GREEN MERRYLANDS

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation the licensee did not comply with the section cited above maintenance and operation, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/22/2026 Plan of Correction Licensee will ensure facility is clean,sanitary and in good repair for residents in care by repairing the sink cabinet, lights in laundry room, water filter leakage in garage-mold on the wall, by POC due date and evidence/invoice to be sent to LPA Singh via email by the Plan of Correction(POC) due date 1/21/2026.

Official classification

Type A

Official code

87303(a)(1)

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.(1) Floor surfaces in bath, laundry and kitchen and facility areas shall be maintained in a clean, sanitary, and odorless condition. Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that floor surfaces in bath, and facility areas shall be maintained in a clean, sanitary, and odorless condition. which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will ensure facility is clean,sanitary and in odorless condition for residents in care by deep cleaning/sanitizing the facility done by POC due date and evidence to be sent to LPA Singh via email by the Plan of Correction(POC) due date 12/12/2025.

Deadline recorded: Dec 12, 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.... (a) 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: Facility staff failed to seek a higher level of care for R1’s pressure injurie[s] which multiplied while in care. The facility staff failed to inquire, assess the number, and seriousness of the pressure ulcers to determine if the level of care being provided to R1 was adequate, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

The Licensee shall ensure that Personnel Requirements are met daily. Staff shall always ensure that residents are receiving care to meet their needs. If a resident need cannot be met, then a higher level of care may be needed. Hospice care shall not relieve staff of their duties. Proof of understanding shall be provided, and emailed to LPA by POC date 8/14/2025.

Deadline recorded: Aug 14, 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) 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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. 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 by not ensuring that one (1) screwdriver and two (2) gallons of laundry detergent in the laundry room, are locked and not accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/08/2024 Plan of Correction Licensee stated to submit Signed Statement of Understanding on CCR 87309(a)(1) to LPA Brown on Plan of Correction (POC) due date.

Official classification

Type A

Official code

1569.618(a)

Regulation authority

HSC

What the official deficiency says

(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the facility has an Administrator during normal working hours as required which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/08/2024 Plan of Correction Licensee stated to hire an additional administrator for the facility and submit Signed Statement of Understanding on HSC 1569.618(a) to LPA Brown on POC due date. *** This is an amended copy of LIC809 issued on 08/07/2024 due to new form LIC421IM issued today w/ amount of $1000.00. Form LIC421FC with the amount of $250.00 issued on 08/07/2024 will be deleted.***

Official classification

Type A

Official code

87411(d)

Regulation authority

CCR

What the official deficiency says

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above by not having the required on the job training and/or related experience in the job for Staff #2 (S2), Staff #3 (S3) and Staff #4 (S4) which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/08/2024 Plan of Correction Licensee stated to submit the required on the job training and/or related experience in the job for Staff #2 (S2), Staff #3 (S3) and Staff #4 (S4) to LPA Brown on Plan of Correction (POC) due date.

Official classification

Type A

Official code

1569.625(b)(1)

Regulation authority

HSC

What the official deficiency says

(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, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. 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 by not ensuring that Staff #3 (S3) and Staff #4 (S4) complete the required Residential Care for the Elderly (RCFE) 40 hours of training which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/08/2024 Plan of Correction Licensee stated to submit S3 and S4 enrollment on the required RCFE 40 hours of training to LPA Brown on POC due date.

Official classification

Type A

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 Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) and Staff #4 (S4) completed the required dementia training annually which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/08/2024 Plan of Correction Licensee stated to submit Signed Statement of Understanding on HSC1569.625(b)(2) and submit to LPA Brown on Plan of Correction (POC) due date.

Official classification

Type A

Official code

1569.626(a)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) and Staff #4 (S4) at the facility completed the required dementia training which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/08/2024 Plan of Correction Licensee stated to submit proof of enrollment of all staff on the required dementia training to LPA Brown on POC due date.

Official classification

Type A

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 Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 and Staff #4 completed the required postural supports, restricted conditions or health services, and hospice care training which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/08/2024 Plan of Correction Licensee stated to submit proof of S3 and S4 training enrollment on postural supports, restricted conditions or health services, and hospice care to LPA Brown on Plan of Correction (POC) due date.

