ALMOND HEIGHTS

Official classification

Type A

Official code

87465(a)(4)

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: (4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on incident report and staff interview the facility did not provide resident, R1 their medications as prescribed which poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator shall letter of understanding of this regulation by 10/07/25. Administrator shall conduct staff training for medication management and to send into CCL a copy of the training and date the training was provided by 10/13/25. Furthermore, facility will train staff regarding written policy of refill medications for residents and shall send a copy to CCL.

Deadline recorded: Oct 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by; Based on record review and interviews, it was concluded that resident, R1 was able to AWOL from the facility, unassisted on 09/12/25 , which poses an immediate risk to the health and safety of residents in care.

Official plan of correction

Administrator shall conduct staff training, regarding AWOL risk for residents and will send training documents to CCL. POC due date is 09/23/25. LPA cleared the POC as record review indicated that facility conducted staff training regarding AWOL risks residents on 09/12/25 and 09/13/25.

Deadline recorded: Sep 23, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

80075(b)(5)(B)

Regulation authority

CCR

What the official deficiency says

80075 -Health Related Services (b)(5)(B) - Once ordered by the physician the medication is given according to the physician's directions.... This requirement was not met as evidenced by: Based on record review from the facility, it was observed that on 09/19/24, resident, R1 was given medications, Calcium Citrate 250mg- 2 tablets, Simvastatin 20mg-1 tablet and Memantine 10 mg- 1 tablet by mistake from staff and these medications were not ordered by R1s physician which poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator agreed to submit a self certification for this regulation and will do training for all staff regarding medication administration and submit proof to LPA by POC date- 10/03/24. Additionally, facility shall conduct monthly staff training for medications administration till December 2024 will send monthly training proofs to Department.

Deadline recorded: Oct 3, 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

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:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidence by; Record review and interviews conducted indicated that staff assisted R1 to their bed on 04/18/24 without their consent which poses an immediate risk to the health and safety of residents in care.

Official plan of correction

Administrator shall submit letter of understanding regarding Regulation-87468 and shall conduct all staff training to go over Residents Personal Rights and send all these documents to CCL by POC date-05/24/24.

Deadline recorded: May 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by; Based on records of the incidents for R2, it was concluded that R2 was able AWOL from the facility unassisted on 05/08/24 which poses an immediate risk to the health and safety of residents in care.

Official plan of correction

Administrator shall conduct staff training regarding AWOL risk residents twice a month till July 2024 and will send training documents to CCL. Outline of training shall be send to CCL by 05/24/24.

Deadline recorded: May 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by; Based on information of the incident for R1 and R2, R1 and R2, AWOL from the facility on 02/26/24. This poses a immediate risk to the health and safety of residents in care.

Official plan of correction

Licensee/administrator will send statement of understating of regulation 87411 and will do staff training regarding providing care and supervision to residents per their needs and service plan. All these documents shall be submitted to department by POC date-03/21/24.

Deadline recorded: Mar 21, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(D)

Regulation authority

CCR

What the official deficiency says

87211-Reporting Requirements(a) (D)- (a) Each licensee shall furnish to the licensing agency such reports as the Department….(D) Any incident which threatens the welfare, safety or health of any resident,…… unexplained absence of any resident…..This requirement is not met as evidenced by; Based on records review,it has been observed that facility did not report R1 and R2s AWOL incident for 02/26/24 to department as required which poses potential health and safety risks for residents in care.

Official plan of correction

Licensee/administrator will send statement of understating of regulation 87211 and will do staff training regarding reporting requirements as required by this regulation. All these documents shall be submitted to department by POC date-04/05/24.

Deadline recorded: Apr 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705-Care of Persons with Dementia- (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually.. this requirement is not met as evidence by; Record review and gathered information indicated that facility does not have updated Medical Assesment (LIC602) and Re-appriasal completed for R1 as required which poses a potenial risk to health and safety for residents in care.

Official plan of correction

Licensee/administartor shall complete medical assesment (LIC602) and re-appraisal for resident R1 as required and will send proof to department once completed. All POC documents are due by 04/05/24.

Deadline recorded: Apr 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(1)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: This requirement is not met as evidenced by: Deficient Practice Statement Based on observatios and staff interviews for medication audit, LPA learned that R1 and R2 have medications in their rooms and they have dementia diagnosis and cannot manage their medications per physicians orders, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/21/2024 Plan of Correction Facility will send a statement of understanding of this regulation and will do staff training for medication administration. All POC douments are due by 03/21/24.

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 record review and interviews it has been concluded that facility does not have Personnel form (LIC 501) for 3 staff out of 10, first aid and CPR certification for 3 out of 10 staff, and Health Screening/TB for 2 out of 10 staff files, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/15/2024 Plan of Correction Facility will complete the Personnel form (LIC 501) for 3 staff out of 10, first aid and CPR certification for 3 out of 10 staff, and Health Screening/TB for 2 out of 10 staff files, for all staff files as required and will send proof to Department once completed. All POC documents are due by 04/15/24.

