GRACIOUS CARE INC #2

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 and record review, the licensee did not comply with the section cited above by having incorrect documentation of PRN medications for Resident #3 (R3). R3's medication is labeled as PRN but being given as a daily medication, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/18/2025 Plan of Correction Administrator stated to submit staff training on documentation and administration of medications to LPA Hernandez by Plan of Correction (POC) due date.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: This requirement is not met as evidenced by: Deficient Practice Statement Based on obsevration, the licensee did not comply with the section cited above by not ensuring facility has hot water. hot water temperature tested at 74 degrees farenheit, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/18/2025 Plan of Correction Administrator stated to fix hot water temperature and send proof to LPA Hernandez by Plan of Correction (POC) due date.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain 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 ensuring a plan of operation is in place for facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2025 Plan of Correction Administrator stated to submit plan of operation to LPA by Plan of Correction (POC) due 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 record review, the licensee did not comply with the section cited above by not having a updated liability insurance, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2025 Plan of Correction Administrator stated to get a updated liability insurance plan and send proof to LPA Hernandez by POC due date.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not ensuring Staff #1 (S1) training was in S1's file/completed, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2025 Plan of Correction Administrator stated to submit S1 training to LPA Hernandez by Plan of Correction (POC) due date.

Official classification

Type B

Official code

87219(a)

Regulation authority

CCR

What the official deficiency says

(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include: 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: 09/29/2025 Plan of Correction Administrator stated to provide activity calendar to LPA by POC due date.

Official classification

Type B

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 record review, the licensee did not comply with the section cited above by not ensuring a updated centrally stored medication log for Resident #1 (R1) was done, which poses, a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2025 Plan of Correction Administrator stated to submit updated centrally stored medication log for R1 to LPA Hernandez by Plan of Correction (POC) due date.

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 the section cited above by not ensuring a pre-placement appraisal or needs or services plan for R1 was located in file, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2025 Plan of Correction Administrator stated to submit pre-placement appraisal and needs and services plan for R1 to LPA Hernandez by 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) has a reappraisal which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2025 Plan of Correction Administrator stated to submit reappraisal for R1 to LPA Hernandez by Plan of Correction (POC) due 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 by not ensuring fire and earthquake drills are being done quarterly, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2025 Plan of Correction Administrator stated to submit fire and earthquake drill to LPA Hernandez by POC due date.

Official classification

Type B

Official code

87307(a)

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 reside in the facility. The following provisions shall apply: 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 bed located in common room, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2025 Plan of Correction Administrator stated to remove bed and send proof to LPA Hernandez by Plan of Correction (POC) due date.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above not having updated physician report for Resident #1 (R1) and Resident #2 (R2), which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/29/2025 Plan of Correction Administrator stated to submit to LPA updated physician reports for R1 and R2 by POC due date.

Official classification

Type A

Official code

80044(a)

Regulation authority

CCR

What the official deficiency says

80044(a) Inspection Auhority of the Licensing Agency The Licensing agency shall have the inspection authority specified in Health and Safety Code Sections 1526.5,1533,1534 and 1538.7 This requirement is not met as evidenced by: Deficient Practice Statement Based on observatoin the licensee did not comply with the section cited above by not having room keys available for licensing to check locked bedroom, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/18/2025 Plan of Correction Administrator stated to submit to LPA understanding of regulation stated above and providing key to facility staff to ensure complete inspection by Plan of Correction (POC) due date.

Official classification

Type A

Official code

87211(1)(A)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... (A) Death of any resident from any cause. Based on record review, licensee did not comply with section cited above by not ensuring death report of former Resident #1 (R1) was provided to R1's responsible party, which poses an immediate health, safety, and personal rights risk to those in care.

Official plan of correction

Licensee stated to notify all resident's responsible parties as well as licensing department for future deaths and severe occurences.

Deadline recorded: Jun 18, 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

87506 Resident Records: (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. Based on record review, licensee failed to meet this requirement by not ensuring Resident #2 (R2) file was completed and located at the facility upon request, which poses a potential health, saftey, and personal rights risk to persons in care.

