BEATRICE SENIOR CARE

Official classification

Type A

Official code

87411

Regulation authority

CCR

What the official deficiency says

(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or This regulation was not met as evidenced by a uncleared indidual present alone in the facility. This presents an immediate threat to resdidents in care.

Official plan of correction

Administrator/Licensee present in the facility working. Uncleared individual left the facility. Licensee / Administrator acknowledges that cleared individuals are to only be present

Deadline recorded: Aug 18, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87205(a)

Regulation authority

CCR

What the official deficiency says

87205(a) — Accountability of Licensee Governing Body No licensee, whether an individual or an entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation and conformance with these regulations and the welfare of the individuals it serves. The licensee failed to do this as evidenced by over the past 60 days the facility being cited two times for not having individuals fingerprint cleared before caring for individuals, this presents an immediate health and safety risk to clients.

Official plan of correction

Licensee will provide a LIC 500 for each facility that shows coverage with cleared individuals by POC date 08/18/26 by 5:00pm to LPA Oropeza @ Melina.Oropeza@dss.ca.gov.

Deadline recorded: Aug 18, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the residents’ need. In providing transportation the licensee shall do so directly or make arrangements for this service. Based on interviews with S1 and S2. The licensee did not ensure R1 made it to doctors appoitments on multiple occations. This poses a potential health, safety, and/or personal rights risk.

Official plan of correction

The Licensee will provide a statment of understanding to LPA Lewis By COB 08/06/2026. Kesha.Lewis@dss.ca.gov

Deadline recorded: Aug 6, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87506(b)(14)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (b) Each resident’s record shall contain at least the following information: (14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services. Based on records review the licensee was not able to provide R'S file for LPA to review. Which poses an immediate health, safety, and/or personal rights risk.

Official plan of correction

The Licensee will provide a statment of understanding to LPA Lewis By COB 08/06/2026. Kesha.Lewis@dss.ca.gov

Deadline recorded: Aug 6, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

87208 Plan of Operation (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

Official plan of correction

The Licensee will provide a statment of understanding to LPA Lewis By COB 08/06/2026. Kesha.Lewis@dss.ca.gov

Deadline recorded: Aug 6, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411

Regulation authority

CCR

What the official deficiency says

(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or This regulation was not met as evidenced by a uncleared indidual present alone in the facility. This presents an immediate threat to resdidents in care.

Official plan of correction

Admin/Licensee present in the facility working. Uncleared individual left the facility. Licensee / Admin acknowledges that cleared individuals are to only be present

Deadline recorded: Jun 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555

Regulation authority

CCR

What the official deficiency says

(b) (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This was not met as evidenced by open freezer burned food.

Official plan of correction

Licenssee Admin will go dispose of freezer burned foods and lable existing foods within 24 hours and send photos to melina.oropeza@dss.ca.gov.

Deadline recorded: Jun 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87219(a)

Regulation authority

CCR

What the official deficiency says

87219 Planned Activities (a)Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. Based on observations, interviews and documentation received. LPA did not observe residents participating in activities during this visit. Which poses a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

The licensee will provide any documentation of refusal of resident participating in activities. The licensee will send updated activity calendar by 5:00pm on June 30, 2026.

Deadline recorded: Jun 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309(a) Storage Space and Access (a) 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: Based on observation, the Administrator did not comply with the section cited above. LPA Lewis observed toxins and medication unlocked and made accessible to residents in care. This poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee removed the mecication and took the key from the door of the laundry room. A statement acknowledging review and understanding of the cited regulation will be emailed to LPA Lewis by 06/17/2026 by the end of the day.

Deadline recorded: Jun 17, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87755(b)

Regulation authority

CCR

What the official deficiency says

" (b) The licensee shall ensure that provisions are made for ... the examination of all records relating to the operation of the facility. " This requirement was not met as evidenced by: Based on interview and observation, the licensee did not make provisions for the examination of records upon demand, which poses an immediate health, safety, and/or resident rights risk.

Official plan of correction

Licensee agrees to produce these documents by POC due date. Failure to do so will result in the assessment of civil penalties. vincent.moleski@dss.ca.gov

Deadline recorded: Oct 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

" The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents... All food shall be selected, stored, prepared and served in a safe and healthful manner. " This requirement was not met as evidenced by: Based on observation, foods were not stored in a safe or healthful manner, which poses a potential health, safety, and/or personal rights risk.

Official plan of correction

Licensee agrees to conduct a staff training regarding food storage procedures by POC due date. vincent.moleski@dss.ca.gov

Deadline recorded: Oct 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(3)

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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Based on record review, one staff member was not associated to this facility's roster prior to starting work, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee submitted an email transfer request during this visit.

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

Official classification

Type B

Official code

87412(a)

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: This requirement is not met as evidenced by: Based on record review and interview, staff files for two staff were incomplete, which poses a potential health, safety, and/or personal rights risk.