Official classification

Type A

Official code

87465(a)(8)

Regulation authority

CCR

What the official deficiency says

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

Official plan of correction

POC Due Date: 08/08/2024 Plan of Correction Licensee stated to obtain/purchase first aid kit and submit proof to LPA Brown on POC due date.

Official classification

Type A

Official code

87465(a)(8)(A)

Regulation authority

CCR

What the official deficiency says

(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. 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 by not ensuring that the facility has a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/08/2024 Plan of Correction Licensee stated to obtain/purchase a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency and submit proof to LPA Brown on Plan of Correction (POC) due date.

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 observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Resident #3 (R3) medications were given per R3 physicians's order as evidenced of one (1) of R3's medication was given to R3 but per Medication Administration Records (MAR) review, it does not show that R3's medication was given per physician's direction. Also, LPA Brown observed one (1) of R3's medication was not given to R3 due to no refill available at the facility since 08/03/2024, two (2) of R3's medication were not given to R3 due to no refill at the facility since 08/04/2024 and one (1) medication was not given to R3 due to no refill at the facility since 08/06/2024. This incidents poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/08/2024 Plan of Correction Licensee stated to train all staff on CCR 87465(c)(2) and submit proof to LPA Brown on POC due date.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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 by allowing Resident #1 (R1) to have full bed rail but per records review, R1 is not on hospice and exception report submitted to licensing for approval for full bed rail which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/08/2024 Plan of Correction Licensee removed R1's full bed rail during the visit. Plan of Correction (POC) cleared.

Official classification

Type A

Official code

87705(c)(4)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have 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 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 by not ensuring that there's a staff scheduled to work the night shift, awake and on duty as required for facility with dementia residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/08/2024 Plan of Correction Licensee stated to schedule a staff to work the night shift and submit an uodated Personnel Report/Staff Schedule to LPA Brown on POC due date.

Official classification

Type B

Official code

87470(c)

Regulation authority

CCR

What the official deficiency says

(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. 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 by not developing the required Infection Control Plan for the Facility which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2024 Plan of Correction Licensee stated to submit the required Infection Control Plan to LPA Brown on Plan of Correction (POC) due date.

Official classification

Type B

Official code

1569.32

Regulation authority

HSC

What the official deficiency says

Any duly authorized officer, employee, or agent of the department may, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation of, this chapter. 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 by denying LPA Brown access to the Administrator Office during the facility Inspection which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2024 Plan of Correction Licensee stated to train all staff on HSC 1569.32 and submit proof to LPA Brown on POC due date.

Official classification

Type B

Official code

87303(f)(3)

Regulation authority

CCR

What the official deficiency says

(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the container used for storage of solid waste is in good repair which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2024 Plan of Correction Licensee stated to replaced the broken container used for storage of solid waste and submit proof to LPA Brown on Plan of Correction (POC) due date.

Official classification

Type B

Official code

87303(f)(4)

Regulation authority

CCR

What the official deficiency says

(f) Solid waste shall be stored and disposed of as follows: (4) Movable bins when used for storing or transporting solid wastes from the premises shall have tight-fitting covers on the containers; shall be in good repair; and shall be rodent-proof unless stored in a room or screened enclosure. 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 by not ensuring that teh movable bin used for storing solid wastes does not have cover which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2024 Plan of Correction Licensee stated to purchase movable bins used for storing or transporting solid wastes with cover and submit proof to LPA Brown on POC due date.

Official classification

Type B

Official code

87307(d)(5)

Regulation authority

CCR

What the official deficiency says

(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms. 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 by not ensuring that nightlights are maintained in hallways and passages to nonprivate bathrooms which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2024 Plan of Correction Licensee stated to obtain/purchase nightlights in hallways and passages to nonprivate bathrooms and submit proof to LPA Brown on Plan of Correction (POC) due date.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. 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 by not ensuring that the outdoor passageway is kept free of obstruction which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2024 Plan of Correction Licensee stated to pull out the broken screen windows, metal wires, boxes, carpets that blocks the outdoor passageway and submit proof to LPA Brown on POC due date.

Official classification

Type B

Official code

87507(c)

Regulation authority

CCR

What the official deficiency says

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. 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 by not ensuring that Resident #2 (R2) and Resident #3 (R3) Admission Agreement were signed by the facility representative which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2024 Plan of Correction LIcensee stated to sign R2 and R3 Admission Agreement and submit proof to LPA Brown on Plan of Correction (POC) due date.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. 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 by allowing Resident #2 (R2), Resident #3 (R3) and Resident #4 (R4) to have half bed rail and not ensuring that they have written order from their physician indicating the need for half bed rail for mobilitywhich poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2024 Plan of Correction Licensee removed R2, R3 and R4 half bed rail during the visit. POC cleared.

