MONTCLAIR ROYALE SENIOR LIVING

Official classification

Type A

Official code

80088(a)

Regulation authority

CCR

What the official deficiency says

Title 22, Division 6 Chapter 1 80088 (a) Furniture, Fixtures, Equipment, and Supplies (a) A comfortable temperature for clients shall be maintained at all areas. This requirement is not met as evidence by: Based on observation, the licensee did not comply with the section cited above by not ensuring that a comfortable temperature is maintained throughout the facility for the residents in care specially in hot weather season which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee/Administrator shall submit a work order/invoice from a licensed heating/ventilation air-conditioning company (HVAC) that showed that the HVAC will fix the issue of facility uncomfortable temperature by plan of correction (POC) due date

Deadline recorded: Jul 17, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

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, record review, the licensee did not comply with the section cited above by not ensuring that resident #1, #2 (R1, R2) medications were dispensed properly as per the physicians order, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/22/2025 Plan of Correction Licensee will submit statement of understanding of the regulation cited above. The licensee will also submit proof of medtech medication training signed by all medtech and conducted by a medical professional.

Official classification

Type A

Official code

87355(b)(2)

Regulation authority

HSC

What the official deficiency says

87355 Criminal Record Clearance (a) The Dept shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 (b)Prior... residing in the facility shall have a criminal record clearance or exemption. This requirement was not met as evidenced by: Based on LPA observations, record reviews and interviews, Staff #1 (S1) did not have a criminal record clearance prior to working at the facility. This poses an immediate health, safety or personal rights risk to residents in care

Official plan of correction

Care Director agreed to send the LPA a written statement on how they plan on ensuring all staff are cleared going forward. This is due by the Plan of Correction (POC) due date.

Deadline recorded: Jul 3, 2025. A deadline is not proof that correction was completed.

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, interview, record review, the licensee did not comply with the section cited above by not having the required carbon monoxide detector installed on each floor of the facility, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/15/2024 Plan of Correction Licensee stated to submit proof of installed carbon monoxide detector on each floor of the facility to LPA Serrano on plan of correction (POC) due date.

Official classification

Type A

Official code

87412(a)(12)

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: (12) Hazardous health conditions documents as specified in Section 87411, Personnel Requirements - General. 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 #4 (S4) 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: 10/15/2024 Plan of Correction Licensee stated to submit medical appointment for Staff #4 to complete the required TB test with TB test result to LPA Serrano on POC due date.

Official classification

Type B

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

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 areas shall be maintained in a clean, sanitary, and odorless condition. 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 floor surface in resident bathroom and the floor bathroom for residents and staff were clean which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2024 Plan of Correction Licensee stated to submit a copy of housekeeping schedule specific to cleaning resident bathrooms to LPA Serrano on plan of correction (POC) due date.

Official classification

Type B

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 administrator was present at the facility for three (3) consecutive weeks and not at the facility during normal working hours which poses a potential health, safety or personal rights ris k to persons in care.

Official plan of correction

POC Due Date: 10/22/2024 Plan of Correction Licenseee stated to submit proof of updated staff schedule showing the administrator working at the facility during normal working hours to LPA Serrano on POC due date.

Official classification

Type B

Official code

87555(b)(15)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (15) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination. 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 ensuring that staff #3 (S3) does not have the required updated ServSafe certification and staff #4 (S4) has an updated food handler card, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2024 Plan of Correction Licensee stated to submit proof of S3 updated ServSafe certification and S4 food handlers card to LPA Serrano on plan of correction (POC) due date.

Official classification

Type B

Official code

87456(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. 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 resident #2 (R2) has the required pre-placement appraisal which poses a potential health, safety or personal , risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2024 Plan of Correction Licensee stated to submit signed statement of understanding on CCR 87456(a)(2) to LPA Serrano 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, record review, the licensee did not comply with the section cited above by not ensuring that facility representative signed Resident #2 (R2) resident #3 (R3) and resident #4 (R4) admission agreement which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2024 Plan of Correction Licensee stated to sign R2, R3, R4 admission agreement and submit signed statement of understanding on CCR 87507(c) to LPA Serrano on plan of correction (POC) due date.

