LEGACY LANE SENIOR LIVING

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: Jul 30, 2026. 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(a) 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 was not met as evidence by: Based on observations two of the facility refrigerators were dirty and unsanitary. A kitchen cabinet was observed broken. This posed a potential health and safety risk to residents in care.

Official plan of correction

The Administrator Tuikenatabua agrees to conduct weekly refrigerator check and clean to ensure that the refrigerators are clean at all times. Log starting today 05/12/2026 to the end of the month will be email to LPA Lee by 05/30/3036 end of day 5:00 PM.

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

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

1569.695(c) Emergency Plans (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… This requirement was not met as evidence by: Based on record review and an interview with Administrator Tuikenatabua, the facility did not ensure quarterly fire drills were conducted, which poses a potential health and safety and/or personal rights risk to persons in care.

Official plan of correction

Administrator Tuikenatabua agreed to conduct and document fire drills every three (3) months on the facility’s fire drill log. Administrator will conduct a fire drill for the month of May 2026 and continue conducting drills every three (3) months thereafter. Proof of the completed May fire drill for 2026, along with a statement acknowledging review and understanding of the cited regulation, will be emailed to LPA Lee by 05/22/2026 by the end of the day.

Deadline recorded: May 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

569.625(b)(2) Staff training; legislative findings; contents (b) (1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours… (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… This requirement was not met as evidence by: LPA Lee reviewed five (5) of five (5) resident files and observed them to be complete. LPA Lee also reviewed three staff files and found one file incomplete. At the time of record review Staff 1’s (S1) file did not contain documentation of employee orientation or the required 40 hours of training completed prior to working at the facility. S1’s employment date was 12/01/2025. Approximately two hours later, Licensee Cleopatra Gardiner texted Administrator Tuikenatabua a photograph of S1’s orientation and 40-hour training documentation. Administrator Tuikenatabua did not have in his file the 20 additional hours of continual training for the year 2025. This poses potential health and safety and/or personal rights risk to persons in care.

Official plan of correction

The Administrator Tuikenatabua agrees to ensure that all staff have 20 additional hours of continual training each year. A statement acknowledging review and understanding of the cited regulation will be emailed to LPA Lee by 05/22/2026 by the end of the day.

Deadline recorded: May 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211(a)(1) 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… This requirement was not met as evidence by: LPA Lee reviewed the facility’s incident binder and compared it with the Regional Electronic Facility File. Based on records reviewed, there were two incidents in March 2026, with only one reported; three incidents in April 2026, with only one reported; and one incident in May 2026, as of 05/12/2026, which had not been reported, which poses a potential health and safety and/or personal rights risk to persons in care. This poses potential health and safety and/or personal rights risk to persons in care.

Official plan of correction

Administrator agrees to send LPA Lee LIC 626/incident reports and to review the applicable 22 CCR sections regarding reporting requirements, and to send LPA Lee a signed statement acknowledging these requirements by POC due date 05/22/2026 end of day 5:00 PM.

Deadline recorded: May 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

7203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: LPA Lee inspected the fire extinguisher and observed that it was last serviced on 03/26/2025, which poses an immediate health and safety and/or personal rights risk to persons in care.

Official plan of correction

Administrator will get the fire extinguisher serviced no later than tomorrow 05/13/2026 and provide LPA Lee proof of service along with a statement acknowledging and understanding of the cited regulation emailed to LPA Lee by 05/13/2026 by the end of the day.

Deadline recorded: May 13, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(3) 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: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature... This was not met as evidenced by: LPA Lee observed the facility had sufficient food supplies to meet the required two-day perishable and seven-day nonperishable food supply requirements at the time of the visit. However, it was learned that the seven-day nonperishable food supply was being stored in the locked garage. Per Administrator Tuikenatabua, the food was locked due to a previous resident who wanders at night to eat. This poses an immediate health and safety and/or personal rights risk to persons in care.

Official plan of correction

The Administrator will ensure that pantry will not be locked and a statement acknowledging review and understanding of the cited regulation will be emailed to LPA Lee by 05/22/2026 by the end of the day.