Official classification

Type B

Official code

87705(c)(7)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (7) An activity program shall address the needs and limitations of residents with dementia and include large motor activities and perceptual and sensory stimulation. 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 by not ensuring that there's an activity program that address the needs and limitations of residents with dementia and include large motor activities and perceptual and sensory stimulation which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2024 Plan of Correction Licensee stated to submit an activity program that address the needs and limitations of residents with dementia and include large motor activities and perceptual and sensory stimulation to LPA Brown on Plan of Correction (POC) due date.

Official classification

Type B

Official code

1569.68(a)

Regulation authority

HSC

What the official deficiency says

HSC 1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having an Administrator present during working hours at the facility which pose potential health, safety and personal rights risks to residents in care.

Official plan of correction

Licensee stated to make sure there's an Administrator present at the facility during normal working hours and submit proof of staff schedule showing Administrator present at the facility during working hours to LPA Brown at Plan of Correction (POC) due date.

Deadline recorded: Mar 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.618

Regulation authority

HSC

What the official deficiency says

HSC 1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having an Administrator present during working hours at the facility which pose potential health, safety and personal rights risks to residents in care.

Official plan of correction

Licensee stated to submit Signed Statement of Understanding on HSC 1569.618 and submit to LPA Brown at POC due date.

Deadline recorded: Mar 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance... This requirement is not met as evidenced by: Based on observation and interview, the Licensee did not comply with the section cited above by not obtaining Staff #5 (S5) criminal record clearance before allowing S5 to work at the facility on 02/20/2024 which pose immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Licensee stated to not allow S5 to work at the facility without obtaining the required Criminal background clearance and submit copy of Staff Schedule and Personnel Summary Report (LIC500) to LPA Brown at Plan of Correction due date.

Deadline recorded: Mar 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(6)

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...(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observation, interviews and records review, the Licensee did not comply with the section cited above by not updating R3, R4 and R5 Medication Adminisitration Record (MAR) after dispensing R3, R4 and R5 medications per their physician's order which pose immediate health, safety and personal rights risks to residents in care.

Official plan of correction

Licensee stated to train all staff on CCR 87465(a)(6) and submit proof of All Staff Training Log to LPA Brown at Plan of Correction (POC) due date.

Deadline recorded: Feb 16, 2024. 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

87309 Storage Space (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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. Based on observation, interview and records review, the LIcensee did not comply with the section cited above by not locking the one (1) knife at the kitchen cabinet making it accessible to residents in care which pose immediate health, safety and personal rights risks to residents in care.

Official plan of correction

Licensee stated to train all staff on CCR 87309(a)(1) and submit proof of Staff Training Log to LPA Brown at POC due date.

Deadline recorded: Feb 16, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(e)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having Resident #1 (R1) record at the facility which poses potential health, safety and personal rights risks to resident in care.

Official plan of correction

Licensee stated to train all staff on CCR 87506(e) and submit proof of Staff Training Log to LPA Brown at Plan of Correction (POC) due date.

Deadline recorded: Feb 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by allowing Resident #2 (R2) to have full bed rail at the facility which pose potential health, safety and personal rights risks to resident in care.

Official plan of correction

Licensee stated to train all staff on CCR 87608(a)(5)(B) and submit proof of training log to LPA Brown at POC due date. Administrator will remove R2 full bed rail and submit proof to LPA Brown at POC due date.

Deadline recorded: Feb 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(a)

Regulation authority

CCR

What the official deficiency says

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required … Licensee did not meet this requirement as evidenced by: Based on interviews, record review and observations, the Licensee refused to accept R1 back to the facility upon hospital discharge. This posed a potential Health, Safety or Personal Rights risk to residents in care.

Official plan of correction

Licensee stated to review Title 22, Section 87224(a) and write a self-certification that the regulation has been read and is understood. and submit to LPA Brown by Plan of Correction (POC) due date.

