FOUR SEASONS CARE HOME

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 as a residents medication was unlocked in the fridge which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/27/2026 Plan of Correction Licensee is to buy a lock box for medications that are to be stored in the fridge. Licensee will then send a picture to LPA via email showing that all medication is locked in the box.

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

(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 resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. 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 in three (3) out of three (3) residents are taking medication that are not listed on their current medication list which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/27/2026 Plan of Correction Licensee is to make a first attempt to reach out to all residents Physicians to get a current and updated medication list for all residents. Licensee will send the proof to LPA.

Official classification

Type B

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

(g) All personnel records shall be maintained at the facility. 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 as one staff is missing the LIC501 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/09/2026 Plan of Correction Licensee will have staff fill out the LIC501 and send to LPA. Additionally Licensee will audit all staff records to ensure they have all the current documents.

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. 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 multiple food items were found with expired dates which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/09/2026 Plan of Correction Licensee is to come up with a schedule of when they need to go through both the perishable and non perishable food items. Licensee will send this schedule to LPA. Additionally Licensee will go through all food items now to ensure there is no expired food.

Official classification

Type B

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 record review, the licensee did not comply with the section cited above in there is only one (1) staff on shift and they do not have CPR which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/09/2026 Plan of Correction Licensee is ensure all staff who are on shift alone are to be CPR certified. Licensee will send all CPR to certifications to LPA once completed.

Official classification

Type B

Official code

87405

Regulation authority

CCR

What the official deficiency says

87405-Administrator - Qualifications and Duties- (d) The administrator shall have the qualifications .......If the licensee is also the administrator, all requirements for an administrator shall apply.(1) Knowledge of the requirements ......(2)Knowledge of and ability to conform to the applicable laws, rules and regulations……this requirement is not met as evidence by; Based on facility's observations and staff's interviews, licensee/ administrator is not complying with applicable laws and regulations resulting in deficiencies and repeat violations which poses a potential health and safety risks to residents in care.

Official plan of correction

Licensee shall attend 8 hour training on Title 22 regulations no later than 08/05/2025. Licensee shall submit training completion documentation and submit to CCL by POC date.

Deadline recorded: Aug 5, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87207

Regulation authority

CCR

What the official deficiency says

False Claims - No licensee, officer or employee of a license shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This required is not met as evidenced by ... Although the Administrator has a current Admin certificate #7005884740 8/28/2024-8/27/2026; the Administrator certificate POSTED has the following altered information: #6019660740 8/28/2022-8/27/2025. The expiration in this case was altered to a later date. This poses a potential healthy and safety risk to residents in care.

Official plan of correction

Licensee shall print out and post the current Administrator certificate by POC due date 7/15/2025.

Deadline recorded: Jul 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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 staff was pre pouring residents medications for 7 days in advance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/09/2025 Plan of Correction Licensee shall send a letter of understanding of this regulation and shall conduct staff training regarding medication management . All POC documents are due by 07/09/25.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 as staff ,S1 does not have required health screening on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/22/2025 Plan of Correction Licensee shall send a letter of understanding of this Regulation and shall ensure that all staff have required health screening per Regulation . All POC documents are due by 07/22/25.

Official classification

Type B

Official code

1569.625(c)

Regulation authority

HSC

What the official deficiency says

(c) The training shall include, but not be limited to, all of the following: 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 as staff, S1 has records of on boarding and annual training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/22/2025 Plan of Correction Licensee shall send a letter of understanding of this Regulation and shall ensure that all staff have required on boarding and annual trainings per Regulations . All POC documents are due by 07/22/25.

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. 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 multiple food items were found with expired dates which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/22/2025 Plan of Correction Licensee shall send a letter of understanding of this Regulation, shall conduct staff training and shall ensure that facility does not have expired food items for residents. All POC documents are due by 07/22/25. Civil penalty of $250.00 was issued as this was repeat citation within 12 months.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on staff's interview and record review, the licensee did not comply with the section cited above as facility was not doing required fire and disaster quarterly drills which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/22/2025 Plan of Correction Facility shall conduct fire and disaster drills quarterly and will keep the record for Departmental review. All POC documents are due by 07/22/25. Civil penalty of $250.00 was issued as this was repeat citation within 12 months.

Official classification

Type B

Official code

87405

Regulation authority

CCR

What the official deficiency says

87405-Administrator - Qualifications and Duties- (d) The administrator shall have the qualifications .......If the licensee is also the administrator, all requirements for an administrator shall apply.(1) Knowledge of the requirements ......(2)Knowledge of and ability to conform to the applicable laws, rules and regulations……this requirement is not met as evidence by; Based on record review and staff's interviews, facility does not have a qualified Administrator which poses a potential health and safety risks to residents in care.

Official plan of correction

Licensee shall hire a qualified administrator and shall notify Department by POC date-10/31/24 . Furthermore, if Licensee wishes to work as administrator, Licensee shall fulfill all required compents and shall renew thier administrator's certificate per Department guidelines.

