TERRACE GARDENS

Official classification

Type A

Official code

1569.311

Regulation authority

HSC

What the official deficiency says

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above did not ensure that the facility has the carbon monoxide detector which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/04/2025 Plan of Correction Licensee will submit a proof of purchase and picture of the carbon monoxide installed at the facility.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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 the required liability insurance which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/03/2026 Plan of Correction Licensee will submit proof of liablity insurance on the plan of correction due date.

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not ensuring that staff #1 (S1) does not have the health screening report on file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/10/2025 Plan of Correction Licensee will provide a copy of the health screening report on plan of correction (POC) due date.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(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: Deficient Practice Statement Based on interview, record review, the licensee did not comply with the section cited above by not ensuring that the facility has the tracking documentation of medication administered to resident #1, #2, #3 (R1, R2, R3) which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/10/2025 Plan of Correction Licensee will provide proof of training and statement of understanding of the regulation cited above on plan of correction (POC) due date.

Official classification

Type B

Official code

87458(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not ensuring that resident #1 (R1) has an updated physician report on file which poses a potential health, safety or personal rights risk to persons in care..

Official plan of correction

POC Due Date: 12/10/2025 Plan of Correction Licensee will provide proof of doctor's appointment to get the physician report updated on plan of correction (POC) due date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

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

Official plan of correction

POC Due Date: 12/10/2025 Plan of Correction Licensee will provide a copy of the emergency/fire drill conducted by the staff on plan of correction (POC) due date.

Official classification

Type A

Official code

87506(b)(15)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not ensuring that resident #4 (R4) have the admission agreement on file which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/27/2024 Plan of Correction Licensee to submit a copy of the admission agreement by the plan of correction (POC) due date.

Official classification

Type A

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not ensuring that resident #2 (R2) and resident #5 (R5) has the required physician's report on file. Licensee did not ensure that the residents has the required tuberculosis (TB) test and TB test result, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/27/2024 Plan of Correction Licensee to submit proof of date of appointment with a physician to have the physician's report by the POC due date.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not ensuring that Staff #1 (S1) has an updated CPR/First Aid certification and Staff #2 (S2) have a CPR/First Aid certification on file, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/24/2025 Plan of Correction Licensee to submit proof of CPR/First Aid certificate on plan of correction (POC) due date.

Official classification

Type B

Official code

87208(a)(12)

Regulation authority

CCR

What the official deficiency says

(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 agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, record review, the licensee did not comply with the section cited above by not ensuring that the facility have the Infection Control Plan available for review at the time of visit, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/02/2025 Plan of Correction Licensee to submit a copy of Infection Control Plan for review on the plan of correction (POC) due date.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above by not ensuring that the facility have an updated liability insurance.which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/24/2025 Plan of Correction Licensee to submit proof of liability insurance on POC due date.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Deficient Practice Statement Based on the following: LPA observed two gates leading from the back yard with locking mechanisms which prevent exiting without a key. LPA observed that the key is maintained in a coded lock box on the side of a backyard shed with the key in it. LPA also observed in the garage an addition of walls and a door. Inside the addition is a bed, clothing and personal effects of caregivers. Administrator admits that they are using the place a a place to rest for the employees. This space is not part of the approved fire clearance as a caregiver room.

Official plan of correction

POC Due Date: 12/01/2023 Plan of Correction Licensee to cease utilizing a locked perimeter by removing any locking device designed to lock individuals on the premesis. In addition licensee to submit LIC 200 to obtain approval to utilize the space in the garage as a living quarters for employees or only use that space for storage. Bed to be removed from the space.

Official classification

Type A

Official code

87468.2(a)(1)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation of cameras in the bedrooms. This is a violation of the residents personal rights.

Official plan of correction

POC Due Date: 12/01/2023 Plan of Correction Licensee to immediately remove all cameras from all areas of the facility where resident care is provided and could be observed with a camera. Licensee must put an addendum post for public view the use of cameras in the facility in common areas.

Official classification

Type B

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by: As indicated on complaint number 56-AS-20220808090401, Resident 1 was found outside the facility and returned to this facility by a visitor.

