BEATRICE HOME CARE

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, a resident had an open wound on their leg and partially ripped off toe nail and the resident was not sent out for immediate medical evaluation. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/12/2026 Plan of Correction The Administrator sent the resident out for a medical evaluation. This POC has been cleared.

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 LPA observation, the Administrator and staff use a shoe to prop open a fire door. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/12/2026 Plan of Correction Administrator stated that the shoe will be removed and the door willnot be prepped open.

Official classification

Type A

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the master bedroom was missing its slider screen. On 08/10/26 when this LPA was here last the door was wide open and this LPA has observed pests in the faciltiy, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/12/2026 Plan of Correction The Administrator stated she will schedule another pest control appointment abd will email the infomation to CCL by the close of business 08/13/26.

Official classification

Type A

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on onservation and record review, this LPA couldn not review proof of any of the 2 staff being CPR/ First AiD cerified at this facility. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/13/2026 Plan of Correction Administrator stated they will supply proof of First Aid /CPR certification or registration of class by close of business tomorrow, 08/12/26

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 this LPA's observations, the medicaiton cabinet was left open and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/12/2026 Plan of Correction Administrator will sign a declaration stating that they understand that the medication cabinet must be locked at all times. This willbe sent to CCL by the close of business tomorrow.

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Deficient Practice Statement Based observation and interview the licensee did not comply with the regulation above when this LPA was met by a worker who was not associated to the facility and who was left unsupervised with residents in care. This posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/13/2026 Plan of Correction The Administrator will submit a letter of understanding stating that she will no longer allow wokers to be left unsupervised with residents in care.

Official classification

Type B

Official code

87470(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

(2) Environmental cleaning and disinfection activities shall be performed following the manufacturers'instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (B) Walls and window coverings in resident care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary and when they are visibly contaminated or soiled. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, this LPA observed reddish brown stains on the wall and furniture in bedroom 4 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/31/2026 Plan of Correction Administrator stated they will clean and disinfect the room by 08/31/26. Pictures will be sent to CCL as proof of correction.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

(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: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the Administrator did not have a copy of her plan of operation at the facility. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/31/2026 Plan of Correction Administrator stated theywill have a copy of the plan of operation here 08/31/26.

Official classification

Type B

Official code

1569.157(h)

Regulation authority

HSC

What the official deficiency says

(h) The text of this section with the heading “Rights of Resident Councils” shall be posted in a prominent place at the facility accessible to residents, family members, and resident representatives. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above as they did not have the Rights of Resident Councils posted which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/31/2026 Plan of Correction Administrator stated they will post the Rights Councils where they are visible by the date above.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) 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 observation, the light switch in the bathroom was broken and there was a drawer in the kitchen missing a knob and the bathroom cabinet was also missing its handles which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/31/2026 Plan of Correction Admistrator stated they will make repairs by 08/31/26.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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 and testing, the hot water took approximately 7 minutes to reach a temperature of 103.6 degrees F. which poses/posed a potential health, safety or personal rights risk to persons in care. After using the restroom people should be able to access hot water in a timely manner to wash their hands.

Official plan of correction

POC Due Date: 08/31/2026 Plan of Correction Administrator will turn the hot water up and keep a temperature log for two weeks and ill submit a copy to licensing by 08/31/26.

Official classification

Type B

Official code

87468(c)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the above were not posted poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/31/2026 Plan of Correction Administrator stated she will post personal rights of residents and she will send a picture for proof of correction.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

87202(a) Fire Clearance-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...This requirement is not met as evidenced by: Based on observation, and interview with R1. the licensee failed to obtain an appropriate fire clearance. LPA observed that R1 is bedridden. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator will find proper placement.

Deadline recorded: Jul 30, 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

(c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another... by providing the following documents to the Department: The Licensee did not ensure this requirement was met as evidenced by: Based on interview and observation, S1 was not associated to this facility. This posed an immediate threat to the health, safety and personal rights of resdients in care.

Official plan of correction

The LIcensee/Administrator obtained the PER ID and stated they would send a copy of the online tranfer requests to this L.PA by the close of buisness on 4/14/26

Deadline recorded: Apr 14, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(g)(1)

Regulation authority

CCR

What the official deficiency says

87411Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and... shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations..This requirement was not met as evidenced by: Based on observations, interview, and record review, the licensee did not ensure staff obtained a fingerprint clearance prior to working in the facility, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee stated that S3 will pick up S1 to get fingerprints completed. Licensee stated S3 will be working S1's shifts until S1 is cleared to work in the facility. LPA Valerio to recieve a statement from licensee stating acknowledgement of 87411 and proof of S3 working S1's shifts by POC due date.

