ABUNDANT PEACE

Official classification

Type A

Official code

87777(a)

Regulation authority

CCR

What the official deficiency says

87777(a) Exclusions The Department may prohibit an individual from serving as a board of directors, executive director, or officer; being employed or allowed in a licensed facility as specified in Health and Safety Code Sections 1569.58 and 1569.59. This requirement was not met as evidenced by: The facility did not ensure excluded individuals (E1) and (E2) were prohibited from being at a licensed facility. (E1) and (E2) were observed at the facility on multiple occasions.

Official plan of correction

Effective immediately, all excluded individuals are prohibited from entering or being present at the licensed facility. The Administrator stated that they will ensure no excluded individual is permitted to work, provide services, visit, or otherwise be present at the facility or have any contact with residents or staff. The Administrator will submit a written plan to CCLD outlining the procedures that will be implemented to ensure excluded individuals are not allowed to work, provide services, interact with residents or staff, or enter the facility in the future. An immediate civil penalty in the amount of $500 was assessed during today's visit

Deadline recorded: Aug 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(d)

Regulation authority

CCR

What the official deficiency says

87464(d) Basic Services (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 was not met as evidence by: Based on interviews with two facility staff who both stated that they were not aware of R1 who need supervision for safety in regard to repositing, transferring and toileting needs as well as wondering behavior. This posed a potential health and safety risk to residents.

Official plan of correction

Licensee/facility staff will review all residents in care LIC 602 Physician’s report to ensure understanding of all resident’s needs. An in-service training course for all staff in regard to basic services will be conducted. Documents used for training and staff sign-in sheets along with statement of reviewing and understanding the regulation cited will also be provided to LPA Lee by POC due date 10/30/2025 end of day.

Deadline recorded: Oct 30, 2025. 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

7211(a)(1)(D) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below… (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidence: Based on file reviewed, CCLD electronic facility files and interviews, the Licensee did not ensure to submit R1’s incident reports to CCLD. This posed an immediate health and safety risk to R1.

Official plan of correction

The licensee/staff agrees to conduct an in-service training course for all staff in regard to reporting requirements that will be conducted. Documents used for training and staff sign-in sheets along with statement of reviewing and understanding the regulation cited will also be provided to LPA Lee by POC due date 10/30/2025 end of day.

Deadline recorded: Oct 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405(a) Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility… This was not met as evidence by: Based on interviews, observation and visits to the facility, the Administrator has not at facility. It was learned that administrator Barbara Williams has not been present at the facility since LPA Lee’s visit on 08/05/2025 and is not carrying out administrator duties. This posed a potential health and safety risk to residents.

Official plan of correction

Licensee/facility agrees to appoint/assign an Administrator by 10/27/2025. Implement a temporary point of contact/Admin by10/24/2025. Admin documents and Temporary admin information should be emailed to LPA Lee by 10/24/2025 by 5:00 PM. A statement of reviewing and understanding the regulation cited will also be provided to LPA Lee by POC due date 10/27/2025 end of day.

Deadline recorded: Oct 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)(1)

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. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation during the garage inspection, the door was found to be unlocked, and multiple toxic substances were accessible to residents. These included multipurpose cleaner, tire shine spray, five paint cans, two toilet bowl cleaners, a Comet deodorizing cleanser, and a super oxygen bathroom cleaner. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2025 Plan of Correction The licensee will conduct storage space and access in-service training. Material used for training, staff sign in sheet and statement of acknowlegement of reading and understanding the regulation cited will be provided to LPA Lee by POC date 10/31/2025 end of day 5:00 PM.

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 observations Medication storage was found to be unlocked and accessible to residents, which is not in compliance with regulations, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2025 Plan of Correction The licensee will conduct Incidental Medical and Dental Care Services in-service training. Material used for training, staff sign in sheet and statement of acknowlegement of reading and understanding the regulation cited will be provided to LPA Lee by POC date 10/31/2025 end of day 5:00 PM.

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 observed the facility is not in good repair due to broken tiles in the kitchen that posed a tripping hazard. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/31/2025 Plan of Correction The licensee will conduct maintenance and operation in-service training and material used for training, staff sign in sheet and statement of acknowlegement of reading and understanding the regulation cited will be provided to LPA Lee by POC date 10/31/2025 end of day 5:00 PM. Per Assistant Administrator Taqasi who stated that he has already purchased tiles and that maintience will be on site today 10/31/2025 to start repair. POC will be cleared by visit.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464(f)(1) 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 met as evidenced by: Based on interviews, the licensee did not ensure care and supervision needs were provided on July 10, 2025, when the administrator left the facility resulted in absence of care and supervision for longer than 1 hour 10 minutes. This poses/posed an immediate health and safety risks to residents in care

Official plan of correction

License/Administrator to submit a written care plan on how the facility will provide adequate care and supervision for residents in care. Licensee/Administrator will also conduct in-service training on basic services and provide training documents used, and staff sign in sheet. A statement of acknowledgement of reading and understanding the regulation cited will also be provided to LPA Lee. The facility shall submit the care plan and statement to Licensing by POC due date of 08/12/2025 end of day 5:00 PM.

Deadline recorded: Aug 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)

Regulation authority

CCR

What the official deficiency says

87355(e) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to the Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by: Based on interviews and records reviews, the licensee/administrator did not ensure that the administrator’s husband (DW) is associated with the facility prior to visiting the facility on multiple occasions.

Official plan of correction

The License/Administrator will conduct in-service training on criminal record clearance and association and provide training documents used, and staff sign in sheet. Administrator/Licensee will also provide a statement of acknowledgement of reading and understanding the regulation cited will also be provided to LPA Lee. The facility shall submit R1’s complete file for LPA Lee to review once completed and a statement to Licensing by POC due date of 08/12/2025 end of day 5:00 PM.