Deadline recorded: Feb 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance... This requirement is not met as evidenced by: Based on observation and interview, the Licensee did not comply with the section cited above by not obtaining Staff #4 (S4) criminal record clearance before allowing S4 to work at the facility on 01/06/2024 which pose immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Licensee stated to not allow S4 to work at the facility without obtaining the required Criminal background clearance and submit copy of Staff Schedule and Personnel Summary Report (LIC500) to LPA Brown at Plan of Correction due date.

Deadline recorded: Jan 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

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 review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance... This requirement is not met as evidenced by: Based on observation and interview, the Licensee did not comply with the section cited above by not transferring Staff #3 (S3) criminal record clearance to the facility before allowing S3 to work at the facility on 01/09/2024 which poses potential health, safety and personal rights risk to residents in care.

Official plan of correction

Licensee stated to transfer S3 criminal record clearance to the facility and submit proof to LPA Brown at POC due date.

Deadline recorded: Jan 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(6)

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...(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observation, interviews and records review, the Licensee did not comply with the section cited above by not updating R3, R4 and R5 Medication Adminisitration Record (MAR) after dispensing R3, R4 and R5 medications per their physician's order which pose immediate health, safety and personal rights risks to residents in care.

Official plan of correction

Licensee stated to train all staff on CCR 87465(a)(6) and submit proof of All Staff Training Log to LPA Brown at Plan of Correction (POC) due date.

Deadline recorded: Jan 23, 2024. 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

87309 Storage Space (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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. Based on observation, interview and records review, the LIcensee did not comply with the section cited above by not locking the one (1) knife at the kitchen cabinet making it accessible to residents in care which pose immediate health, safety and personal rights risks to residents in care.

Official plan of correction

Licensee stated to train all staff on CCR 87309(a)(1) and submit proof of Staff Training Log to LPA Brown at POC due date.

Deadline recorded: Jan 23, 2024. 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...This requirement is not met as evidenced by: Based on observation and interview, the Licensee did not comply with the section cited above by not having the kitchen cabinet and laundry cabinet in good repair which pose potential health, safety and personal rights risks to residents in care.

Official plan of correction

Licensee stated to repair the broken cabinet in the kitchen and in the laundry room and submit proof to LPA Brown at Plan of Correction (POC) due date.

Deadline recorded: Jan 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.618(a)

Regulation authority

HSC

What the official deficiency says

HSC 1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having an Administrator present during working hours at the facility which pose potential health, safety and personal rights risks to residents in care.

Official plan of correction

Licensee stated to submit Signed Statement of Understanding on HSC 1569.618 and submit to LPA Brown at POC due date.

Deadline recorded: Jan 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(e)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having Resident #1 (R1) record at the facility which poses potential health, safety and personal rights risks to resident in care.

Official plan of correction

Licensee stated to train all staff on CCR 87506(e) and submit proof of Staff Training Log to LPA Brown at Plan of Correction (POC) due date.

Deadline recorded: Jan 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by allowing Resident #2 (R2) to have full bed rail at the facility which pose potential health, safety and personal rights risks to resident in care.

Official plan of correction

Licensee stated to train all staff on CCR 87608(a)(5)(B) and submit proof of training log to LPA Brown at POC due date. Administrator will remove R2 full bed rail and submit proof to LPA Brown at POC due date.

Deadline recorded: Jan 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(a)

Regulation authority

CCR

What the official deficiency says

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required … Licensee did not meet this requirement as evidenced by: Based on interviews, record review and observations, the Licensee refused to accept R1 back to the facility upon hospital discharge. This posed a potential Health, Safety or Personal Rights risk to residents in care.

Official plan of correction

Licensee stated to review Title 22, Section 87224(a) and write a self-certification that the regulation has been read and is understood. and submit to LPA Brown by Plan of Correction (POC) due date.

Deadline recorded: Jan 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.618(b)

Regulation authority

HSC

What the official deficiency says

1569.618(b)Administration and management of residential care facilities; substituted qualifications; employee scheduling.(b).one ..manager..designated substitute qualifications.. responsible designated substitute shall meet..This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above evidenced by not having a designated substitute which poses an immediate Health, Safety or personal rights risk to persons in care.