Official classification

Type B

Official code

1569.695(e)(2)

Regulation authority

HSC

What the official deficiency says

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. 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 resident #5 (R5) has the required needs and services plan and facility representative sign the completed needs and services plan for resident #2 (R2) and resident #4 (R4), which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2024 Plan of Correction Licensee stated to submit signed statement of understanding on HSC 1569.695(e)(2) to LPA Serrano on 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,record review, the licensee did not comply with the section cited above by not ensuring that resident #1 (R1) and resident #2 (R2) have half bedrail with written order from their physician indicating the need for half bed rail for mobility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2024 Plan of Correction Licensee stated to submit copies of R1 and R2 written order from their physician indicating the need for half bedrail for mobility to LPA Serrano on plan of correction (POC) due date. Also, Licensee that if they are not able to obtain the physician order to remove the half bedrails and submit proof to LPA Serrano on POC due date.

Official classification

Type A

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705 CAre of Persons with Dementia (c) Licensse who accept and retain residents with dementia shall be responsible for ensuring the following:(5) Each resident with dementia shall have an annual medical assessment as specified in section 87458, medical assessment... 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 resident #3 (R3) has the required annual medical assessment as R3s medical asessment date is 08/12/2022 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/15/2024 Plan of Correction Licensee stated to obtain a medical appointment for R3 to complete the required annual medical assessment and submit proof to LPA Serrano on the plan of correction (POC) due date.

Official classification

Type A

Official code

87705(l)(7)

Regulation authority

CCR

What the official deficiency says

87705 Care of Person with Dementia. (l) The following iniatial and conitnuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (7) The licensee shall not accept or retain residents determined by a physician to have a primary diagnosis of a mental disorder unrelated to dementia. 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 accepting resident #2 (R2) in memory care and per documents review R2 does not have a diagnosis of dementia but with a primary diagnosis of a mental disorder unrelated to dementia which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/15/2024 Plan of Correction Licensee stated to remonve R2 in memory care and transfer R2 to assisted living and submit proof to LPA Serrano on POC due date.

Official classification

Type A

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...Thirty (30) days written notice to the resident is required... This requirement was not met as evidenced by: Based on record reviews and interviews the Administrator did not comply with the regulation listed above when the resident was relocated without a proper 30 day eviction notice. This posed an immediate Health, Safety and Personal Rights risk to persons in care.

Official plan of correction

Administrator agrees to complete an In Service Review with a sign in sheet with staff who are involved in making the decisions to retain, discharge or evict residents. Additionally, Administrator and staff will complete a statement of understanding by way of a LIC9098. Administrator agrees to submit Verification of the Inservice and LIC9098 form to community care licensing within the following business day.

Deadline recorded: Dec 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87224(C)

Regulation authority

CCR

What the official deficiency says

87224 - Eviction Procedures (C)A statement informing residents of their right to file a complaint with the licensing agency... (a)(4), including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office. This requirement was not met as evidenced by: Administrator failed to ensure the correct contact information for the Long Term Care Ombudsman was on the eviction notice. This posed a potential health, safety and/or personal rights risk to residents in care.

Official plan of correction

Licensee/Administrator agrees to read and review the 87224 Evictions Procedures entirely. Also, send LPA a self-certified letter that the regulation was read, understood and will demonstrated in furture evictions. This form is to be submitted to the Community Care Licensing Office within 1 business day.

Deadline recorded: Oct 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(f)(1)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation " (f)Solid waste shall be stored and disposed...(1)Solid waste shall be stored, located and disposed of in a manner that will not permit the transmission of a communicable disease... " This requirement is not met as evidenced by: Based on observations, the Administrator failed to uphold the requirement listed above by not properly disposing of a resident's solid waste which poses an immediate Health, Safety and Personal Rights risk to persons in care.