Official plan of correction

Licensee stated to submit to LPA Hernandez Resident #2 (R2) completed facility file by Plan of Correction due date as well as have hard copy availabile at facility.

Deadline recorded: Apr 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(A)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency..(1) A written report shall be submitted to the licensing agency..(A) Death of any resident from any cause regardless of where the death occurred.. Based on record review, licensee failed to meet this requirement by not ensuring Resident #1 (R1) death was reported to licensing within seven days of occurence, which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee stated to submit staff training on reporting requirements regulation 87211 by Plan of Correction (POC) due date to LPA Hernandez.

Deadline recorded: Apr 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

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 interview and record review , the licensee did not comply with the section cited above by not having a staff who had aqequate qualifications to be on premises 24 hours per day which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/21/2024 Plan of Correction The Administrator stated they will hire a staff memeber who has the 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.

Official classification

Type A

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. 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 non-skid mats which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/21/2024 Plan of Correction The House Manager Brandon Chavez stated they will send prood to LPA a non-skid mat has been placed.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain 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 having Plan of Operation maintain at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/21/2024 Plan of Correction House Manager stated send proof to LPA the Plan of Operation is maintain at the facility.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation , the licensee did not comply with the section cited above by the hot water temperature tested at 78F which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/21/2024 Plan of Correction House Manager stated they will send proof to LPA the hot water temperature has been fixed.

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 bedroom number one had one of the drawers broken which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/21/2024 Plan of Correction House Manager stated they will replace the drawer and will send proof to LPA Rico.

Official classification

Type B

Official code

87311

Regulation authority

CCR

What the official deficiency says

All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility. 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 facility phone off which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/14/2024 Plan of Correction House Manager stated they will read the regulation cited above and will send proof of staff training to LPA Rico.

Official classification

Type B

Official code

87412(a)(13)(B)

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: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement. 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 Administrators vaild requirements which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/21/2024 Plan of Correction House Manager stated they will send Administrators valid requirements to LPA Rico.

Official classification

Type B

Official code

87219(a)

Regulation authority

CCR

What the official deficiency says

(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: 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 providing the 10:45am activities for residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/21/2024 Plan of Correction House Manager stated they will train their staff on the regulation cited above and will ensure staff follow activities calendar.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. 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 perishable foods for a minmum of two days which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/21/2024 Plan of Correction House Manager stated they will go grocery shopping and send proof to LPA Rico.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by R1 not having Pre-Admission Appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/21/2024 Plan of Correction House Manager stated they will create a pre-admission appraisal for R1 and will send a copy to LPA Rico

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by R2 and R3 not having a LIC602 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/21/2024 Plan of Correction House Manager stated they will obtain a LIC602 for R2 and R3. House Manager agreed to send a copy to LPA Rico.

Official classification

Type A

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

(g) All personnel records shall be maintained at the facility. 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 all personnel recorsa at the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/21/2024 Plan of Correction House Manager stated they will ensure all personnel records are maintained at the facility and will send proof to LPA Rico.

Official classification

Type A

Official code

80044(a)

Regulation authority

CCR

What the official deficiency says

80044(a) Inspection Auhority of the Licensing Agency The Licensing agency shall have the inspection authority specified in Health and Safety Code Sections 1526.5,1533,1534 and 1538.7 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 allowing LPAs enter upstairs bedroom which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/21/2024 Plan of Correction House Manager stated to submit Statement of Understanding to California Code of Regulations (CCR) 8044(a) to LPA Rico and will provide access to Community Care Licensing Department.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309(a) Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. Based on observation and interview the licensee did not comply with the section cited above evidenced by not having cleaning solutions locked which poses an immediate Health, Safety or personal rights risk to persons in care.

