NORTHERNCARE FACILITY

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities (a) (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met based on video and statements that found S1 did not provide appropriate transfer request to R1. This posed and immediate risk to R1.

Official plan of correction

Licensee will submit a statement of training, oversite and supervisory actions by the POC date of 1/13/26.

Deadline recorded: Jan 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training… This requirement was not met based on records review and interview finding no recorded training for S1 or S2. This posed a potential risk to residents.

Official plan of correction

Licensee will submit a statement of understanding as well as a facility training record template used to meet this requirement by the POC date of 2/6/26.

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

Official classification

Type B

Official code

87307(a)(3)(4)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (a)(3)(F) Basic laundry service… This requirement was not met based on statements that resident personal belongings were not kept separate from others and that R1’s personal linens were not properly laundered. This posed a potential risk to resident.

Official plan of correction

Licensee will submit proof of staff training regarding proper laundering of resident belongings, control of infection and ensuring resident's personal belongings by the POC date of 2/6/26.

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

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. This requirement was not met based on records and statements that found R1's medications were not administered as ordered. This posed an immediate risk to resident.

Official plan of correction

Licensee will submit proof of registration for training provided by a ccld vendorized medication specific for RCFEs training by the POC date od 1/23/26. The training is to be completed by 2/23/26 and proof will be submitted.

Deadline recorded: Feb 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87470(a)(4)(C)

Regulation authority

CCR

What the official deficiency says

Infection Control Requirements (a)(4)(C) Gloves shall be removed and discarded in the nearest appropriate waste receptacle with a tight-fitting cover immediately following the glove use as required. This requirement was not met based on observations and interviews. This posed an potential risk to residents health and safety.

Official plan of correction

Licensee will submit proof of registration for training provided by a ccld vendorized medication specific infection control training for all staff.. The training is to be completed by 2/23/26 and proof will be submitted.

Deadline recorded: Feb 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(c)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility… This requirement was not met based on records review and interview that found S1 and S2 did not have verified clearance prior to living and working at the home 5/27/25- 5/28-25.

Official plan of correction

Licensee will submit a statement of understanding and intent to comply with this requirement by the POC date of 1/23/26.

Deadline recorded: Jan 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(d)(2)

Regulation authority

CCR

What the official deficiency says

Administrator - Qualifications and Duties (d) (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. Administrator failed to hiring, train, seek criminal record clearance of S1 and S2, meet reporting requirements, ensure fire safety, create initiate resident behavior plans, ensure infection control and to have been arguing with family in the presence of residents. This posed a potential risk to residents.

Official plan of correction

Licensee will submit proof of registration for CEUs to cover training for the deficiencies sited by the POC date of 1/30/26.

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

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (h)(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. There was not a recording of R1 skin treatment in the centrally stored medication record.

Official plan of correction

Licensee will audit and update all resident storage records and demonstrate records are complete and accurate by the POC date of 2/6/26. This POC to be cleared by visit.

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

Official classification

Type B

Official code

87211(a)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require. This requirement was not met based on interviews that Administrator failed to report incidents identified. This posed a potential risk to residents.

Official plan of correction

Licensee will submit a statement of understanding of this requirement as well as a policy of the process from an incident, notifications and submitting written reports by the POC date of 2/6/26.

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

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements (b)(8) All food shall be of good quality… Food in damaged containers shall not be accepted, used or retained. This requirement was not met based on observation. This posed a potential risk to residents.

Official plan of correction

Licensee will conduct an audit of all food supplies and ensure all food is safely stored and organized in a way that allows for easy identification of " first in/ first out " procedures by the POC date of 2/6/26. POC to be cleared by visit.

Deadline recorded: Feb 6, 2026. 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

(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: Based on LPAs' observations, the facility did not ensure that water temperatures were controlled and maintained at not less than 105 degrees F and not more than 120 degrees F when hot water was measured at 123 degrees F, which poses an immediate health, safety or personal rights risk to persons in care. A civil penalty in the amount of $250 was assessed for repeat violation.

Official plan of correction

Facility will adjust water temperature at the facility to be no less than 105 degrees F and no more than 120 degrees F. LPA will return to facility to check water temperatures. Facility will adjust water temperature by POC due date.

Deadline recorded: Aug 28, 2024. 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

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on LPAs' observations, the facility did not ensure that tools and other items that could pose a danger to residents if readily available were locked and inaccessible to residents in the garage and backyard area, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility will ensure storage for hazardous items and ensure that hazardous items are locked and inaccessible to residents in care by POC due date. LPA will return to facility at a future date to check that all hazardous items are locked and inaccessible to residents in care.