Deadline recorded: May 22, 2026. 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

87465(c)(2) Incidental Medical and Dental Care (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: LPA Lee reviewed medications and medication administration records (MARs) for three residents and found discrepancies involving two residents. Resident 1 (R1) had two creams, Hydrocortisone 2.5% and Clotrimazole 1%, present at the facility; however, only Hydrocortisone 2.5% was listed on the MAR. Administrator Tuikenatabua stated that Clotrimazole 1% had been discontinued, but no documentation supporting the discontinuation was available. This poses an immediate health and safety and/or personal rights risk to persons in care.

Official plan of correction

he Administrator will ensure that physician orders are followed at all times and ensure that the residents of MAR log are current and accurate at all times. In addition, the administrator will ensure that all residents medication is being administered not out of sequence and following the correct week per the bubble pack instructions. A statement acknowledging review and understanding of the cited regulation will be emailed to LPA Lee by 05/22/2026 by the end of the day.

Deadline recorded: May 22, 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

87309(a) Storage Space and Access (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: Based on observation, the Administrator did not comply with the section cited above. LPA Lee observed toxins and sharp knives unlocked and made accessible to residents in care. This poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Administrator agrees to put a locked cabinet in the garage to store the chemicals and sharp knives and have it locked at all times. Administrator will email LPA Lee photo of the cabinet with the chemicals and knives by 05/22/2026 end of day 5:00 PM.

Deadline recorded: May 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

" 87355 Criminal Record Clearance (e) All individuals subject to a criminal record ... (2) Obtain a California clearance or a criminal record exemption as required by the Department or... " This requirement was not met as evidenced by: Based on interviews the facility staff did not comply with the section cited above due to unassociated and excluded persons having been present in this facility. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee and admnisitrator stated P1 and P2 will not return to the facility without clearances. By POC due date, licensee/ administrator will submit a sworn statement of understanding of regulation 87355.

Deadline recorded: Dec 5, 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 Administrator - Qualifications and Duties d) The administrator shall ... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. " This requirement was not met as evidenced by: Based on interviews, record review, observations, Administrator did not ensure all adults entering gthe facility shall have a criminal record clearance or exemption. P1 and P2 are not associated to the facility nor is there any personnel records for them at the facility.

Official plan of correction

By POC due date, licensee/ administrator will submit a sworn statement of understanding of regulation 87405.

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

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish… (1) A written report ... to the licensing agency and to the person responsible …(D) Any incident which threatens the welfare, safety or health of any resident … this requirements was not met as evidenced by staff not reporting suspected abuse that was reported to them by resident 1(R1) on the week of 9/19/25. Additionally, staff did not complete the required SOC 341 form and failed to complete a telephone report shall be made to the local law enforcement agency within 24 hours of the mandated reporter observing, obtaining knowledge of, or suspecting the physical abuse, and a written report shall be made to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator submitted LIC 624 to LPA Tamayo on 9/29/25. By POC due date, Licensee will submit a sworn statement of review and understanding of regulation 87211 Reporting Requirements in addition to a plan to train all staff on mandated reporter requirements. POC can be submitted to cynthia.tamayo@dss.ca.gov.

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

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents ... All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirements was not met as evidenced by interview and observations made of staff not ensuring that resident's dietary needs are met. Additionally, It was observed that in between-meal nourishment or snacks were not made available for all residents in care. This poses an immediate health and safety risk to residents in care.

Official plan of correction

By POC due date, Licensee will submit a sworn statement of review and understanding of regulation 87555 General Food Service Requirements in addition to a plan to ensure that resident's dietary needs are met and all foods shall be selected, stored, prepared and served in a safe and healthful manner. ADministrator also stated new cooking staff will be hired. POC shall be submitted to Cynthia.tamayo@dss.ca.gov

Deadline recorded: Dec 12, 2025. 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

87309 Storage Space and Access(a) Except as specified in subsection (b) ... disinfectants, cleaning solutions, poisonous substances ... and other similar items ...are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidenced by LPA observations of cleaning supplies unsecured and acessible to residents in care which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Facility has agreed to lock disinfectants, cleaning solutions, poisonous substances, and medications etc. located in the garage and conduct training for all staff members. Licensee will provide training materials to the department by The POC due date.

