COTTAGES AT HEMET

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

The licensee shall ensure that residents receive care and supervision...requires the facility to have planned procedures and immediate capabilities to respond to medical needs....This requirement was not met as evidenced by: Based on interviews and record reviews,staff failed to conduct rounds every 1 to 2 hours for residents who are a falll risk, leaving resident unobserved and unattended for 6 hours after a fall. This posed an immediate health and safety risk for resident.

Official plan of correction

An in-service training will be conducted with medtechs and care staff on having knowledge of residents care plans and fall risks residents, and making rounds. Documentation of this training will be provided to the Department by POC 8/26/26.

Deadline recorded: Aug 26, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(e)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidenced by: Based on interviews conducted, the paper and electronic medication administration records for R1 were not properly retained in the facility after R1 moved out of the facility on 02/14/2026. This poses a potential health/safety/personal rights risk to residents in care.

Official plan of correction

Administrator reported on 4/22/26 they will conduct a staff training regarding proper organization of resident records and quality assurance checks for proper medication management. POC will be emailed to LPA by close of business on 04/24/2026.

Deadline recorded: Apr 24, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(g)

Regulation authority

HSC

What the official deficiency says

The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by: Licensee did not call 911 in a timely manner when immediate medical care was needed for R1's injuries.

Official plan of correction

Licensee shall certify plan to address how the facility plans to remain in complaince with this regulation. Licensee will provide an in-service training to staff and to Med-techs to call 911 immediately when resident has any injury that requires medical attention that includes falls. Plan must be emailed to LPA Shaw-Ross by POC 03/19/2026.

Deadline recorded: Mar 19, 2026. 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...(1) A written report shall be submitted to the licensing agency ...(D) Any incident which threatens the welfare, safety or health of any resident, ... This requirement is not met as evidence by: Based on documents reviewed licensee did not ensure staff were submitting incident reports for incidents sustained while in care for R2 which poses a potential risk to the health, personal rights, and safey of the residents in care.

Official plan of correction

Administrator will certify in writting that any incidents pertaining the residents will be submitted to the department via unusual incident report which will be submitted to the department by POC due date 4/11/25.

Deadline recorded: Apr 11, 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

Resident Records- All resident 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 was not met as evidenced by: R1's resident record was not made available to LPA Ramirez upon demand during normal business hours.

Official plan of correction

Licensee shall certify plan to address how the facility plans to remain in complaince with this regulation. Plan must be emailed to LPA Ramirez by 4/4/25.

Deadline recorded: Apr 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

Personnel Records- All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement was not met as evidenced by: S1's peronnel record was made available to LPA Ramirez for review.

Official plan of correction

Licensee shall certify plan to address how the facility plans to remain in complaince with this regulation. Plan must be emailed to LPA Ramirez by 4/4/25.

Deadline recorded: Apr 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463

Regulation authority

CCR

What the official deficiency says

Reappraisals: The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented. This was not met by: Based on record review and interviews, the Licensee did not comply with the above regulation with R1. R1 was hospitalized due to a fall, after being discharged from the hospital R1 was not reassessed to determine level of care for R1. This was an immediate safety risk to R1.

Official plan of correction

Administrator will send documentation that all staff have received new traning on reporting residents' change of condition, list of procedures to follow when observed, and updating all parties involved.

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

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes...and that appropriate assistance is provided...licensee shall ensure that such changes are documented and brought to the attention of...physician and ... responsible person ...This was not met by: Based on record review and interviews, the Licensee did not comply with the above regulation with R1. R1 exhibited throwing themselves out of their wheelchair on a regular basis. R1 was hospitalized due to a fall. This was an immediate safety risk to R1.

Official plan of correction

Administrator will send documentation that all staff have received new traning on reporting residents' change of condition, list of procedures to follow when observed, and updating all parties involved. A new procedure will be created for a updated care plan for residents.

Deadline recorded: Mar 7, 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 of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation and interview, the ceiling in the laundry room of one(1) of the memory care cottage had a hole, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee must ensure repairs are made with proof of repair to licensing by the POC due date

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

Official classification

Type A

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 record review, the licensee did not comply with the section cited above in 6 out of 6 times which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/30/2024 Plan of Correction The licensee agrees to enroll, and have 6 out of 6 staff complete CPR training. Proof of POC is to be submitted to the department by 5pm on the due date indicated.

Official classification

Type A

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 in 2 out of 2 times, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/30/2024 Plan of Correction The licensee agrees to conduct an emergency disaster drill and document it. Proof of POC is to be submitted to the department by 5pm on the due date indicated.

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 in 1 out of 1 times which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/13/2024 Plan of Correction The licensee agrees to obtain liability insurance. Proof of POC is to be submitted to the department by 5pm on the due date indicated.

Official classification

Type A

Official code

87355(e)

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: 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 1 out of 1 time which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/30/2024 Plan of Correction THERE IS NO POC DUE AS THE PROPER DOCUMENTATION WAS LOCATED VERFYING THAT R1 HAS PROPER FINGERPRINT CLEARANCE AND IS ASSOCIATED TO THE FACILITY.

Official classification

Type B

Official code

80075(b)

Regulation authority

CCR

What the official deficiency says

80075(b) Health Related Services. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by:

Official plan of correction

Licensee stated that they shall conduct an in-service training for all staff members that assist in administering medication. Licensee stated they will FAX proof of training completion by the POC date to the Department.