Deadline recorded: Jan 10, 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

(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, the licensee did not comply with the section cited above. Disenfectant spray was observed in the master bath; a pair of scissors were observed in the hallway bathroom sink cabinet; . These pose an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/25/2025 Plan of Correction Corrected on site: the scissors and disenfectant spray were removed. Per discussion, the licensee will submit a written statement of understanding of the regulation noted above. Submit statement by POC due date.

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, the licensee did not comply with the section cited above. Insulin injections belonging to resident were observed inside the kitchen refrigerator that were unlocked and accessible to resident; during the visit on 7/24/25, medication in a resident closet; LPAs observed the medication cabinet to be unlocked, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/25/2025 Plan of Correction Corrected on site during the 7/16/25 visit: Administrator bought a locked box for the medication. Per discussion, the licensee will submit a written statement of understanding of the regulation noted above. Submit statement by POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) 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 observation, the licensee did not comply with the section cited above. LPAs observed light switch in the hallway bathroom to be in disrepair; door of the laundry area was off; locking latch of the exit door of the Master bedrrom was hard to unlock; per staff, a resident broke it; exit door to the backyard had a hole; garage was observed to be in disarray. These poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction Per discussion, licensee will submit a photo of each of the repairs by POC due date.

Official classification

Type B

Official code

87303(e)(4)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPAs did not observe grab bars in the shower area which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction Per discussion, licensee will submit a photo of the installed grab bars to the Department by POC due date.

Official classification

Type B

Official code

87465(a)(8)

Regulation authority

CCR

What the official deficiency says

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. First Aid was incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction Per discussion, licensee will submit a photo of the missing items in their first aid kit by POC due date.

Official classification

Type B

Official code

87465(b)

Regulation authority

CCR

What the official deficiency says

(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. 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. Review of resident, PRN Authorization Letter was not observed, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction Per discussion, the licensee will submit a written statement of understanding of the regulation noted above. Submit statement by POC due date.

Official classification

Type B

Official code

87465(d)

Regulation authority

CCR

What the official deficiency says

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: 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 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction Per discussion, the licensee will submit a written statement of understanding of the regulation noted above. Submit statement by POC due date.

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. Resident records were found to be incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction Per discussion, the licensee will submit a written statement of understanding of the regulation noted above. Submit statement by POC due date.

Official classification

Type B

Official code

87506(b)(10)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (10) Reports of the medical assessment specified in Section 87458 Medical Assessment, and of any special problems or precautions. 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. 2 of 6 residents did not have physican's report avialable for review during this visit, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction Per discussion, the licensee will submit a written statement of understanding of the regulation noted above. Submit statement by POC due date.

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. 2 resident did not have updated medical assessment; 2 residents did not have medical assessments available for review during this visit. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction Per discussion, the licensee will submit a written statement of understanding of the regulation noted above. Submit statement by POC due date.

Official classification

Type B

Official code

87633(a)(4)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident's hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident's or prospective resident's Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s). 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. 1 of 2 hospice resident did not have hospice care plan on file available for review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction Per discussion, the licensee will submit a written statement of understanding of the regulation noted above. Submit statement by POC due date.

Official classification

Type B

Official code

87633(b)(6)(B)

Regulation authority

CCR

What the official deficiency says

(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan. (B) The hospice agency will provide training specific to the current and ongoing needs of the individual resident receiving hospice care and that training must be completed before hospice care to the resident begins. 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. Evidence of hospice training from the hospice agency was not available for review during this annual, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction Per discussion, the licensee will submit a written statement of understanding of the regulation noted above. Submit statement by POC due date.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(c ) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Deficient Practice Statement Based on interviews and record review, the licensee did not comply with the section cited above. Review of 3 of 3 staff files, staff obtained their training from an online only service called the National CPRFoundation and is not an approved trainer for the Department of Social Services since it does not meet the regulation requirements. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction Per discussion, licensee agreed to submit a plan on when they will obtain the first aid/cpr training. Per discussion, licensee agreed to submit updated first aid/cpr certificate for all staff. Submit certificate by POC due date.