Official plan of correction

Administrator agreed to have the resident's room thoroughly cleaned during LPA visit Administrator agrees to have staff check on the resident and the room every 30 minutes.. POC has already been completed on 8/31/23

Deadline recorded: Aug 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair. This requirement was not met as evidenced by: Based on observations, the Administrator failed to have the resident's window repaired when it became weathered and damaged causing the resident access outside a second story.

Official plan of correction

Administrator agrees to have the window screen replaced with a screen free of damage, that can be secured to the resident's window.

Deadline recorded: Aug 31, 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 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on observations, the Administrator failed to keep the resident's bathroom clean, safe and sanitary. This poses a potential Health, Safety and Personal Rights risk to persons in care.

Official plan of correction

Administrator agrees to have the resident's bathroom cleaned and maintained by housekeeping staff. Administrator was able to have this completed during the visit. POC has been completed on 8/31/2023. Administrator also agrees to read and review the mentioned regulation, complete a statement of understanding by way of an LIC9098 form and submit it to the community care licensing office with in the next 7 days.

Deadline recorded: Sep 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

HSC

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities ...Residents in privately operated RCFEs shall have all of the following...rights: To care, supervision, & services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, & competency to meet their needs. This requirement was not met as evidenced by: Based on observations and interviews, Administrator failed to provide the level of care and supervision needed for R1 & R2, which poses an immediate health, safety and personal rights risk to persons in care.

Official plan of correction

The POC has already taken place, R2 was moved off of the Memory Care Unit, separating R1 from R2. Additionally, medical treatment was sought and provided to R1. LPA observed the intervention methods in place.

Deadline recorded: Jul 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

Not listed

Regulation authority

HSC

What the official deficiency says

Deficiency narrative not available.

Official plan of correction

The plan of correction has already been addressed as the facility is and continues to patch leaks in and around the facility.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenence and Operation (e)(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Based on interviews and record reviews the Administrator did not insure the facility provided hot water to residents for personal care which poses a potential Health, Safety and Personal Rights risk to persons in care.

Official plan of correction

Plan of Correction was completed on 2/6/23 when the facility's boiler was fixed resuming hot water to residents in care.

Deadline recorded: Aug 22, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 - Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by: Based on observations and interviews, the Licensee failed to keep the storage of chemicals and toxins inaccessible to residents in care. Which poses an immediate Health, Safety and or personal rights risk to resident in care.

Official plan of correction

Licensee agrees to conduct another staff training regarding maintaining secure storage of chemicals on 8/23/23. Licensee also agrees to increase the amount of staff on the floor for additional supervision of the residents in care.

Deadline recorded: Aug 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(17)

Regulation authority

CCR

What the official deficiency says

87555.General Food Service Requirements. (b)The following food service requirements shall apply: (17) In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service. If this person is not a nutritionist, a dietitian, or a home economist, provision shall be made for regular consultation from a person so qualified. The consultation services shall be provided at appropriate times, during at least one meal. A written record of the frequency, nature and duration of the consultant's visits shall be secured from the consultant and kept on file in the facility. Based on observation, interview and document review, the licensee did not comply with the section cited above evidenced by not employing a qualified kitchen staff to ensure the residents were provided with proper food service 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 87555 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee hired a qualified kitchen staff on 1/3/2023. The staff started working on 1/16/2023. The POC due date is 7/31/2023.

Deadline recorded: Jul 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

80087(a)

Regulation authority

CCR

What the official deficiency says

80087 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by: Based on observations and interviews, Administrator did not ensure the residents' room was kept in good repair at all times. Which poses poses a potential Health, Safety or Personal Rights risk to persons in care.

Official plan of correction

Administrator and Care Coordinator agree to have the resident's window shades replaced, the resident's carpet shampooed and towel rack in the restroom repaired within the next 30 days. Administrator agrees to submit proof the repairs were made to the Community Care Licensing Office within the next 30 days.

