Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(a)(11)
- 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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 staff does not have a health screen which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/31/2025 Plan of Correction Licensee is to obtain a health screening report for S1 and send to LPA by POC due date.
Staffing, personnel, and trainingType B
- 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 in 1 out of 1 staff does not have annual training which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/14/2026 Plan of Correction Licensee is to ensure that S1 completes the annual training and send to LPA by POC due date.
Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87506(a)
- Regulation authority
- CCR
What the official deficiency says
(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. 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 residents had incomplete files which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/14/2026 Plan of Correction Licensee is to audit all resident files and correct the following for each resident. R1 and R2 need Needs & Service plan. R3 and R4 need admission agreements, ID page, Consent forms, Needs & Service and personal rights. R5 needs Needs & Service plan and personal rights. R6 documents are from their pervious facility and need to be switched to current facility. Send proof 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 record review, the licensee did not comply with the section cited above in 2 out of 6 resident do not have medical assessments which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/14/2026 Plan of Correction Licensee is to obtain Physicians report (LIC602) for R1 and R2 and submit copies to LPA by POC due date.
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 record review, the licensee did not comply with the section cited above in facility has not conducted drills in the last year which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/31/2025 Plan of Correction Licensee is to conduct a drill by POC due date and submit to LPA. Additionally, Licensee is to come up with schedule for quarterly drills.