Official classification

Type A

Official code

87411

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by; Based on records of the incidents for R1, R1 AWOL from the facility on 10/12/23 and on 11/01/23. This poses a immediate risk to the health and safety of residents in care.

Official plan of correction

Licensee/administrator will send statement of understating of regulation 87411 and will do staff training regarding providing care and supervision to residents per their needs and service plan. All these documents shall be submitted to department by POC date-11/29/23.

Deadline recorded: Nov 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(D)

Regulation authority

CCR

What the official deficiency says

87211-Reporting Requirements(a) (D)- (a) Each licensee shall furnish to the licensing agency such reports as the Department….(D) Any incident which threatens the welfare, safety or health of any resident,…… unexplained absence of any resident…..This requirement is not met as evidenced by; Based on records review,it has been observed that facility did not report R1s AWOL incident for 11/01/23 to department as required which poses potential health and safety risks for residents in care.

Official plan of correction

Licensee/administrator will send statement of understating of regulation 87211 and will do staff training regarding reporting requirements as required by this regulation. All these documents shall be submitted to department by POC date-12/12/23.

Deadline recorded: Dec 12, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(d)

Regulation authority

CCR

What the official deficiency says

87506-Resident Records- (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours…this requirement is not met as evidenced by; Facility did not provide requested documents to department related to resident, R1s elopement incident which were requested on 10/23/23,10/25/23 and 10/30/23 which poses a potential health and safety risks for residents in care.

Official plan of correction

Facility shall provide all requested documents for resident, R1 to the department by POC date, 11/02/23 by 5pm via E-FAX/E-MAIL. result in civil penalties. Failure to submit Proof of Correction (POC) by Plan of Correction date may result in civil penalties.

Deadline recorded: Nov 2, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464-Basic Services-(f)Basic services shall at a minimum include:(1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not as evidence by…. Based on record review and interviews, it has been concluded that facility did not provide proper care and supervision for R1 in which R1 sustained a fall on 02/14/2023 resulting in a fractured neck which poses an immediate health and safety risk for residents in care.

Official plan of correction

Licensee agrees to the following: Licensee will make sure to provide care and supervision to residents so residents care needs can be met per RCFE regulation 87464. Licensee shall submit letter of understanding of this regulation and staff training to CCL by POC date-08/18/23. Additionally, the facility will conduct monthly staff training to mitigate falls and injuries for residents and send weekly training records to CCL for next 90 days. Additionally, the facility will submit a plan on how the licensee will ensure staff are aware of all resident care needs.

Deadline recorded: Aug 18, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

80075(b)(5)(B)

Regulation authority

CCR

What the official deficiency says

80075 Health Related Services (b)(5)(B) - Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on record review from the facility, on 06/04/23, R1 was given medications, Fenofibrate 54mg- 1 tablet, and Fluoxetine 10 mg- 1 tablet by mistake from staff and these medications were not ordered by R1s physician which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/Administrator agreed to submit a self-certification in regard to providing medication training for all staff regarding medication administration and submit proof to LPA by POC date- 06/20/23.

Deadline recorded: Jun 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465

Regulation authority

CCR

What the official deficiency says

** amended** Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by records and interviews that found R1 and R1 did not received medications as prescribed and orders by their physicians. This posed an immediate health risk to residents.

Official plan of correction

In review of prior incident involving S1, statements indicated S1 has been retrained. Licensee will provide an assessment of why the errors by S1 occurred as well as specific retraining documentation for S1 by the POC date of 9/19/22

Deadline recorded: Sep 19, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(3)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (a)(3) When residents require prosthetic devices, vision and hearing aids, the staff shall be familiar with the use of these devices and shall assist such persons with their utilization as needed. This requirement was not met based on statements and records that R1's for a time did not require all of the assistance needed to manage their hearing aid.

Official plan of correction

Records indicate staff received inservice on May 2022. Licensee will submit the content or the in-service and staff that attended.

Deadline recorded: Sep 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department [...]: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident [...] (D) Any incident which threatens the welfare, safety or health of any resident [...] This requirement was not met as evidenced by: interviews and documentation reviewed. The licensee did not comply with the section cited above by not reporting incidents which threatened the welfare of R1. This poses a potential health, safety, and/or personal rights risk to residents in care.

Official plan of correction

Licensee to review section 87211 Reporting Requirements and send a letter of understanding to Community Care Licensing by 09/02/2022 by fax. Additionally, licensee to ensure incident reports are completely filled out and faxed to CCL.

Deadline recorded: Sep 2, 2022. A deadline is not proof that correction was completed.