Deadline recorded: Aug 18, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(b)

Regulation authority

HSC

What the official deficiency says

Eviction Procedures (b) The licensee may, upon obtaining prior written approval from the licensing agency, evict the resident upon three (3) days written notice to quit. The licensing agency may grant approval for the eviction upon a finding of good cause. This requirement was not met as evidenced by: Based on interviews, collected documentations and onservations the licensee did not acquire the approval of a 3 day eviction from Community Care Licensing. The 30 day Eviction Notice pursued after the denial was invalid as it was not complete which which poses a potential Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Administrator/Licensee agrees to complete a 30 Day Eviction correctly with applicable dates and re-issue the eviction to the resident's Power of Attorney. Administrator will also submit proof the Eviction Notice was issued to the Community Care Licensing Office. Adminstrator agrees to work with the Long Term Care Ombudsman and Innovage, Social Worker to secure suitable, licensed care and housing for the resident in care. Administrator agrees to complete a LIC9098 self-certifying that the Eviction Procedure Regulation is understood. Each task is to be completed within the next 30 days

Deadline recorded: Aug 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.683(a)(2)

Regulation authority

CCR

What the official deficiency says

§1569.683 Eviction notices; reasons for eviction contents; service (a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction...the notice to quit shall include all of the following:(2) Resources available to assist in identifying alternative housing and care options, including public and private referral services and case management organizations. This requirement was not met as evidenced by: Based on record reviews and interviews, the Administrator illegally issued an eviction notice to the resident when the wrong contact information was given as a resource. This poses a potential health, safety and personal rights risk to persons in care,

Official plan of correction

The plan of correction has been addressed, the Administrator re-issued a corrected eviction notice for R1. LPA observed the corrected eviction notice.

Deadline recorded: Mar 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

80087(a)

Regulation authority

HSC

What the official deficiency says

80087 - Buildings and Grounds- (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement was not met as evidenced by: Observations of the residents room windows missing a number of blinds. Observations of no record of the window blinds being reported. This poses a potential Health, Safety or Personal Rights risk to persons in care.

Official plan of correction

Licensee/Administrator agrees to make changes to the work order system to better address how work orders are processed in order to address resident needs. Administrator/Licensee agrees to have residents or staff complete a work order form when the resident reports something to be fixed. Administrator/Licensee agrees to adopt this change from this day (5/30/23) forward. During visit, staff made changes to the way in which work orders are placed and progress can be tracked.

Deadline recorded: May 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(1)

Regulation authority

HSC

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance... This requirement was not met as evidenced by: Based on observations of the resident room and resident interviews the resident was not accorded personal privacy while care was being provided and the window shades were missing. This poses a potential Health, Safety and Personal Rights risk to persons in care,

Official plan of correction

Administrator agreed to have the missing window shades replaced by the maintenance staff. As of 5/30/23, the resident's window shades have been replaced, verification submitted to Community Care Licensing. The plan of correction has been completed.

Deadline recorded: May 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

The following space & safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair & shall provide a safe & healthful environment. This requirement was not met as evidenced by: LPA observed a broken front door and LPA received a recorded video of the facility common room ceiling leaking heavily. This poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

As of today's visit, the facility has repaired the memory care unit and facility front doors. The facility shall submit proof of recent service for roof maintenance to the Department no later than the POC date

Deadline recorded: Dec 9, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

The following food service requirements shall apply: All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement was not met as evidenced by: Witness interviews confirm that expired food items and milk were stored and sometimes served to residents in care. This poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

As of today's visit, the facility had a change in kitchen management and proper food handling practices are currently in place. CCL shall receive an end of year progress report from head chef on newly implemented procedures for all kitchen staff by the POC date.

Deadline recorded: Dec 30, 2022. 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

(e) All individuals subject to a criminal record review pursuant to HSC Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a CA clearance or a criminal record exemption as required by the Department... This requirement was not met as evidenced by: Records review and staff interview confirm that S1 was working prior to receiving their background clearance. This poses an immediate safety and personal rights risk to residents in care.

Official plan of correction

At the time of the initial visit, S1 had been separated from the facility. During today's visit, it was found that Staff1 is currently working while their clearance is still pending.