Deadline recorded: Aug 12, 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

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: Based on interviews, the administrator provided false statements to LPA Lee and Ombudsman Toliver. This poses/posed a potential health and safety risks to residents in care.

Official plan of correction

License/Administrator will provide a statement of acknowledgement of reading and understanding the regulation cited by POC due date of 08/19/2025 end of day 5:00 PM.

Deadline recorded: Aug 19, 2025. 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

87405(d)(2) Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on interviews and records reviews the administrator did not conform to title 22 regulations when administrator left residents in care unsupervised, incidents reports are not reported to CCLD and responsible party, providing false statement and allowing an individual at the facility without being associated to the facility. This poses/posed a potential health and safety risks to residents in care.

Official plan of correction

License/Administrator will provide a statement of acknowledgement of reading and understanding the regulation cited by POC due date of 08/19/2025 end of day 5:00 PM.

Deadline recorded: Aug 19, 2025. 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(a) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified… (D) Any incident which threatens the welfare, safety or health of any resident… This requirement is not met as evidenced by: Based on interviews and records reviews, the licensee/administrator is not reporting incident reports to CCLD. This poses/posed a potential health and safety risks to residents in care.

Official plan of correction

The License/Administrator will conduct in-service training on reporting requirements and provide training documents used, and staff sign in sheet. Administrator/Licensee will also provide a statement of acknowledgement of reading and understanding the regulation cited will also be provided to LPA Lee. The facility shall submit statement to Licensing by POC due date of 08/19/2025 end of day 5:00 PM.

Deadline recorded: Aug 19, 2025. 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(d) Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by: Based on interviews and records reviews, the licensee/administrator did not ensure that R1 has a complete file on site for LPA Lee and Ombudsman Toliver to review. This poses/posed a potential health and safety risks to residents in care.

Official plan of correction

The License/Administrator will conduct in-service training on resident records and provide training documents used, and staff sign in sheet. Administrator/Licensee will also provide a statement of acknowledgement of reading and understanding the regulation cited will also be provided to LPA Lee. The facility shall submit R1’s complete file for LPA Lee to review once completed and a statement to Licensing by POC due date of 08/19/2025 end of day 5:00 PM.

Deadline recorded: Aug 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

87465(a)(1) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews conducted, Administrator Williams did not assist Resident 1 (R1) in a timely manner after R1 experienced a fall and was unable to get up.

Official plan of correction

The Administrator has agreed to conduct an in-service training on Incidental Medical and Dental Care. As part of the Plan of Correction (POC), the Administrator will provide LPA Lee with the following documentation: Training materials used during the session, a sign-in sheet listing all staff members who attended the training and a written statement of acknowledgment confirming administrator have read and understood the cited regulation. The completed POC is due to LPA Lee by August 12, 2025, no later than 5:00 PM.

Deadline recorded: Aug 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(d)(4)

Regulation authority

CCR

What the official deficiency says

87307(d)(4) Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement is not met as evidenced by: PA Lee observed ramps that were put in place in the patio were not sturdy and a tripping hazards. This posed an immediate risk to residents in care.

Official plan of correction

Licensee will ensure that the there are no tripping hazards, side rails will be added to the patio for safety of the residents and fence are to be sturdy. POC will be clear by visit. POC due by 05/23/25 end of day 5:00 PM.

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

Official classification

Type A

Official code

87311

Regulation authority

CCR

What the official deficiency says

87311 Telephones All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility. This requirement is not met as evidenced by: LPA Lee observe telephone on the premises does not have services. This posed an immediate risk to residents in care.

Official plan of correction

Licensee will ensure to have telephone services on the premises. POC will be cleared by visit. POC due by 05/23/25 end of day 5:00 PM.

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

Official classification

Type B

Official code

87212(c)

Regulation authority

CCR

What the official deficiency says

87212(c) Emergency Disaster Plan (c) Emergency exiting plans and telephone numbers shall be posted. This requirement is not met as evidenced by: LPA Lee did not observe an emergency telephone number posted in the facility. This posed a potential risk to residents in care.

Official plan of correction

Licensee will post emergency telephone numbers in the facility and made visible. Licensee will send LPA Lee pictures of the emergency telephone numbers being posted by 05/23/25 end of day 5:00 PM.

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

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) 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: LPA Lee observed exposed wires in the common area by the television. This posed a potential risk to residents in care.

Official plan of correction

Licensee will remove the exposed wires for the safety of the residents in care. POC will be cleared by visit. POC due by 05/23/25 end of day 5:00 PM.

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

Official classification

Type B

Official code

87208(a)(7)(A)

Regulation authority

CCR

What the official deficiency says

87208 Plan of Operation The licensee shall have and maintain a current, written definitive plan of operation for the facility… (7) Sketches, showing dimensions, of the following: (A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents… This requirement is not met as evidenced by: LPA Lee observed that one of the resident’s bedrooms was switched with the staff room based on observation and facility sketch that was submitted to the department. This posed a potential risk to residents in care.

Official plan of correction

Licensee will ensure that the submitted facility sketch is maintained and accurate at all times. Licensee will review the submitted facility sketch and ensure that residents and staff room are switched and accurate. POC will be cleared by visit. POC due by 05/23/25 end of day 5:00 PM.

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

Official classification

Type B

Official code

87219(i)

Regulation authority

CCR

What the official deficiency says

87219(i) Planned Activities (a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include This requirement is not met as evidenced by: LPA Lee did not observe multiple activities, equipment and supplies for residents. LPA Lee only observed books and a guitar. This posed a potential risk to residents in care.

Official plan of correction

Licensee will ensure that there are multiple activities and equipment made available to residents in care. POC will be cleared by visit. POC due by 05/23/25 end of day 5:00 PM.

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