Deadline recorded: Sep 30, 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 was not met as evidenced by LPA observations of kitchen exhaust fan not working properly which poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Licensee will have exhaust fan repaired by POC due date. Licensee will send maintenece work order/invoice to LPA Tamayo at cynthia.tamayo@dss.ca.gov by POC due date.

Deadline recorded: Oct 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a) all facilities shall have a qualified and currently certified administrator ...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 as specified ... When the administrator is not in the facility ... a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities... This requirement was not met as evidenced by facilities not having a qualified administrator, this poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Facility must designate a qualified administrator to facility at all times. Licensee will submit an updated LIC 308,provide a statement of review and understanding for 87405(a), and a plan to ensure there is always a qualified Administrator to LPA by POC due date.

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

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain ... This requirement was not met as evidenced by facilities not a record available for all working staff , this poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Licensee will submit a statement of review and understanding for 87412(a) and a plan to ensure there is always a personnel record for all past and future staff and volunteers effective by POC due date. Licensee will also ensure all on-call/ back up staff are listed on all future LIC 500 Personnel Record forms

Deadline recorded: Oct 3, 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 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator ... there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management .. This requirement was not met as evidenced by facilities not having a qualified and currently certified administrator, this poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Original POC dated 6/30/25 was not completed by POC due date. CP was issued on 7/23/25 for Failure to Correct. Another CP was issued 8/12/25 for failure to correct. Facility will designate a qualified administrator to facility at all times by POC due date.

Deadline recorded: Aug 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87309(b)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space and Access: 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 was not met as evidenced by LPA observations of bleach, cleaning supplies unsecured and acessible to residents in care which poses a potential ealth, safety and personal rights risk to residents in care.

Official plan of correction

POC dated 6/30/25 was not completed by POC due date. Licensee conduct a training regarding 87309 Storage Space and Access for all staff members. Licensee will provide training materials to the department by The POC due date.

Deadline recorded: Aug 11, 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 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator ... there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management .. This requirement was not met as evidenced by facilities not having a qualified and currently certified administrator, this poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

POC dated 6/30/25 was not completed by POC due date. Facility will designate a qualified administrator to facility at all times by POC due date.

Deadline recorded: Aug 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (e) Water supplies... (2) Hot water temperature controls shall be maintained to .... 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 record review and interview, this requirement was not met as evidenced by kitchen faucet water is 98 degrees F. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee will schedle maintenace to regulate water temperature attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C) by POC due date.

Deadline recorded: Aug 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

Storage Space and Access: 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 was not met as evidenced by LPA observations of bleach, cleaning supplies unsecured and acessible to residents in care which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Facility has agreed to: lock cabinets containing disinfectants, cleaning solutions, poisonous substances, etc. and conduct training for all staff members. Licensee will provide training materials to the department by The POC due date.

Deadline recorded: Jul 7, 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 Administrator - Qualifications and Duties a) All facilities shall have a qualified and currently certified administrator ... there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management .. This requirement was not met as evidenced by LPA observations of administrator not being in the facilty for over a month with no known return date, this poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Facility has agreed to: Communicate with LPA Tamayo to inform CCL of Administrator return date. Assign a qualified certified administrator during Administrator absence.

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

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency …(1) A written report shall be submitted to the licensing … within seven days of the occurrence…(A) Death of any resident from any cause regardless of where the death occurred, including … a hospital. Based on record review and interview, this requirement was not met as evidenced by licensee not submitting a written death report to Community Care Licensing within seven days of the occurrence. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee failed to correct Deficiency cited on 6/13/25 by POC due date on 6/27/25. Licensee agrees to send timley reports and provide verification of review and understanding of regualtion 87211 to LPA Cynthia Tamayo by POC due date at cynthia.tamayo@dss.ca.gov . A Civil Penality is assessed for failure to correct.