Deadline recorded: Nov 28, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

The following space & safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair & shall provide a safe & healthful environment. This requirement was not met as evidenced by: LPA observed a broken front door and LPA received a recorded video of the facility common room ceiling leaking heavily. This poses an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

As of today's visit, the facility has repaired the memory care unit and facility front doors. The facility shall submit proof of recent service for roof maintenance to the Department no later than the POC date.

Deadline recorded: Dec 9, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)(3)(D)

Regulation authority

CCR

What the official deficiency says

Policies and procedures regarding medications, including knowledge in Section 87411(d)(4). Any on-the-job training provided for the requirements in Section 87411(d)(4) may also count towards the requirement in this subsection. This requirement was not met as evidenced by: Staff interview revealed that S2 has not completed their initial medication training and the facility is unable to provide proof that S2 had received such training. This poses an immediate health and safety risk to residents in care.

Official plan of correction

As of today's visit, the facility has implemented a documented two full week training for all staff administering medication. As of today's visit, S2 is no longer associated to the facility.

Deadline recorded: Dec 9, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing...(2) Request a transfer of a criminal record clearance... This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by not transferring Staff 6 (S6) Criminal Background Clearance to the facility. This poses a potential Health and Safety risk to the resident in care.

Official plan of correction

Licensee stated to trasfer and update S6 Criminal Background Clearance and submit proof to LPA Brown by POC due date. Licensee will submit a Signed Statement of Understanding on CCR 87355(e)(2) to LPA Brown by POC due date.

Deadline recorded: Oct 28, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency... This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by not submitting Special Incident Report (SIR) of R1's hospitalization CCLD ASC. This poses a potential Health and Safety risk to the resident in care.

Official plan of correction

Licensee stated to train all staff on CCR 87211(a)(1) and submit proof of Staff Training Log to LPA Brown by POC due date. Licensee will submit Signed Statement of Understanding on CCR 87211(a)(1) to LPA Brown by POC due date.

Deadline recorded: Nov 3, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(9)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have ... (9) To have communications to the... This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by not having a staff answer facility telephone calls from the hospital involving R1 the night of 07/11/2022. This poses a potential Health and Safety risk to the resident in care.

Official plan of correction

Licensee stated to train all Medtech staff in CCR 87468.1(a)(9) and will submit Training Log to LPA Brown by POC due date. Licensee will submit a Statement of Understanding on CCR 87468.1(a)(9) to LPA Brown by POC due date.

Deadline recorded: Nov 3, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(f)

Regulation authority

CCR

What the official deficiency says

A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement was not met as evidenced by: The Department did not receive notices of eviction until investigation of complaint #s 18-AS-20220105101235 and 56-AS-20220318083750.

Official plan of correction

Licensee and staff shall review regulation section 87224. A statement of understanding of the regulations shall be provided to CCL by end of POC due date 5/9/2022.

Deadline recorded: May 9, 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

All facilities shall have a qualified & currently certified administrator. The licensee & administrator may be...the same person. The administrator shall have sufficient freedom from other responsibilities & shall be on the premises a sufficient number of hours to permit adequate attention to the management & 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 was not met as evidenced by: Based on interviews and observations, facility has not submitted an LIC308, Designation of Facility Responsibility, to the Department since Administrator went on medical leave/full time telework/on-call status on

Official plan of correction

Licensee submit to the Department an LIC308 and staff qualification and LIC507 showing Administrator's hours in the facility no later than end of POC due date 5/20/2022.

Deadline recorded: May 20, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87224(b)

Regulation authority

CCR

What the official deficiency says

The licensee may, upon obtaining prior written approval from licensing agency, evict the resident upon 3 days written notice to quit. The licensing agency may grant approval for eviction upon a finding of good cause. Good cause exists if the resident is engaging in behavior which is a threat to the mental and/or physical health or safety of himself or...others in the facility. This requirement was not met as evidenced by: The Department did not receive eviction notices until complaint #56-AS-20220318083750 was filed and investigated.

Official plan of correction

Licensee and staff shall review regulation section 87224. A statement of understanding of the regulations shall be provided to CCL by end of POC due date 5/9/2022.