Official plan of correction

Licensee agrees to provide completed staff records for S1 and S2 by POC due date. Failure to adhere to this POC will result in additional civil penalties. vincent.moleski@dss.ca.gov

Deadline recorded: Jun 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

“(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.” This requirement was not met as evidenced by: Based on interviews and observations, food was not stored or prepared in a safe and healthful manner, which poses a potential health, safety, and/or personal rights risk.

Official plan of correction

Licensee agrees to provide LPA Moleski with an inservice training record by POC due date. vincent.moleski@dss.ca.gov

Deadline recorded: Jun 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87219(a)

Regulation authority

CCR

What the official deficiency says

“(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:” This requirement was not met as evidenced by: Based on interviews and observations, residents were not encouraged to participate in a variety of planned activities, which poses a potential health, safety, and/or personal rights risk.

Official plan of correction

Licensee agrees to provide LPA Moleski with a planned activities calendar to be used daily, with all refusals documented, by POC due date. vincent.moleski@dss.ca.gov

Deadline recorded: Jun 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

" 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department ... " This requirement was not met as evidenced by: Based on interviews, one individual without a criminal record clearance resided in this facility for one night, which poses an immediate health, safety, and/or personal rights risk.

Official plan of correction

Licensee agrees to provide LPA Moleski with a signed acknowledgement affirming that these requirements have been reviewed and will be adhered to in the future. Licensee provided LPA Moleski this signed statement during this visit. This POC will be cleared.

Deadline recorded: May 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, fire extinguishers were not annually serviced, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/06/2025 Plan of Correction Licensee agrees to schedule maintenance service for their fire extinguishers by POC due date. Licensee shall inform LPA Moleski of the scheduled date of maintenance by POC due date. vincent.moleski@dss.ca.gov

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, water temperatures measured above 120, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/06/2025 Plan of Correction Licensee adjusted the water heater during this visit. Licensee agrees to retest and to provide LPA Moleski with a photograph of the updated reading by POC due date. vincent.moleski@dss.ca.gov

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) 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, cleaning solutions were not kept in locked storage, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/06/2025 Plan of Correction Licensee removed the offending substances during this visit. This POC will be cleared.

Official classification

Type A

Official code

87355(e)(3)

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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, two staff members were not associated to this facility's roster which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/06/2025 Plan of Correction Licensee sent in transfer requests during this visit. LPA Moleski will clear this POC after they have been transferred. vincent.moleski@dss.ca.gov

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, medications were left in unlocked storage in the refrigerator, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/06/2025 Plan of Correction Licensee removed the medications during this visit. This POC will be cleared.

Official classification

Type B

Official code

87412(a)

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: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, S1's staff file was incomplete and S2's staff file was not present, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/12/2025 Plan of Correction Licensee agrees to provide scans of both S1 and S2's complete staff files by POC due date. vincent.moleski@dss.ca.gov

Official classification

Type B

Official code

87506(b)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, resident files were incomplete, and one was missing altogether, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/14/2025 Plan of Correction Licensee agrees to provide complete scans of all resident files by POC due date. vincent.moleski@dss.ca.gov

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

" (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication. " This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, centrally stored medication records were not kept, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/14/2025 Plan of Correction Licensee agrees to write a statement acknowledging the requirements of this section and affirming that centrally stored medication records will be kept in the future by POC due date. vincent.moleski@dss.ca.gov

Official classification

Type A

Official code

87156(a)

Regulation authority

CCR

What the official deficiency says

Licensing Fees An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. This requirement has not been met by: Based on the file review conducted by LPA VBrown the license fees are not current. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator shall pay license fees by POC due date and fax confirmation to the CCL office.

Deadline recorded: Jun 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement has not been met by: Based on the observation of LPA VBrown the Licensee/Administrator did not keep facility free of flies in the kitchen and common bathroom of the facility. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator shall submit a plan to rid the home of flies by POC due date and fax confirmation to the CCL office.

Deadline recorded: Jun 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement has not been met by: Based on water temperature measured by LPA VBrown the licensee/Administrator did not ensure water was within required range. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator shall turn down water heater by POC due date and fax confirmation to the CCL office. Also keep a water log for 1 week to be submitted by fax.

Deadline recorded: Jun 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements Supplies of nonperishable foods for a minimum of one week...shall be maintained on the premises. This requirement has not been met by: Based on observation by LPA VBrown the licensee/Administrator did not ensure a variety of fruits were present on premisis. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator shall purchase nonperishable fruits and receipt to be faxed by POC due date.

Deadline recorded: Jun 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement has not been met by: Based on observation by LPA VBrown the licensee/S1 did not ensure R1 received dignity by assisting with clothing. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator shall submit a plan on when an inservice to provide personal rights training to all staff will occur by POC due date and fax confirmation to the CCL office. Completion of in-service with signature shall be faxed to the office.

Deadline recorded: Jun 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement has not been met by: Based on observation by LPA VBrown the licensee/Administrator did not ensure medications were locked and inaccessible. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator shall submit confirmation that medications are inaccessible to residents by POC due date and fax confirmation to the CCL office.