Official plan of correction

Licnesee stated they will hire a designated substitue who meet the require qualifications. Licensee proof to LPA The POC is due by 09/09/2023

Deadline recorded: Sep 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.618(a)

Regulation authority

HSC

What the official deficiency says

1569.618(a)Administration and management of residential care facilities; substituted qualifications; employee scheduling.(a)... operation of the facility when the administrator is temporarily absent from the facility. Based on observation and interview the licensee did not comply with the section cited above evidenced by not having administractor present during working hours which poses an immediate Health, Safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to hire an Administractor who will be present during wokring hours. Licensee has agreed to send proof of Adminstration and their schedule. The POC is due by 09/09/2023

Deadline recorded: Sep 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.153(d)

Regulation authority

HSC

What the official deficiency says

1569.153(d)Theft and loss program; standards, property inventories and surrender of personal effects; secured areas(d) A written resident personal property inventory..This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above evidenced by not having residents' written inventory which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to provide written inventory for all resident. The licensee has agreed to send proof of written inventory for residents. POC due date by 9/21/2023

Deadline recorded: Sep 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87462

Regulation authority

CCR

What the official deficiency says

87462 Social Factors The facility shall obtain sufficient information about each person's likes and dislikes and interests and activities..suggest the program of activities in which the individual may wish to participate. This requirement is not met as evidence by: Based on observation and interview the licensee did not comply with the section cited above evidenced by not obtaining information dislikes and likes activites which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to provide written document of residents dislikes and likes and provide activites calendar. Licensee has agreed to send proof to LPA. POC due date 9/21/2023

Deadline recorded: Sep 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.267(d)

Regulation authority

HSC

What the official deficiency says

1569.267(d) Resident's Bill of Rights (d)The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented. This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above evidenced by not providing poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to provide training for staff. The licensee has agreed to send proof of staff training. POC due date 9/21/2023

Deadline recorded: Sep 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.158(g)(2)

Regulation authority

HSC

What the official deficiency says

1569.158(g)(2) Family councils (1) If a facility has a family council, the facility shall include.. members.. (2) If a facility does not have a family council, the facility shall provide, upon admission of a new resident, written representative of their right to form a family council. Based on observation and interview the licensee did not comply with the section cited above evidenced by not providing poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

LIcensee has agreed to provide documents and send copies to LPA POC due date 9/21/2023

Deadline recorded: Sep 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

1569.618(c)(3) Administration and management of residential care facilities; substituted qualifications; employee scheduling (c) The facility shall employ..:(3) Ensure that at least one staff member who has (CPR)on the premises at all times..This requirement is not met as evidenced by: Based on observation, interview and reecord review the licensee did not comply with the section cited above by not having at least one staff member on premises at all times who is certified CPR.

Official plan of correction

The licensee has agreed to have at least one staff member on premises at all times who is certified CPR.The licensee has agreed to send proof of staff schedule and proof of valid certificate POC due date 9/9/2023

Deadline recorded: Sep 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87413(a)(1)

Regulation authority

CCR

What the official deficiency says

87413(a)(1) Personnel - Operations (a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.This requirement is not met as evidenced by: Based on observation, interview and record review the licensee did not comply with the section cited above evidenced by not providing staff coverage when regular staff return from their country

Official plan of correction

The licensee has agreed to provide an updated LIC 500 and provide the following documents of which staff members provide coverage while others go back to their country. POC due date 9/9/2023

Deadline recorded: Sep 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87470(c)

Regulation authority

CCR

What the official deficiency says

87470(c) Infection Control Requirements (c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.This requirement is not met as evidenced by Based on observation and interview the licensee did not comply with the section cited above evidenced by creating An Infection Control Plan which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to develop Infection Control Plan. Licensee has agreed to send LPA facility Infection Control Plan. POC due date 9/14/2023

Deadline recorded: Sep 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

87208(a)Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing.. the license application..This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above evidenced by not providing a copy of facility Plan Of Operation which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to have a copy of facility Plan of Operation. Licensee has agreed to send LPA proof of evidence. POC due date 9/14/2023

Deadline recorded: Sep 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(d)

Regulation authority

CCR

What the official deficiency says

87411(d) Personnel Requirements - General (d)All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69.. This requirement is not met as evidenced by: Based on observation, interview and record review the licensee did not comply with the section cited above evidenced by not providing dementia training and initial training which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee has agreed to send LPA proof of staff annual trainings POC due date 9/21/2023

Deadline recorded: Sep 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87707(1)

