Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(d)
- Regulation authority
- CCR
What the official deficiency says
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. 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 that the administrator did not have an active administrator certificate which poses a potential health, safety or personal rights risk to four (4) out of four (4) residents in care.
Official plan of correction
POC Due Date: 05/06/2026 Plan of Correction Licensee agrees to submit proof of recertification of the Administrator Certification to the Department by POC due date of 5/6/2026.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87458(c)(1)(A)
- Regulation authority
- CCR
What the official deficiency says
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. 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 that Resident #1 (R1) and Resident #2 (R2) did not have the results of their communicable tuberculosis on file which poses a potential health and safety risk to two (2) out of two (2) residents in care.
Official plan of correction
POC Due Date: 05/06/2026 Plan of Correction Licensee agrees to submit proof of the results for R1's and R2's communicable tuberculosis test results to the Department by POC due date of 5/6/2026.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(i)
- Regulation authority
- CCR
What the official deficiency says
(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making. 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 R1 and R2 did not have a reappraisal on file, and R3 and R4 had their last reappraisals in 2024 which poses a potential health and safety risk to four (4) out of four (4) residents in care.
Official plan of correction
POC Due Date: 05/06/2026 Plan of Correction Licensee agrees to submit the reappraisals for R1-R4 to the Department by POC due date of 5/6/2026.