Deadline recorded: Jun 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement has not been met by: Based on observation by LPA VBrown the licensee/administrator did not ensure medications were not in its orignal container until medication pass was to occur. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator shall submit a letter stating medication are not stored in 7 day pill boxes by POC due date.

Deadline recorded: Jun 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(b)

Regulation authority

CCR

What the official deficiency says

Storage Space Medicines which are centrally stored shall be stored as specified in Section 87465 and separately from other items specified in (a) above. This requirement has not been met by: Based on observation by LPA VBrown the licensee/administrator did not ensure medications are disposed of properly. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator shall submit a letter stating medication are not stored with chemicals in the garage by POC due date.

Deadline recorded: Jun 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87412(a-h)

Regulation authority

CCR

What the official deficiency says

Personnel Records The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee... This requirement has not been met by: Based on observation by LPA VBrown the licensee/Administrator did not ensure a file was created for S2. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator shall ensure a file is created and maintained for all staff. A letter of confirmation shall be submitted by fax to the office by POC due date.

Deadline recorded: Jun 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(g)(1-3)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements - General Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: This requirement has not been met by: Based on observation by LPA VBrown the licensee/Administrator did not ensure S2 was fingerprint cleared and associated to the facility. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator shall submit a plan to ensure S2 is cleared and associated to the facility by POC due date and fax confirmation to the CCL office.

Deadline recorded: Jun 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87305(b)

Regulation authority

CCR

What the official deficiency says

Alterations to Existing Building or New Facilities The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists. This requirement has not been met by: Based on observation by LPA VBrown the licensee/Administrator did not ensure staff was not sleeping in the shed in the backyard. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator shall submit a plan to seek confirmation from the Fire Dept on the approval of the shed being used as a living space or ensure it is used for its proper use by POC due date and fax confirmation to the CCL office.

Deadline recorded: Jun 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87413(a)(1)

Regulation authority

CCR

What the official deficiency says

87413(a)(1) Personnel-Operations. (a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement was not met as evidenced by: Based on record review, interviews, and observation, licensee did not ensure appropriate staff coverage consistent with facility staffing schedule for purposes of monitoring the activities of residents for their general health, safety, and well-being. This posed a potential health and safety risk to residents in care.

Official plan of correction

Licensee will read regulation 1569.312(e) and submit a signed declaration of understanding to LPA by POC due date.

Deadline recorded: Apr 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87616(b)

Regulation authority

CCR

What the official deficiency says

87616(b) Exceptions for Health Conditions The licensee may submit a written exception request if ... the resident has a ...restrictive health condition. This requirement was not met as evidenced by: Based on observation, interviews and record review, the new resident has a catheter and no exception request was received before her arrival.

Official plan of correction

Licensee will submit an exception request for resident with catheter. Exception was received during inspection of facility.

Deadline recorded: Feb 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement was not met as evidenced by: Based on LPA review of medical documentation and interviews with licensee and staff. R1 did not have any wounds when they came to the facility in June but by September the wound appeared. This poses a potential health, safety and personal rights risk of residents in care.

Official plan of correction

Licensee will develpo a plan on how to avoid residents sustainings wounds in the feature and sumbit to LPA Lewis via email by POC date.

Deadline recorded: Jan 27, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

80075(k)

Regulation authority

CCR

What the official deficiency says

80075Health Related Services (k)The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications...This requirement was not met as evidenced by: Based on observations and records review, the licensee did not ensure client records were maintained, medication in bottle did not match MAR. Which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee will have an inservice training to ensure medication records are reviewed consistenly, discontinued medications will be correctly documented. Licensee to send an in-service sign in sheet to LPA by POC due date.

Deadline recorded: Jan 16, 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

87303 Maintenance and Operation (a) ... 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: Based on LPAs review of the electric bills the electricity was shut down for non-paymment which poses a potential health, safety and personal rights risk of residents in care.

Official plan of correction

Licensee has set up auto-pay for the electricty bill to ensure that this does not happen again. No further Plan of Correction is required.

Deadline recorded: Nov 23, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87616(a)(b)

Regulation authority

CCR

What the official deficiency says

Exception for Health Conditions: The licensee may submit a written exception if she/he agrees the resident has a prohibited health condition but believes that the intent of the law can be met through alternative means. Written request shall include... documentation of resident’s health condition…licensee’s plan for ensuring the resident’s health related needs can be met by the facility. This requirement is not met as evidenced by: Based on interview and review of medical record on 10/04/2022 and medical discharge paperwork, the licensee/staff failed to seek an exception as required to retained R1 with a prohibited health condition. This posed a potential health and safety risk to resident’s in care.

Official plan of correction

Licensee agrees to submit a request for an exception to retain (R1) who has prohibited health condition. Licensee shall review the regulation on prohibited health condition and submit a statement of understanding of this regulation. By close of business on 11/17/2022

Deadline recorded: Nov 17, 2022. A deadline is not proof that correction was completed.