Regulation authority

CCR

What the official deficiency says

87707(1) Training Requirements If Advertising Dementia Special Care, Programming And/Or Environments (1) Direct care staff shall complete six hours of orientation specific to the care of ..This requirement is not met as evidenced by: Based on observation,interview and record review the licensee did not comply with the section cited above evidenced by not providing dementia training and initial training which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee has agreed to send LPA proof of staff dementia training annual trainings POC due date 9/21/2023

Deadline recorded: Sep 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.69(3)

Regulation authority

CCR

What the official deficiency says

1569.69 (3) Employees assisting residents with self-administration of medication; training requirements (3) An employee shall be required for hands-on shadowing training. resident in the self-administration of medications... This requirement is not met as evidenced: Based on observation,interview and recrod review the licensee did not comply with the section cited above by not having medication training for staff, which poses a potential health and safety risk to persons in care

Official plan of correction

Licensee has agreed medication training for staff. Licensee agreed to send LPA proof of staff training POC due date by 9/9/2023

Deadline recorded: Sep 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

87458(a) Medical Assessment (a)Prior to a person's acceptance as a resident, .. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.This requirement is not met as evidenced: Based on observation,interview and recrod review the licensee did not comply with the section cited above by not having three(3)physician reports, which poses a potiential health and safety risk to persons in care

Official plan of correction

Licensee has agreed to send LPA Physician's Report for three(3) residents POC due date by 9/9/2023

Deadline recorded: Sep 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(g)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements...(g)prior to employment or initial presence in the facility, all employees and volunteers...shall:(1) Obtain a California clearance...as required by law..This requirement is not met as evidenced by: The Licensee did not obtain a criminal record clearance for Staff #3 (S3) prior to S3 beginning employment or initial presence in the facility. Which poses an immediate health and safety risk to residents in care.

Official plan of correction

Staff (S3) immediately left facility. Licensee/Administrator will submit a written statement of understanding of the regulation cited by POC due date 09/09/2023

Deadline recorded: Sep 9, 2023. 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

87465(h)(2)Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in centrally stored medication.This requirement is not met as evidenced by: Based on observation, interview and record review the licnesee did not comply with the section cited above by having the centrally stored medication cabinet accessible to residents which poses an immediate Health, Safety or personal rights risk to persons in care.

Official plan of correction

Licensee stated they will review the cited regulation, and will provide training for staff. Licensee has agreed to send proof to LPA. POC due date 09/09/2023

Deadline recorded: Sep 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(a)

Regulation authority

CCR

What the official deficiency says

87507(a) Admission Agreements (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement is not met as evidenced by: Based on observation,interview and recrod review the licensee did not comply with the section cited above by not having one(1) admission agreements, which poses a potiential health and safety risk to persons in care

Official plan of correction

Licensee has agreed to have documnets readily available to facility staff and to licensing agency staff. Licnesee has agreed to send proof to LPA. . POC due date 9/21/2023

Deadline recorded: Sep 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(b)(15)

Regulation authority

CCR

What the official deficiency says

87506(b)(15)Resident Records (b) Each resident’s record shall contain at least the following information:(15)The.. Admission Agreements and 87457, Pre-admission Appraisal... This requirement is not met as evidenced by: Based on observation,interview and recrod review the licensee did not comply with the section cited above by not having three(3) admission agreements, which poses a potiential health and safety risk to persons in care

Official plan of correction

Licensee has agreed to send LPA the three(3)misssing and have their forms at the facility. POC due date 9/21/2023

Deadline recorded: Sep 21, 2023. 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... the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above by having bathroom cabin broken and not in good repair which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee has agree to send a LPA reciept and photo of bathroom cabin repaired. POC due date by 9/21/2023

Deadline recorded: Sep 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(d)(3)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements - General (d) All personnel shall be given on the job training.. (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement is not met as evidenced by: Based on obeservation,interview and record review, the licensee did not comply with the section cited above by not having staff being able to adequately communicate with residents due to lanaguage barrier which poses an immediate Health, Safety or personal rights risk to persons in

Official plan of correction

Licensee stated they train and hire staff who can communicate with residents. Licensee has agreed to send proof to LPA of staff schedule. POC due date 9/9/2023

Deadline recorded: Sep 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87628(a)

Regulation authority

CCR

What the official deficiency says

87628 Diabetes.(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. Based on interview and document review, the licensee did not comply with the section cited above evidenced by unskilled staff administering glucose testing to a resident which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to read regulation 87628 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to accept residents that can administer their own glucose testing and or hire a qualified professional to... administer glucose testing.The licensee has agreed to train the facility staff on what services can be provided to diabetic residents and send proof of the training to LPA. The POC is due by 8/5/2023.

