ATIENZA RESIDENTIAL CARE

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. 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 drawer that contains sharps locked leaving it 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: 03/26/2026 Plan of Correction Administrator will need to conduct a training with staff and provide a written statement that the regulation cited has been reviewed and provide proof along with signatures to LPA by POC due date.

Official classification

Type A

Official code

87355(e)(4)

Regulation authority

CCR

What the official deficiency says

(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: (4) 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 and record review, the licensee did not comply with the section cited above by not having Tenant #1 (T1) associated to the facility, T1 is associated to 331880723 but not 361880724 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/26/2026 Plan of Correction Administrator will need to associate T1 to the facility (361880724) and provide proof to LPA by POC due date.

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(8) 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 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 having a green peas can that expired in 2018 in the cabinet which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/26/2026 Plan of Correction Administrator will need to conduct training with all staff, remove all expired perishable and/or non perishable foods, provide proof of training and acknowledgment of regulation to LPA by 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, record review, the licensee did not comply with the section cited above because there is no evidence that staff are administering medications according to the physician’s orders, as the dates punched on the medication packaging are not in chronological order. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/26/2026 Plan of Correction Administrator will conduct training with staff and provide proof of acknowledgment to the regulation being cited and provide to LPA by 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, record review, the licensee did not comply with the section cited above by not having an infection control plan available for review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction Administrator will create and provide an infection control plan to LPA by 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 observation, interview, record review, the licensee did not comply with the section cited above by not having a liability insurance available for review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction Administrator will purchase and provide proof of liabiity insurance to LPA by POC due date.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

(c) All window screens shall be clean and maintained in good repair. 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 having bedroom #4 window screen in disrepair, as well as the sliding door screen in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction Administrator will need to repair bedroom #4 window screen, sliding door screen, along with any other window screens in disrepair and provide proof to LPA by 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 observation, interview, record review, the licensee did not comply with the section cited above by not having a record of medication for resident #1 (R1) which are centrally stored which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction Administrator needs to conduct training to staff and create record of dosages of medication that is centrally stored for R1 and provide proof to LPA by POC due date.

Official classification

Type B

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 having a first aid kid available for review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction Administrator will purchase a first aid kit and provide proof to LPA by POC due date

Official classification

Type B

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, record review)], the licensee did not comply with the section cited above by not having a first aid kit manual available for review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction Administrator will purchase a first aid kit manual and provide proof to LPA by POC due date.

Official classification

Type B

Official code

87465(c)(3)

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: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. 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 in by not having a record of each PRN dose that resident #1 (R1) has administered which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction Administrator will conduct a training and create a record of when Resident #1 (R1) administers their PRN and provide proof to LPA by POC due date.

Official classification

Type B

Official code

1569.695(a)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, 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 having an emergency disaster plan available for review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction Administrator will create and provide an emergency disaster plan to LPA by 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 [(observation, interview, record review)], the licensee did not comply with the section cited above by not having a record of quarterly disaster drills available for review which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction Administrator will provide training and proof of quarterly logs to LPA by 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 having a needs and service plan (LIC 625) for resident #1 (R1) which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction Administrator will create and provide a needs and service plan (LIC625) for resident #1 (R1) to LPA by POC due date.

Official classification

Type A

Official code

87211(d)(5)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: (d) The licensee shall notify the Department, the State Long-Term Care Ombudsman, all residents, and, if applicable, their representatives, in writing within two business days of any of the following specified events, or knowledge thereof: (5) A utility company has sent a notice of intent to terminate electricity, gas, or water service on the property within not more than 15 days of the notice. Deficient Practice Statement Based on [(observation, interview, record review)], the licensee did not comply with the section cited above by not paying the gas since November 2025, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/26/2026 Plan of Correction Administrator will provide proof of minimum payment of $375 to the gas company and submit a plan to ensure timely reporting of financial distress to LPA by POC due date.

Official classification

Type B

Official code

87203

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. Deficient Practice Statement Based on [(observation, interview, record review)], the licensee did not comply with the section cited above by not having charged fire extinguishers, the two (2) fire extinguishers at the facility are dated from the year 2020 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction Administrator will purchase and provide proof of charged fire extinguishers to LPA by POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: 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. Deficient Practice Statement Based on [(observation, interview, record review)], the licensee did not comply with the section cited above by having bedroom closet doors in room #2 and #4 in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction Administrator will repair closet doors in bedrooms #2 and #4 and provide proof to LPA by POC due date

Official classification

Type A

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (g) All personnel records shall be maintained at the facility. Based on observation, interview, and record review, the licensee did not comply with the section cited above by not having personnel records for Residents 2,3,4, & 5 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee has agreed to provide LPA with all required documents for all residents by the POC due date.

Deadline recorded: Sep 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances ... All food shall be selected, stored, prepared and served in a safe and healthful manner. Based on observation, interview, and record review, the licensee did not comply with the section cited above by having expired non perishable foods which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

LPA had Caregiver toss the expired food LPA observed, Licensee has agreed to go through the rest of the pantry to toss out anymore expired non perishable foods and conduct a training for all staff and provide proof to LPA by due date.