Deadline recorded: May 9, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.17(b)(2)(C)

Regulation authority

HSC

What the official deficiency says

Fingerprints and criminal records of individuals in contact with clients; exemptions; criminal records clearances - (C) A third-party contractor retained by the facility if the contractor is not left alone with clients in care. This requirement was not met as evidenced by: Based on interviews and record reviews, the licensee has retained the contractor since July 2021 and allowed the contractor to work alone with residents.

Official plan of correction

Licensee shall circulate a facility memo to administrative staff instructing staff to assign a fingerprinted staff with third-party contractor when the contractor is present with residents. Licensee shall submit a copy to the Department no later than the end of POC date 12/23/21.

Deadline recorded: Dec 23, 2021. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(b)(2)

Regulation authority

CCR

What the official deficiency says

87303 (b) (1) Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. Based on interviewss and record review, this requirement is not met as evidenced by: AC unit was broker from 7/24/21-9/8/21. This poses a potential health and safety risk to persons in care.

Official plan of correction

The licensee to shall repair the AC unit.

Deadline recorded: Sep 21, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(3)(f)

Regulation authority

CCR

What the official deficiency says

87307 (3)(f) Personal Accommodations and Services: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (F) Basic laundry service (washing, drying, and ironing of personal clothing). This requirement was not being met as evidenced by Facilities washers and dryers endure a 6-month period in which one of the main industrial dryers used for drying residents’ linens was broken.

Official plan of correction

Licensee will ensure there is enough staffing to handle the facilities laundry needs by adding additional staff to laundry department. A a new staffing schedule for laundry services must be submitted to CCL by due date before deficiency can be cleared.

Deadline recorded: Oct 14, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(g)(1)

Regulation authority

CCR

What the official deficiency says

87307 (3)(f) Personal Accommodations and Services: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (F) Basic laundry service (washing, drying, and ironing of personal clothing). This requirement was not being met as evidenced by: Facilities washing machines and dryers been in-operable or in need of repair for a prolonged period, as a result residents clean clothing needs were not being met. This posed an immediate health and safety risk to resident in care.

Official plan of correction

Licensee will purchase own laundry equipment for facility or find alternative company that will ensure laundry equipment is in good repair at all times and capable of handling facility laundry needs. Proof of correction must be sent to CCL by provided due date before deficiency can be cleared.

Deadline recorded: Oct 14, 2021. 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

87411 (a) Personnel Requirements: (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 being met as evidenced by: Interviews with staff members revealed that staffing gaps occur due to a high turnover rate from employees. Per staff’s statements this creates more workload for staff than they can handle. This posed an immediate health and safety risk to resident in care.

Official plan of correction

Licensee will conduct a staffing assessment to ensure that all the departments within the facility meet the required staffing needs to provide care and supervision for residents. In addition, a plan must be develop and approved by CCL that addresses staffing gaps that occur do to high turnover rates, heavy workloads, and recruitment and retention of personnel. Plan must be submitted for review to LPA by due date.

Deadline recorded: Oct 14, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(2)

Regulation authority

CCR

What the official deficiency says

87211(2) Reporting Requirements:(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not being met as evidenced by Facilities failing to report scabies outbreak after first case, as a result 3 other cases developed within the memory unit. This posed an immediate health and safety risk to resident in care.

Official plan of correction

Licensee will develop a statement of understanding outlining compliance with regulation in addition to having a departmental meeting communicating reporting requirements to all department heads. Proof of correction must be submitted to CCL due date before deficiency can be cleared..

Deadline recorded: Oct 14, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

87465(a)(1) Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met evidence by: Facility failed to seek timely medical attention for residents R1,R2, R3, and R4. After the first case of scabies was identified by a medical professional, this poses a potential risk to the health , safety, and personal rights of residents in care.

Official plan of correction

Licensee will develop and implement a policy that addresses the immediate medical attention needed after a resident has been identified with a contagious condition which can affect the residents and staff at the facility by due date.

Deadline recorded: Oct 14, 2021. A deadline is not proof that correction was completed.