Deadline recorded: Aug 28, 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

(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: Based on LPAs' observations, the facility did not ensure that medications were locked and inaccessible to the residents in care, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility will repair existing medication storage or obtain a different medication storage. Facility will ensure that medication storage is locked. LPA will return at a future date to ensure that medications are locked and inaccessible to the residents in care.

Deadline recorded: Aug 28, 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

(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 LPA's observations, the facility did not ensure that water temperatures were controlled and maintained at not less than 105 degrees F and not more than 120 degrees F when hot water was measured at 127 degrees F, which poses an immediate health, safety or personal rights risk to persons in care. A civil penalty in the amount of $250 was assessed for repeat violation.

Official plan of correction

POC Due Date: 05/30/2024 Plan of Correction Facility will adjust water temperature at the facility to be no less than 105 degrees F and no more than 120 degrees F. LPA will return to facility to check water temperatures. Facility will adjust water temperature by POC due date.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations, the facility did not ensure that chemical, tools, and other items that could pose a danger to residents if readily available were locked and inaccessible to residents in the kitchen, bathroom, garage, and backyard area, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/30/2024 Plan of Correction Facility will ensure storage for hazardous items and ensure that hazardous items are locked and inaccessible to residents in care by POC due date. LPA will return to facility at a future date to check that all hazardous items are locked and inaccessible to residents in care.

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 LPA's observations, the facility did not ensure that medications were locked and inaccessible to the residents in care, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/30/2024 Plan of Correction Facility will ensure that medication storage is locked. LPA will return at a future date to ensure that medications are locked and inaccessible to the residents in care.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations, the facility did not ensure that the premises was clean, safe and sanitary in the garage, backyard area, living room area, and kitchen refrigerator, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/29/2024 Plan of Correction Licensee will clean facility and clear clutter and debris by POC due date. LPA will return at a future date to ensure that facility is clean, safe, and sanitary.

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 and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations and records reviewed, facility did not ensure that one (1) of six (6) residents had an LIC 602A on file, which poses/posed a potential health, safety or personal rights risk to persons in care. A civil penalty in the amount of $250 was assessed for repeat violation.

Official plan of correction

POC Due Date: 06/29/2024 Plan of Correction Facility will ensure that all residents obtain a Physician's Report LIC 602A and that documentation is maintained at the facility at all times. Facility will submit missing LIC 602A for one (1) resident to LPA by POC due date.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observations, the facility did not ensure that fire extinguisher was serviced and fire exits were unobstructed, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/30/2024 Plan of Correction Facility will ensure that evacuation exits are clear of clutter and debris and are unobstructed. Facility will service fire extinguisher. LPA will return to facility on a future date to clear deficiency.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was is not met as evidenced by: Based on observation, facility didn't ensure fire exit was unobstructed by installing chain lock on front door out of reach of non-ambulatory residents, which poses an immediate health, safety, and personal rights risk to the residents in care.

Official plan of correction

Administrator removed chain from front door during investigation. Administrator will complete a statement of understanding regarding regulation 87203 and submit statement to LPA by POC due date of 11/17/2023.

Deadline recorded: Nov 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.625(b)(1)

Regulation authority

CCR

What the official deficiency says

§1569.625 Staff training; legislative findings; contents (b) (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: Based on records reviewed, facility did not ensure that staff were acquiring all required trainings per Health and Safety Code, which poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Administrator will ensure that new caregivers receive required initial training. Administrator will also complete a statement of understanding regarding Health and Safety Code §1569.625 and submit statement to LPA by POC due date of 12/15/2023.

Deadline recorded: Dec 15, 2023. A deadline is not proof that correction was completed.

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 and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Deficient Practice Statement Due to observation, facility did not ensure that one (1) resident had an LIC 602 on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2023 Plan of Correction Facility will have resident assessed by a physician and obtain a copy of the resident's LIC 602. Facility will submit copy of LIC 602 to LPA by POC due date.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (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 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Deficient Practice Statement Due to observation, facility did not ensure that water temperatures were controlled and maintained at not less than 105 degrees F and not more than 120 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/01/2023 Plan of Correction Facility will adjust water temperature at the facility to be no less than 105 degrees F and no more than 120 degrees F. LPA will return to facility to check water temperatures. Facility will adjust water temperature by POC due date.