Fire safety and emergency preparednessType B
- 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 interview and record review, the licensee did not comply with the section cited above in one out of [one emergency drill documentation, which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/11/2025 Plan of Correction Administrator will email an all staff emergency drill training by POC date.
Hazardous items and storageType B
- Official classification
- Type B
- Official code
- 87309(a)
- Regulation authority
- CCR
What the official deficiency says
87309(a) STORAGE SPACE AND ACCESS 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 in one out of one unsecured kitchen drawer which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 09/11/2025 Plan of Correction The knives were immediately relocated to a secured drawer under the kitchen sink. The allocated drawer will need to be repaired by POC date. Administrator will email a visual proof of correction by POC date.