was not met as evidenced by: Based upon review of facility and other records, observations, and interviews with pertinent individuals, licensee failed to ensure that R1 was provided with care, supervision, and services required. As a result, R1 sustained an unstageable pressure injury while at facility. This violation posed an immediate health and saftey risk to residents in care.

Official plan of correction

Licensee stated to read over regulation with facility staff and not allow facility staff to care for any residents with prohibited health conditions.

Deadline recorded: Feb 2, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

87615 Prohibited Health Conditions (a) ) Persons who require health services for or have a health condition...(1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on observations and interviews, the licensee did not comply with section cited above by not ensuring that R1 was relocated due to pressure injury and or notified licensing department, which poses an immediate health, saftey and personal rights risk to residents in care.

Official plan of correction

Licensee stated to read over regulation and to not accept residents with prohibited health care conditions without care by licensed care professional and/or notifying licensing department. POC will be cleared.

Deadline recorded: Feb 2, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operate Facilities (a) In addition to the rights listed... (4) To care, supervision... This requirement was not met as evidenced by: From around June 13th 2025, until July 16th, 2025, R1 was not provided care and services to meet their needs. Records revealed that R1 needed care and assistance in ADLs, including incontinent care, as well as observation with history of skin condition or breakdown. Under the care of facility staff, R1 sustained an unstageable pressure injury, and subsequently passed away. This posed an immediate risk to residents in care.

Official plan of correction

Licensee stated to not admit any future residents with prohibited health conditions unless waiver is submitted to licensing department and care is provided by a licensed care professional.

Deadline recorded: Feb 2, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs... Based on observation and interviews, the licensee did not comply with section cited above by not ensuring R1's responsible party was notified of change of condition in R1, which poses an immediate health, saftey, and personal rights risk to persons in care.

Official plan of correction

Licensee stated to read over regulation with facility staff on Observation of the Resident. POC will be cleared.

Deadline recorded: Feb 2, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(d)(5)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them... (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. This requirement is not met as evidenced by: Based on observation and interviews, the licensee did not comply with section cited above by not ensuring R1 received care from an appropriate skilled professional and having staff care for R1 instead, which poses an immediate health, saftey, and personal rights risk to residents in care,

Official plan of correction

Licensee stated to read over regulation with facility staff and acknowledged having only appropriate skilled professionals care for residents with prohibited/restricted health care conditions. POC will be cleared.

Deadline recorded: Feb 2, 2026. 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(e)(1) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall...facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by: Based on observations and record review, the Administrator did not comply with section cited above by not obtaining a criminal record clearance for Staff #1 (S1) prior to working at the facility, which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee stated to understand regulation and will ensure facility staff are background cleared prior to working at the facility. POC will be cleared.

Deadline recorded: Feb 2, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87467(a)

Regulation authority

CCR

What the official deficiency says

87467 Resident Participation in Decisionmaking (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... Based on observation and record review, the licensee did not comply with section cited above by not ensuring R1 had a completed care plan while living at the facility, which poses an immediate health, safety and personal rights risk to persons in care.

Official plan of correction

Licensee stated to understand regulation and moving forward will ensure each resident's care plan will be completed. POC will be cleared.

Deadline recorded: Feb 2, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

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 having toilet bowl bleach cleaner located underneath Resident #1 (R1) and Resident #2 (R2) bathroom sink unlocked, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/28/2025 Plan of Correction Facility staff removed cleaning solution during visit.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by having full bed rails for Resident #3 (R3) with no hospice care services or doctor order, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/28/2025 Plan of Correction Licensee stated to remove bed rails by Plan of Correction (POC) due date or obtain a physician order for full bed rails and submit to LPA Hernandez.

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 their 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 Based on record review, the licensee did not comply with section cited above by not ensuring Resident #3 and Resident #4 have a completed Apprasial/Needs and Services Plan, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/02/2025 Plan of Correction Licensee stated to submit complete Needs and Services Plan for R3 and R4 to LPA Hernandez by Plan of Correction (POC) due date.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. 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 ensuring Resident #1 (R1), Resident #2 (R2), Resident #3 (R3) and Resident #4 (R4) have a Reapprasial plan, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/02/2025 Plan of Correction Licensee stated to submit a Reapprasial Plan for R1, R2, R3, and R4 to LPA Hernandez by Plan of Correction (POC) due date.

Official classification

Type A

Official code

87465(c)(3)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with section cited above by not ensuring PRN administration is documented correctly in MAR (Medication Administration Record), which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/28/2025 Plan of Correction Licensee stated to submit staff training on documenting all PRN medications to LPA Hernandez by Plan of Correction (POC) due date.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation... (2) Once ordered by the physician the medication is given according to the physician's directions. 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 ensuring for daily medications for residents are documented in MAR, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/28/2025 Plan of Correction Licensee stated to submit staff training on documenting daily medications to LPA Hernandez by POC due date.

Official classification

Type A

Official code

87705(5)

Regulation authority

CCR

What the official deficiency says

87705 Care Of Person with Dementia (5) Each Resident with dementia shall have an annual medical assesment as specified in Section 87458, Medical Assement, and a reppariasal done at least annual, both of which shall include a ressessment of the resident's dementia care needs. 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 by 1 out of the 4 dementia residents do not have their annual medical assesment which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2024 Plan of Correction The licensee has agreed to send LPA the annual medical assesment.The licensee has agreed to read regulation 87705 entirely and send LPA a self-certified letter that the regulation was read and understood.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

The following requirements shall apply to medications which are centrally stored:Centrally stored medicines shall be kept in a safe and locked place...The facility has failed to meet this requirement as evidenced by LPA observation of liquid seizure medication, laxative medication and tums located in an unlocked cabinet during this inspection. This poses a risk to the health and safety of residents in care.

Official plan of correction

cited and provide a statement of understanding of the regulatory requirement by POC due date.

Deadline recorded: Mar 16, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

Not listed

What the official deficiency says

All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department...The facility has failed to meet this requirement as evidenced by LPA observation of a makeshift sleeping quarters located in the garage are aof the facility. This poses a risk to the health and safety of indivuals in care.

Deadline recorded: Mar 16, 2022. A deadline is not proof that correction was completed.