Licensing and administrationType A
- Official classification
- Type A
- Official code
- 87205(b)
- Regulation authority
- CCR
What the official deficiency says
(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Delgado observation , interview and record review, the licensee did not comply with the section cited above in the Licensee corporation is suspended as of 06/30/2025 according to the California Secretary of State which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/01/2025 Plan of Correction Licensee will ensure corporation is active and email LPA by POC due date.
Resident rightsType B
- Official classification
- Type B
- Official code
- 1569.153(d)
- Regulation authority
- HSC
What the official deficiency says
(d) A written resident personal property inventory is established upon admission and retained during the resident’s stay in the residential care facility for the elderly. Inventories shall be written in ink, witnessed by the facility and the resident or resident’s representative, and dated. A copy of the written inventory shall be provided to the resident or the person acting on the resident’s behalf. All additions to an inventory shall be made in ink, and shall be witnessed by the facility and the resident or resident’s representative, and dated. Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility at the written request of the resident, the resident’s family, a responsible party, or a person acting on behalf of a resident. The facility shall not be liable for items which have not been requested to be included in the inventory or for items which have been deleted from the inventory. A copy of a current inventory shall be made available upon request to the resident, responsible party, or other authorized representative. The resident, resident’s family, or a responsible party may list those items which are not subject to addition or deletion from the inventory, such as personal clothing or laundry, which are subject to frequent removal from the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Delgado observation, interview and record review, the licensee did not comply with the section cited above in R1 did not have an inventory of personal property in file which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/14/2025 Plan of Correction Licensee will ensure an inventory is in resident's file and email a copy to LPA by POC due date.
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(d)
- Regulation authority
- CCR
What the official deficiency says
(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in Room #3 did not have any lamps for residents (2) which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/14/2025 Plan of Correction Licensee will obtain lamps for room #3 and send picture to LPA by POC due date.
Staffing, personnel, and trainingType B
- 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 LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in no valid Administrative certification was observed which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/14/2025 Plan of Correction Licensee will email a copy of the valid certificate to LPA by POC due date.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 1569.625(b)(1)
- Regulation authority
- HSC
What the official deficiency says
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in no training was observed for S1 and S2 in files which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/14/2025 Plan of Correction Licensee will email copies of training to LPA by POC due date.
Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87506(b)(17)(E)
- Regulation authority
- CCR
What the official deficiency says
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (E) Section 87463, Reappraisals; and This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in R4 did not have a reappraisal in file which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/14/2025 Plan of Correction Licensee will email copy of reappraisal to LPA by POC due date
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87456(a)(2)
- Regulation authority
- CCR
What the official deficiency says
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in R1, R2, R3, R4 did not have completed signed pre-admission appraisals in their files which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/14/2025 Plan of Correction Licensee will email copies of the completed pre-admission appraisals to LPA by POC due date.
Admission, assessment, and evictionType B
- 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 documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in R4 did not have a medical assessment in file which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/14/2025 Plan of Correction Licensee will obtain a medical assessment for R4 and email a copy to LPA by POC due date.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87507(c)
- Regulation authority
- CCR
What the official deficiency says
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in R4 did not have an admission agreement in their file which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/14/2025 Plan of Correction Licensee will ensure R4 has a completed admission agreement in file and email a copy to LPA by POC due date.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(a)(2)
- Regulation authority
- HSC
What the official deficiency says
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in no emergency food and water was observed which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/14/2025 Plan of Correction Licensee wil obtain emergency food and water and email pictures to LPA by POC due date.
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(c)
- Regulation authority
- CCR
What the official deficiency says
Maintenance and Operation (c) all window screens shall be in clean and maintained in good repair. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA Delgado's observation and interview, the licensee did not comply with the section cited above in exterior window screen is tethered and sliding window screen is missing which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/14/2025 Plan of Correction Licensee will repair and replace screens and email pictures or receipt from vendor to LPA by POC due date.