Deadline recorded: Oct 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can 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: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on medications count, record review and staff's interviews, it was noted that for resident, R2- No update medications order list for resident R2 for 2024 in thier file, Expired Eye Drops x4 bottles, Aspirin 81mg (wrong medication), Alendronate Sodium Tablet-70mg-1tablet every friday with start date 06/17/24, sholud have 5 tablets out of 12 but count was 8 tablets ON HAND and FOR R1- Bupropion HCL 150MG-1 tablet twice a day with start date 05/21/24,180 tablets filled 05/21/24, count was OVER 69 tablets ,Simvastin 20 mg, 100 tablets filled on 05/17/24, start date- 05/17/24, 19 tablets extra during today's count which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2024 Plan of Correction Administrator shall send a letter of understanding of this Regulation by 08/09/24 to Department and shall ensure to have updated Med List for all residents, shall keep proper record of Centrally Stored Log for all medications. All POC documents are due by 08/09/24.

Official classification

Type B

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 LPAs observations, facility has one fire extinguisher which was last serviced in 2022 which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2024 Plan of Correction The Licensee agrees to have the fire extinguisher serviced and will send a receipt and/or photograph of the fire extinguisher having been serviced. The receipt/photograph will be due by the POC due date - 08/22/24.

Official classification

Type B

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 LPA observed that facility's laundry room has no lock on the door and has disinfectants, cleaning solutions which were accessible to residents and poses a potential health and safety risks to residents in care.

Official plan of correction

POC Due Date: 08/22/2024 Plan of Correction Licensee will send the letter of understanding of this regulation and will train staff regarding this regulation and will send training documents to CCL. POC due date - 08/22/24.

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations in pantry and kittchen area, LPA found mulpile food items with expired dates which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/22/2024 Plan of Correction Administrator shall submit a letter of understanding of this Regulation to CCL and ensure that all expired food items will be removed. Addiontionaly, facility shall ensure that plan will be implemented to remove all expired food items in future. All POC documents are due by 08/22/24.

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 staff's interview and record review, the licensee did not comply with the section cited above as LPA found , Missing Consent Form, Pre-Admission Appraisal, Personal Belongings form, Personal Rights Form for Resident,R1 file and Missing Consent Form, Personal Belongings form, Personal Rights Form for Resident,R2 file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/31/2024 Plan of Correction Administrator will send a letter of understanding of this Regulation and will ensure that all residents files have all required documents per this Regulation and send proof to CCL once completed. All POC documents are due by 08/31/24.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on staff's interview and record review, the licensee did not comply with the section cited above as facility was Not doing required fire and disaster quarterly drills which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/08/2024 Plan of Correction Facility shall conduct fire and disaster quarterly drill and will keep the record for Departmental review. All POC documents are due by 09/08/24.

Official classification

Type B

Official code

87406(g)

Regulation authority

CCR

What the official deficiency says

87406(g)- Administrator Certification Requirements. Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements. This requirement is not met as evidence by; The administrator certificate for Ioan Nagy expired on 08/07/2020 (#6019660740) and was not put in for renewal till date (08/29/23). This is a potential risk to the health and safety of the residents in care.

Official plan of correction

By 09/28/23, the licensee shall appoint an administrator with a current administrator's certificate until Mr. Nagy’s Administrator certificate is approved. Licensee shall submit newly appointed Administrator and an updated LIC500 and LIC308 to CCL by POC date-09/28/23.

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

Official classification

Type B

Official code

87412(b)

Regulation authority

CCR

What the official deficiency says

(b) Personnel records shall be maintained for all volunteers and shall contain the following: This requirement is not met as evidenced by: Deficient Practice Statement During file review, LPA observed that S2 file missing LIC501,LIC503,TB test ,LIC9052 as required which poses a potential health risks to residents in care.

Official plan of correction

POC Due Date: 08/15/2023 Plan of Correction Licensee shall complete all required documents for S2 file per this regulation and send a copy to CCL by POC date-08/15/23.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement During file review, LPA observed that S2 file missing annual training as required which poses a potential health risks to residents in care.

Official plan of correction

POC Due Date: 08/15/2023 Plan of Correction Licensee shall complete all required annual training for S2 file per this regulation and send a copy to CCL by POC date-08/15/23.

Official classification

Type B

Official code

1569.696(a)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: This requirement is not met as evidenced by: Deficient Practice Statement During file review, LPA observed that S2 file missing training for above section(s) as required which poses a potential health risks to residents in care.

Official plan of correction

POC Due Date: 08/15/2023 Plan of Correction Licensee shall complete all required training for S2 file per this regulation/section and send a copy to CCL by POC date-08/15/23.

Official classification

Type B

Official code

87464(d)

Regulation authority

CCR

What the official deficiency says

(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This requirement is not met as evidenced by: Deficient Practice Statement During file review for R2, LPA observed that R2 file missing pre-admission appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2023 Plan of Correction Licensee shall complete pre-admission appraisal for R2 file per this regulation/section and send a copy to CCL by POC date-08/15/23.

Official classification

Type B

Official code

87412(a)(13)(B)

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: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 1. For Certified Administrators, a copy their current and valid Administrative Certification meets this requirement. This requirement is not met as evidenced by: Deficient Practice Statement During annual inspection on 08/04/22, LPA found that facility administrator has expired administartor certificate- Ioan Nagy (#6019660740, 08/07/20)

Official plan of correction

POC Due Date: 09/04/2022 Plan of Correction Licensee agrees to submit in the required documentation to associate an Administrator with an active/current administrator certificate to the facility to LPA by 09/04/22.