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

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (e) Water supplies... (2) Hot water temperature controls shall be maintained to .... 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 record review and interview, this requirement was not met as evidenced resident bathroom faucet measuing 144 degrees F and kitchen faucet water is measured at 98 degrees F. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee will schedle maintenace to regulate water temperature attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C) by POC due date.

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

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician...and the label shall contain...information. This requirment was not met as evidenced by: Over the counter medication that are not prescribed by resident's doctor was administered to resident on 6/29/25 which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Facility agrees to submit an SIR for medication administration error. Licensee will provide training materials to the department by The POC due date.

Deadline recorded: Jul 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (c)... facility staff designated by the licensee shall be permitted to assist the resident with self-administration...(3)A record of each dose is maintained in the resident's record... the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirment was not met as evidenced by: Staff signed off that resident received a prescribed medication from 6/22-6/31/5 even though they did not administer medications, as the medication were done by 6/21/25. which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Licensee will submit an SIR to Community care Licenseing for medication administration errors. Licensee will conduct training for all staff members and provide training materials to the department by The POC due date.

Deadline recorded: Jul 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(c)

Regulation authority

CCR

What the official deficiency says

87507 Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative ...no later than seven days following admission... This requirment was not met as evidenced by incomplete resent records which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Resident records for all residents will be filled out, signed, and dated by POC due date and submitted to LPA Tamayo via email.

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

Official classification

Type B

Official code

87211(a)(1)(A)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency …(1) A written report shall be submitted to the licensing … within seven days of the occurrence…(A) Death of any resident from any cause regardless of where the death occurred, including … a hospital. Based on record review and interview, this requirement was not met as evidenced by licensee not submitting a written death report to Community Care Licensing within seven days of the occurrence. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee agrees to send timley reports and provide verification of review and understanding of regualtion 87211 to LPA Cynthia Tamayo by POC due date at cynthia.tamayo@dss.ca.gov

Deadline recorded: Jun 27, 2025. 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

Storage Space and Access: 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 was not met as evidenced by LPA observations of bleach, cleaning supplies and one sharp knife unsecured and acessible to residents in care which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Facility has agreed to: Facility has agreed to conduct training for all staff members and will provide training materials to the department by The POC due date.

Deadline recorded: May 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by Reported elopement of resident who has been determined by their physician that they cannot leave the facility unassisted which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

facility has agreed to: Facility has agreed to provide a written plan of correction to address staffing and ensure appropriate levels of staffing and ensure overnight supervision.

Deadline recorded: May 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia: For facilities with fewer than 16 residents, ensuring there is at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal, or observation, to require awake night supervision. This requirement is in addition to requirements specified in Section 87415, Night Supervision. This requirement was not met as evidenced by Statements obtained from the licensee that there are no awake staff scheduled daily during overnight hours and confirmed by staff schedules and statements obtained from staff members present which poses an immediate health safety and personal rights risks to residents in care.

Official plan of correction

facility has agreed to: Facility has agreed to provide a written plan of correction to address staffing and ensure appropriate levels of staffing and ensure overnight supervision.

Deadline recorded: May 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: 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 was not met as evidenced by, LPAs observations of insulin medication being stored in a fridge in the garage that was not made inacessible to residents in care wich poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

LPA observed a lock back be delivered to the facility. LPA will clear deficiency.

Deadline recorded: Mar 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(2)

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: (2) Bedridden persons This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above in. It was learned that there is a resident who is bedridden; however, the facility is not fire clear for bedridden residents. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/21/2025 Plan of Correction Licensee stated she is going to have resident re-assed and will talk to family members and find new placement for resident. Licensee will review the regulation cited and provide LPA Lee a statement of acknowledgement of understanding the regulation cite. POC due to LPA Lee by 02/21/25 end of day 5:00 PM.