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

Official classification

Type A

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. Based on observation, the licensee did not comply with the section cited above, by having live crockroaches in the main hallway near the dining room and not ensuring resident shared bathroom is providing clean water which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee has agreed to call a pest control company to conduct an inspection and a plummer to inspect the facilities water and provide a schedules appointment along with an invoice to LPA by POC due date.

Deadline recorded: Sep 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. Based on observation the licensee did not comply with the section cited above by not identifying tap water that delivers water above 125 degree F by warning signs which poses/posed a immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee stated to put a warning sign on tap water that delivers hot water above 125 degree F and submit proof to LPA by POC due date.

Deadline recorded: Sep 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: Based on observation and interviews, the licensee did not comply with the section cited above by using the living room and a residents' bedroom as a staff bedroom/living area which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee has agreed to clean the living room and staff befroom to it's original state reflecting the floor plan.

Deadline recorded: Sep 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained ...a temperature of not less than 105 and not more than 120 degree F. Based on observation the licensee did not comply with the section cited above by not ensuring the hot water temperature maintained 105 and not more than 120 degree F which poses/posed a immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee has agreed to adjust the water temperature to ensure it is in complaint of 105 to 120 degree F and provide proof to LPA by POC due date.

Deadline recorded: Sep 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)

Regulation authority

HSC

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: Based on observation, record review, and interviews the Licensee did not comply with the section cited above by not having a background clearance for S3

Official plan of correction

Licensee will obtain a background clearance for S3 and provide proof to LPA by POC due date.

Deadline recorded: Sep 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(4)

Regulation authority

HSC

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review ...(4) 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. Based on observation, record review, and interviews the Licensee did not comply with the section cited above by not having S4 associated to the facility

Official plan of correction

Licensee has agreed to associate S4 to the facility and provide proof to LPA by POC due date.

Deadline recorded: Sep 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care 87465(h)(2) The following requirements shall apply to medications: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible... This requirement was not met as evidenced by: Based upon observation, LPA requested to audit medications and observed the medications cabinet to be unlocked. The staff did not ensure that the centrailly stored medications were locked and inaccessible to residents, which poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator will conduct a staff training on centrally stored medications, review section 87645 and sign a Statement of Understanding and submit proof to LPA by the Plan of Correction due date.

Deadline recorded: Sep 16, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87633(f)(1)

Regulation authority

CCR

What the official deficiency says

87633 Hospice Care of Terminally Ill Residents (f) The licensee shall maintain a record of all hospice-related training provided... (1) The record of each training session shall specify the names... This requirement was not met as evidenced by: Based upon record review, LPA did not observe staff training specifically related to hospice care. The facility did not ensure that staff were trained in hospice care which poses an immediate risk to the health and safety of residents in care.

Official plan of correction

Administrator will make arrangements with the Hospice agency to provide training for staff and submit proof to LPA by Plan of Correction (POC) due date.

Deadline recorded: Sep 16, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(1)(A)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements(1)(A) (1) A written report shall be submitted to the licensing agency... (A) Death of any resident from any cause regardless of where the death occurred... This requirement was not met as evidenced by: Based upon record review, LPA did not observe a Death Report. The Administrator did not ensure that the death reporting requirements were followed which posed a potential health and safety risk to residents in care.

Official plan of correction

The Administrator will review the Reporting Requirements and submit a Statement of Understanding to LPA by Plan of Correction (POC) due date.

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

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a centrally... This requirement was not met as evidenced by: Based upon a request to review records, LPA observed a few of the current resident files but not the requested file. The facility did not ensure that all residents files were available for review which posed a potential health and safety risk to residents in care.

Official plan of correction

Administrator will locate Resident 1 (R1) file and provide a copy to LPA by Plan of Correction (POC) due date.

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

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above by having bleach unlocked under the sink in the bathroom and knives unlocked in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2025 Plan of Correction Administrator has agreed to train staff and send proof of POC to LPA by POC due date.

Official classification

Type A

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 observation, interview, and record review, the licensee did not comply with the section cited above by Staff #1 did not have a CPR certificate on file, as well as other caregivers which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2025 Plan of Correction Administrator has agreed to send LPA all staff 's CPR certificates by POC due date.

Official classification

Type A

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

(g) All personnel records shall be maintained 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 not having personnel records for Residents 2,3, & 4 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2025 Plan of Correction Administrator has agreed to send proof of personnel records to LPA by POC due date.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 staff #1 and #2 are not associated to facility on guardian which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2025 Plan of Correction Administrator has agreed to associate staff #1 and #2 to facility on guardian and submit proof to LPA by POC due date.

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) 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 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 having expired non perishable foods which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2025 Plan of Correction Administrator has agreed to toss out all expired foods, train staff, and submit proof of training to LPA by POC due date.