Deadline recorded: Aug 5, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87609(b)(2)

Regulation authority

CCR

What the official deficiency says

87609 Allowable Health Conditions and the Use of Home Health Agencies (b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (2) The licensee provides the supporting care and supervision needed to meet the needs of the resident receiving home health care. Based on interview and document review, the licensee did not comply with the section cited above evidenced by not having a care plan to support a resident’s home health needs which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to read regulation 87609 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed that moving forward all residents under the care of home health will have a care plan in place that... supports the residents home health needs. The POC is due by 8/5/2023.

Deadline recorded: Aug 5, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(c)(1)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records. (c) All information and records obtained from or regarding residents shall be confidential. (1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. Based on interview and record review, the licensee did not comply with the section cited above evidenced by denying resident records to a resident’s legal conservator who is appointed for estate and person which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to read regulation 87506 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to train staff on resident records and has agreed to provide LPA proof that the legal conservator was given the documents requested. The POC is due by 7/14/2023

Deadline recorded: Jul 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87156(a)

Regulation authority

CCR

What the official deficiency says

87156 Licensing Fees(a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. Based on interview, record review, and observation the licensee did not comply with the section cited above evidenced by a past due amount of $1,484.00 in licensing fees which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to read regulation 87156 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to pay the amount due by POC due date. POC due date is 6/23/2023.

Deadline recorded: Jun 23, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(c)

Regulation authority

CCR

What the official deficiency says

87355. Criminal Record Clearance. (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: Based on interview, observation, and record review, the licensee did not comply with the section cited above evidenced by not processing a criminal record transfer for S1. S1 has worked at the facility for three (3) years without being associated to the facility.

Official plan of correction

The licensee has agreed to submit a signed Criminal Background Clearance Transfer Request, LIC 9182, with a copy of the individual's: (A)Driver's license, or (B)Valid identification card issued by the Department of Motor Vehicles, or (C)Valid photo identification issued by another state or the United States government if the individual is not a California resident or complete the process to transfer the employee on the guardian website by the POC due date. The POC is due by 12/23/2022.

Deadline recorded: Dec 23, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(c)

Regulation authority

CCR

What the official deficiency says

87355. Criminal Record Clearance. (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: Based on interview, observation, and record review, the licensee did not comply with the section cited above evidenced by not processing a criminal record transfer for S2. S2 has worked at the facility for one (1) and a half months without being associated to the facility.

Official plan of correction

The licensee has agreed to submit a signed Criminal Background Clearance Transfer Request, LIC 9182, with a copy of the individual's: (A)Driver's license, or (B)Valid identification card issued by the Department of Motor Vehicles, or (C)Valid photo identification issued by another state or the United States government if the individual is not a California resident or complete the process to transfer the employee on the guardian website by the POC due date. The POC is due by 12/23/2022.

Deadline recorded: Dec 23, 2022. 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

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 as specified in this section. When the administrator is not in the facility, there shall be coverage by 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 when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and records not available for LPA review, the licensee did not comply with the section cited above by not having proof of a current administrator which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/15/2022 Plan of Correction The licensee agreed to send valid administrator documentation to licensing by planned POC date. The licensee agreed to read regulation 87405 entirely. The licensee agreed to send a self-certify letter to licensing detailing that the regulation was read and is understood.

Official classification

Type B

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

Personnel Records. (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by not having a staff personnel record for S1 for licensing to review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/28/2022 Plan of Correction The licensee has agreed to read regulation 87412 entirely. The licensee has agreed to send a self-certify letter to licensing that the regulation has been read and is understood.

Official classification

Type A

Official code

87411(g)(1-3)

Regulation authority

CCR

What the official deficiency says

Personnel Requirements – General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or (3 )Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. 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 by allowing S2 to work in the facility without having a criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/26/2022 Plan of Correction The licensee agrees to not allow S2 to work in the facility until they obtain a criminal background clearance. The licensee agrees to read regulation 87411 entirely. The licensee agrees to send licensing a self-certify letter that the regulation has been read and is understood.