Official classification

Type A

Official code

87202(a)(1)

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. (1) Nonambulatory persons. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above. Non-ambulatory resident residing in a bedroom cleared for ambulatory use only (bedroom #4 in the facility sketch) which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/25/2025 Plan of Correction Per discussion, the licensee will submit a written plan to the Department by POC due date.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

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 observation, the licensee did not comply with the section cited above. During physical observation on 7/16/25 and 7/24/25, LPAs observed the fire door to be propped open with a shoe/sandal; the two fire extinguishers during the 7/16/24 visit were observed to be expired and was last serviced on 4/15/24, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/25/2025 Plan of Correction Per discussion, the licensee will submit a written statement of understanding of the regulation noted above. Submit statement by POC due date.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(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: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on medication review of 4 of 5 residents, the licensee did not comply with the section cited above. Some medications for 3 residents were rnot available at the facility during the initial visit on 7/16/25; also, one resident had one medication that was observed to be expired on 4/10/25; some medications from one resident did not have discontinue orders from their physician. These poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/25/2025 Plan of Correction Per discussion, the licensee will submit a written statement of understanding of the regulation noted above. Submit statement by POC due date.

Official classification

Type A

Official code

87411(g)(2)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance... This requirement was not met as evidenced by: Based on observations, records review, and interviews, the licensee did not ensure 1 out of 2 staff present in the facility were fingerprinted and cleared. This poses an immediate health, safety, and personal rights risk to residents.

Official plan of correction

Licensee stated the administrator will take the staff member to get a fingerprint clearance today, 11/26/24. Licensee to send LPA Valerio proof by POC due date of 11/27/24.

Deadline recorded: Nov 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(1) Knives,...tools and other items that could constitute a danger to the resident(s).(2)... cleaning supplies and disinfectants. This requirement was not met as evidenced by: Based on observations, the licensee did not comply with the regulation cited above. LPA Villanueva observed cleaning supplies under the kitchen sink and under the bathroom sink area accessible to the residents in care. This poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

During this visit, staff on duty removed the cleaning chemicals and store them in a locked closet. Per Administrator they plan to train staff and put lock for the storage under the sink. Per Administrator, they will send their plan to the Department by POC due date. Then send the staff training once completed by 10/31/24.

Deadline recorded: Oct 25, 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

(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). Based on observation, the licensee did not comply with the regulation cited above. Hot water in 2 bathrooms and kitchen sink were measured betwween 123*F and 125*F. This poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

Per discussion with Administrator, initially, check daily for a week and send readings to LPA by 10/31/24. After that, check hot water every month to continue monitoring hot water. Per Administrator, they will send their plan to the Department by POC due date.

Deadline recorded: Oct 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(l)(6)

Regulation authority

CCR

What the official deficiency says

(6) Locked exterior doors or perimeter fences with locked gates shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents. Based on observation, the licensee did not comply with the regulation cited above. LPA observed the gate latch to be locked as evidenced by being tied with a string.

Official plan of correction

The staff has already removed the lock. The Administrator/Licensee agrees to send the date and time of when she will provide a training on fire safety regarding exits and fire department fire access by the POC date.

Deadline recorded: Oct 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(1) Knives,...tools and other items that could constitute a danger to the resident(s).(2)... cleaning supplies and disinfectants. This requirement was not met as evidenced by: Based on observations, LPA Valerio observed, cleaning supplies, a knife, and a tool out on the kitchen area accessible to the residents in care. This poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

Licensee had staff lock away the sharps and cleaning supplies during the visit. Licensee to submit a Training Plan by POC due date. The plan will describe when training related to 87705 will be held with all staff.

Deadline recorded: May 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(6)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6)... to not be locked into any room, building, or on facility premises by day or night. This requirement was not met as evidenced by: Licensee did not ensure facility staff did not install a locking mechanism on the resident bathroom and bedroom. This poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

Licensee removed nails and ropes during LPA's visit. Licensee to submit a Training Plan by POC due date. The Training Plan will describe when an all staff training will be held regarding 87468.1 Personal Rights of Residents in All Facilities.

Deadline recorded: May 30, 2024. A deadline is not proof that correction was completed.