Official plan of correction

Licensee has agreed to send proof they have read and understood the regulation and will send proof they have trained all staff on the regulation cited above. POC due date 03/01/2024

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

Official classification

Type A

Official code

87413(a)(1)

Regulation authority

CCR

What the official deficiency says

87413(a)(1) Personnel - Operations (a) In each facility: (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: Based on observation, interview and record review the licensee did not comply with the section cited above evidenced by not providing staff coverage when regular staff are on vacation

Official plan of correction

The licensee has agreed to provide an updated LIC 500 and provide the following documents of which staff members provide coverage while other staff are on vacation. Licensee will submit Signed Statement of Understanding on the cited regulation to LPA Rico by POC due date. POC due date 03/01/2024

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

Official classification

Type A

Official code

1569.618(b)

Regulation authority

HSC

What the official deficiency says

1569.618(b)Administration and management of residential care facilities; substituted qualifications; employee scheduling.(b).one ..manager..designated substitute qualifications.. responsible designated substitute shall meet..This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above evidenced by Licensee admitting not having a designated substitute which poses an immediate Health, Safety or personal rights risk to persons in care.

Official plan of correction

Licensee has agreed to have a designated susbstitue when the Administrator is not present. Licensee will send proof to LPA. Licensee will submit Signed Statement of Understanding on the cited regulation to LPA Rico by POC due date. POC due date 3/1/2024

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

Official classification

Type A

Official code

1569.618(a)

Regulation authority

HSC

What the official deficiency says

1569.618(a)Administration and management of residential care facilities; substituted qualifications; employee scheduling.(a)... operation of the facility when the administrator is temporarily absent from the facility. Based on observation and interview the licensee did not comply with the section cited above evidenced by Administractor admitting they not present during working hours which poses an immediate Health, Safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to send proof of when the Administrator will be return to the facility and copy of the schedule. Licensee will submit Signed Statement of Understanding on the cited regulation to LPA Rico by POC due date. POC due date 3/1/2024

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

Official classification

Type A

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) to CCL for R2 fall and R1 and R3 Death Report. This pose potential health, safety and personal rights risk to resident in care.

Official plan of correction

Licensee stated to train all staff on CCR 87211(a)(1) and submit proof of Staff Training Log to LPA Rico by POC due date. Licensee will submit Signed Statement of Understanding on CCR 87211(a)(1) to LPA Rico by POC due date. POC due date 3/1/2024

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

Official classification

Type A

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 review of records and LPA observation the licensee did not comply with the section cited above as volunteers E1 and E2 are working without supervision which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/25/2023 Plan of Correction Licensee to ensure that no volunteer is left unsupervised in the presence of residents at any time. LIC 500 to be provided to indicate appropriate staffing types for around the clock awake supervision.

Official classification

Type A

Official code

1569.69(a)(3)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (3) An employee shall be required to complete the training requirements for hands-on shadowing training described in this subdivision prior to assisting any resident in the self-administration of medications. The training and instruction described in this subdivision shall be completed, in their entirety, within the first two weeks of employment. This requirement is not met as evidenced by: Deficient Practice Statement Based on review of employee records, the licensee did not comply with the section cited above in three (3) out of (3) records reviewed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/01/2023 Plan of Correction Licensee to provide training in the area cited by POC due date and maintain training records at all times at the facility.

Official classification

Type B

Official code

87411(d)

Regulation authority

CCR

What the official deficiency says

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by: Deficient Practice Statement Based on review of employee training records, LPA observed no traiing records are maintained. The licensee did not comply with the section cited above in (3) out of (3) records reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/01/2023 Plan of Correction Licensee to provide the required training to all employees and maintain training records at all times at the facility by POC due 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 designee interview the licensee did not comply with the section cited above. The facility is not maintaing records for disaster drills which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/01/2023 Plan of Correction Licensee to develope a disaster log by POC due date and maintain documentation of disaster drills quarterly.

Official classification

Type B

Official code

87705(c)(3)

Regulation authority

CCR

What the official deficiency says

(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 shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by: Deficient Practice Statement Based on lack of training records present for review the licensee did not comply with the section cited above in (3) out of (3) employee records reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/01/2023 Plan of Correction Licensee to conduct training and maintain training records at the facility by POC due date.

Official classification

Type B

Official code

87705(c)(5)(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: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review R1 and R2 have not had Medical Assessment updates since 2021. The licensee did not comply with the section cited above in (2) of (5) records reviewed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/01/2023 Plan of Correction Licensee to work with family to schedule reassessment by POC due date and provide dates of scheduled visits to CCL by POC due date.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation of the last marked service tag of 01/01/2019 the licensee did not comply with the section cited above in they have not serviced or replaced their fire extinguisher annually which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/26/2023 Plan of Correction Licensee to service or replace their fireextinguisher mounted in the dining room by POC due date and verification to be submitted to CCL within 24 hours.