Official plan of correction

Licensee has installed a monitoring system outside the facility and audible signals for exit doors before today's visit. The correction was in place before this visit.

Deadline recorded: Oct 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(l)(2)

Regulation authority

CCR

What the official deficiency says

The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement was not met as evidenced by: LPA and Staff 1 viewed one of two side gates secured and locked with padlock. This poses a potential safety risk to residents in care.

Official plan of correction

Licensee shall keep both side gates secured but not locked in any capacity. If Licensee wishes to keep gates locked, Licensee shall submit proof to the Department that requirements as outlined in CCR Section 87705(l) no later that end of POC date, 8/31/2022.

Deadline recorded: Aug 31, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(b)

Regulation authority

CCR

What the official deficiency says

If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication. This requirement was not met as evidenced by: Administrator interview showed that Resident 1 is receiveing two nonprecription PRN medications. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee shall submit written proof of Resident's physician's order for two nonprescription PRN medication no later than the end of POC date, 8/31/2022.

Deadline recorded: Aug 31, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(1)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities : (a) In addition to the rights listed...residents... ave all of the following personal rights: (1) To have...privacy in...medical treatment, personal care and assistance... This requirement was not met as evidenced by: Based on interviews, the Licensee did not comply with the above regulation with at least one resident (R1). Licensee stated that S1 took photos of R1 when paramedics responded to provide medical aid. Licensee does not have consent on file. This posed a potential personal rights violation to R1.

Official plan of correction

Licensee agrees to obtain a written consent form from all residents and their responsible parties prior to taking any photographs of them. Licensee to provide LPA Colvin with Statement of Understanding by Plan of Correction date of 10/29/21.

Deadline recorded: Oct 29, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)(13)(B)

Regulation authority

CCR

What the official deficiency says

Personnel Records : (a) The licensee shall ensure...records are maintained on...each employee. Each personnel record shall contain...: (13) For employees...(B) Documentation of either a criminal record clearance or a criminal record exemption... This requirement was not met by: Based on record review and interview, the Licensee did not comply with the above regulation with one staff member (S2). Licensee was unable to provide LPA Colvin with proof of clearance or transfer in S2's personnel file. This is a potential safety risk to all residents in care.

Official plan of correction

Licensee agrees to update S2's file to include all required documents. Licensee to submit Statement of Understanding to LPA Colvin regarding all documents required to be maintained in staff files. Statement to be submitted to LPA Colvin by Plan of Correction date of 10/29/21.

Deadline recorded: Oct 29, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements: (a) Each licensee shall furnish to the licensing agency...the following:(1) A written report shall be submitted...within seven days...of any of the events specified ...(D) Any incident which threatens the welfare, safety or health of any resident... This was not met by: Based on record review, the Licensee did not comply with the above regulation with at least one incident. LPA Colvin observed that emergency services were called out to the facility on 6/8/20 but the facility never submitted an Incident Report to CCL. This was an immediate safety risk to all residents.

Official plan of correction

Licensee agrees to review Title 22 Regulation Section 87211 regarding Reporting Requirements. Licensee to Statement of Understanding to LPA Colvin regarding reporting incidents to CCL by Plan of Correction date of 10/18/21.

Deadline recorded: Oct 18, 2021. 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

Criminal Record Clearance: (e) All individuals ...shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met by: Based on observations and record review, the Licensee did not comply with the above regulation with one staff member (S2). LPA Colvin observed that S2 was present in the facility wihtout proof of background clearance. S2 is not associated to the facility. This is an immediate safety risk to residents in care.

Official plan of correction

Licensee agrees to remove S2 from the schedule until S2 obtains a criminal background clearance and/or has the background clearance transferred to this facility. Licensee to submit proof of S2 being removed from schedule and a Statement of Understanding regarding requirements in Title 22 for all staff to have background clearance AND be associted to the facility prior to starting work/training at the facility. Requested items to be submitted to LPA Colvin by the Plan of Correction date of 10/18/21.

Deadline recorded: Oct 18, 2021. A deadline is not proof that correction was completed.