Deadline recorded: Apr 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

80087(a)

Regulation authority

CCR

What the official deficiency says

Based on records reviewed, the Licensee did not ensure that medication was properly administered to a resident in care. This poses a potential health and safety risk to clients in care.

Deadline recorded: Apr 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

REPORTING REQUIREMENTS: a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to...(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 of any of the events specified in (D) Any incident which threatens the welfare, safety or health of any resident...This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not being met as evidenced by: During interview with ED on 10/20/2023, ED verbally stated that one resident had a fall and ED failed to report the resident had fall that resulted in bruising on temple and forehead on 09/30/2023. This poses an immediate health and safety risk to residents in care.

Official plan of correction

ED stated that they will report all incidents and falls to Licensing according to requirements.

Deadline recorded: Oct 23, 2023. 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

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 of residents, employees and visitors. This requirement was not met as evidenced by: Licensee did not ensure hot water was available for all residents. This poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Facility has repaired the hot water and LPA verified hot water is operational during this visit today.

Deadline recorded: Sep 28, 2023. 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

Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1...(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on observation, records review and interview,resident's care plan is not being executed as indicated with total assist for toileting, and not enough staff being present to fulfill this need. This resulting in a fall.

Official plan of correction

Facility will submit in writting a new plan for mitigating the resident's fall risk that will meet the total assist critera needed for the resident. This will included facility plan for staffing. This will be provided to LPA by POC date.

Deadline recorded: Sep 1, 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

Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, & competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. This requirement was not met as evidenced by: Kitchen staff did not report, to management, of potentially dangerous mold in the kitchen walk-in refrigerator. This poses a health and safety risk to residents in care.

Official plan of correction

LIcensee shall read the requlation in it's entirety, train staff on regulation, submit a statement of understanding and training log to CCL by the POC due date of 5/13/2022.

Deadline recorded: May 13, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes...and that appropriate assistance is provided...licensee shall ensure that such changes are documented and brought to the attention of...physician and...responsible person...This was not met by: Based on record review and interviews, the Licensee did not comply with the above regulation with R1. R1 had sustained 12 falls in 2019 alone yet no additional protective measures were taken for R1 despite this need being identified. This was an immediate safety risk to R1.

Official plan of correction

Licensee has conducted an all-staff meeting and expressed expectation that NOC staff are to visually inspect residents during rounds to ensure safety and wellness. Additionally, Licensee has instituted that staff are to monitor residents with incontinence more closely during the night. No POC needed.

Deadline recorded: Sep 17, 2021. 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

Additional Personal Rights...in Privately Operated Facilities: (a) In addition to the rights listed...residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs... This requirement was not met as evidenced by: Based on record review and interviews, the Licensee did not comply with the above regulation with R1. On 11/23/21, R1 suffered from an unwitnessed fall in the facility, which resulted in bruising on most of R1's extremeties and facial hematoma. This was an immediate health risk to R1.

Official plan of correction

Licensee agrees to address changes in all residents' conditions and follow through with observed unmet needs through updated Needs & Services Plans as well as taking neccesary actions (such as possible eviction) to ensure adequate level of care. No further POC needed.

Deadline recorded: Sep 17, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87415(a)(3)

Regulation authority

CCR

What the official deficiency says

Night Supervision: (a) The following persons providing night supervision...shall...be available as indicated below to assist in caring for residents... (3) In facilities caring for one hundred one (101)...residents...one employee shall be on call and capable of responding within ten minutes. This was not met by: Based on record review, the Licensee did not comply with the above regulation with at least one shift (NOC). LPA Colvin observed the NOC shift to only have two caregivers to four cottages, and at times, one caregiver to four cottages. Response times show excess of ten minutes. This is a potential personal rights risk.

Official plan of correction

Licensee agrees to conduct audit of resident alarm response times for all cottages for a 30 day period and compare with staff scheduling to identify any unmet needs. Findings of audit to be provided to LPA Colvin by Plan of Correction date of 10/1/21 as well as plan for addressing any needs identified in audit.

Deadline recorded: Oct 1, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

Observation of the Resident: The licensee shall ensure...residents are...observed for changes...When changes...are observed, the licensee shall ensure that such changes are...brought to the attention of the resident's physician...and responsible person, if any. This requirement was not met by: Based on record review and interviews, the Licensee did not comply with the above regulation. R1 lost 23 pounds and had symptoms, and was nott given prompt medical attention. This posed an immediate health risk to R1.

Official plan of correction

Licensee conducted a meeting with all staff regarding procedures for resident weight changes and when resident's skip a meal. Additionally, the Memory Care Director has taken over responsiblity for weighing residents. No further POC needed.

Deadline recorded: Sep 17, 2021. 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

REPORTING REQUIREMENTS: (a) Each licensee shall furnish to the licensing agency such reports...(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 of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidence by: The facility did not provide CCLD with writen notification of one positive COVID-19 staff. Potential health, safety risk, and personal rights to residents in care.

Official plan of correction

Management states upon receiving positive report, Management will notify CCLD via Fax, follow-up with a phone call and then call the County of Public Health to obtain the directions. Management will do in-service training with Staff regarding COVID-19 positives. In stand-up meetings held daily Monday through Fridays to update the team with new COVID cases. Statement of understanding and training due by 9/6/2021.

Deadline recorded: Sep 6, 2021. A deadline is not proof that correction was completed.