Official classification

Type A

Official code

87202(a)(2)

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... This requirement is not met as evidenced by: Deficient Practice Statement Based on review of the record for R4 indicating bedridded status of page 5 of 6 the licensee did not comply with the section cited above as evidenced by lack of bedridden fireclearance approval, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/26/2023 Plan of Correction Licensee to notify local fire authority of R4's bedridden status and submit LIC 200 to seek approval for bedridden status by POC due date.

Official classification

Type A

Official code

87355(b)(2)(B)

Regulation authority

CCR

What the official deficiency says

The following persons are exempt from requirements applicable requirements...A volunteer to whome all of the following apply...The volunteer is not left alone with clients in care. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation of volunteers left alone to provide client care the licensee did not comply with the section cited above in (2) out of (2) staff scheduled at this facility. LPA arrived and E1 was alone caring for 5 residents. THey are cleared as volunteer only which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/26/2023 Plan of Correction Licensee to immediately assign employee status clearance employees to care for residents. LIC 500 to be provided to CCL by POC due date.

Official classification

Type A

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

All facilities shall have a qualified and currently certified administrator...The administrator shall have sufficient freedom from other responsibilities and shall be on the premesis a sufficient number of hours to permit adequate attention to management and administration of the facility as specified in this section. This requirement is not met as evidenced by: Multiple serious deficiencies issued on this date are sympromatic that oversight of the facility is insufficiently being met by the licensee. The administrator reports overseeing (5) facilities as well as covering as caregiving at multiple locations. Deficient Practice Statement Based on the deficiencies regarding fire clearance, volunteers being left alone, fire safety, lack of updated records for residents and staff and missing training records it is evident the administrator is not available to provide the oversight needed. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/01/2023 Plan of Correction Licensee to provide plan for administrator schedule to assure their time is sufficient and free from other obligations for 20 hours per week to oversee this facility by POC due date.

Official classification

Type A

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

...The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility The licensee is nable to fulfil their obligation to this requirement as evidenced by their inability to be at the facility due to personal circumstances.

Official plan of correction

A designee must be appointed to oversee this facility that can be present to oversee the management and administration of the facility. Please submit LIC308, corporate meeting notes designating a new administrator along with administrator qualifications/certification by POC due date.

Deadline recorded: Jun 22, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87156(a)

Regulation authority

CCR

What the official deficiency says

87156 Licensing Fees(a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. Based on interview, record review, and observation the licensee did not comply with the section cited above evidenced by a past due amount of $495.00 in licensing fees which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to read regulation 87156 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to pay the amount due by POC due date. POC due date is 6/23/2023.

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

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Based on observation, record review and observation the facility is not meeting this requirement as evidenced by one caregiver working alone for since 0without 8/20/2022 without help and providing care for four residents with dementia which require physical assistance and supervision. This poses a risk to the health and safety of thestaff and residents in care.

Official plan of correction

Licensee will immediately provide additional staffing in order to regain a safe environment for meeting residents needs. If staff is not available the administrator or Licensee will come to the facility to provide assistance by close of business (1700) 08/25/2022. LIC9098 to be signed self ceritfying the correction has been made and understanding of the regulation section cited and submitted to CCL * Civil Penalty accompanies this repeat violation.

Deadline recorded: Aug 25, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Based on observation, record review and observation the facility is not meeting this requirement as evidenced by one caregiver working alone for the past 24 hours without help and providing care for residents with dementia which requiring moderate physical assistance.

Official plan of correction

Licensee will immediately provide additional staffing in order to regain a safe environment for meeting residents needs. If staff is not available the administrator or Licensee will come to the facility to provide assistance by close of business (1700) 02/07/22. Proof of correction to be emailed to LPA Goldenberg by close of business. Failure to correct will result in civil penalty assessments.

Deadline recorded: Feb 7, 2022. A deadline is not proof that correction was completed.