Official classification

Type A

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 observation, interview, and record review, the licensee did not comply with the section cited above by not having a Medication Administration Record which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2025 Plan of Correction Administrator has agreed to create a MAR for all residents, train staff, and submit proof of MAR and training to LPA by 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 observation, interview, and record review, the licensee did not comply with the section cited above by not having admission agreements, pre admission appraisal, physicians reports for residents #2,3,4 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2025 Plan of Correction Administrator has agreed to submit proof of documents stated above to LPA by POC due date.

Official classification

Type B

Official code

87219(a)

Regulation authority

CCR

What the official deficiency says

(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above by not offering activities for residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/15/2025 Plan of Correction Administrator has agreed to create an activites plan for residents and submit proof to LPA by POC due date.

Official classification

Type B

Official code

1569.695(e)(1)

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: (1) A resident roster with the date of birth for each resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above by not having an updated resident roster which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2025 Plan of Correction Licensee has agreed to create a new resident roster and submit proof to LPA by POC due date.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff This requirement is not met as evidenced by: LPA request files for resident 1, 2, 3, & 4 that could not be provided or the file was not complete for review. This is a potential health and safety risk for residents in care.

Official plan of correction

The licensee has agreed to provide complete files for R1, R2,R3 ,R4 The administrator has also agreed to provide a written statement of understanding of the cited regulation.

Deadline recorded: Oct 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)

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, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for ..... This is requirement is not being met as evidenced by: LPA requested special insident reports for R1 and R4 and there were no reports available for review. This is a potential health and safety risk for residents in care.

Official plan of correction

Licensee has agreed to provide incident reports for R1 and R4. The administrator has also agreed to provide a written statement of understanding of the cited regulation signed by all staff members.

Deadline recorded: Sep 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(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: (h) All personnel records shall be retained for at least three (3) years following termination of employment....This requirement is not met as evidenced by: During the visit LPA Allen requested personnel files that could not be provided. This is requirement is not being met as evidenced by: S1 and S2 did not have a file for review. This is a potential health and safety risk for residents in care.

Official plan of correction

The licensee has agreed to provide complete files for all staff members eligible to work at the facility. Administrator has also agreed to provide a statement of understanding of the cited regulation.

Deadline recorded: Oct 7, 2024. 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

(a) An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. This is requirement is not being met as evidenced by: LPA noted that annual fees have not been paid.

Official plan of correction

The licensee has agreed to pay facilitiy fees by the POC date and provide proof that fees have been paid.

Deadline recorded: Oct 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87355(a)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, resident... This requirement was not met as evidenced by: LPA observed two staff members who were not associated to the faciity.Rosalinda Antonio Penela and Carmelita Dadivas did not have clearance or associated to the facility.

Official plan of correction

The licensee has agreed to prived proof of Criminal Record Clearance for Staff membersRosalinda Antonio Penela and Carmelita Dadivas

Deadline recorded: Oct 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

(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, by compliance with the following: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.This requirement was not met as evidenced by: LPA observed Residents medications were transferred between containerswhich poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The licensee has agreed to provide training to all staff members to ensure medications remain in it original packaging and provide a written statement of understanding of the cited regulation signed by all staff members.

Deadline recorded: Oct 7, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(23)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, the licensee did not comply with the section cited above by having uncovered perishable food items in kitchen refrigerator; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/25/2024 Plan of Correction The Licensee/Administrator shall submit to the Licensing Agency a self certification stated that they have read and understand the regulation cited.

Official classification

Type A

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 LPA observations, the Licensee did not comply with the section cited above by LPA observed medications that resident (R1), (R2), (R3), (R4), and (R5) were taking were not all documented and did not have a record of dosages; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/25/2024 Plan of Correction The Licensee shall submit to the Licensing agency a self certfication that resident's have a updated medication dosages on file.

Official classification

Type A

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, the licensee did not comply with the section cited above by LPA observed in resident #2 (R2) had medication box, medication in a zip-lock bag with no prescription label. LPA observed in resident #3 (R3) medication box, a medication that was missing the name of medication, dosage, and instructions; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/25/2024 Plan of Correction The Licensee shall submit to the Licensing Agency proof of in-service medication management staff training by POC due date.

Official classification

Type B

Official code

87412(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations, the licensee did not comply with the section cited above by not providing LPA upon demand access to staff files; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2024 Plan of Correction The Licensee shall submit to the Licensing Agency documentation of infection control plan, four (4) staff health screening, four (4) employee personal records, and documentation of either a criminal record clearance or a criminal record exemption for four (4) staff.

Official classification

Type B

Official code

87412(c)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations, the licensee did not comply with the section cited above by not maintaining record of staff on the job training, dementia training, and first aid training; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2024 Plan of Correction The licensee shall submit to the Licensing Agency documentation of four (4) staff training documentation by POC due date.

Official classification

Type B

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 LPA observations, the licensee did not comply with the section cited above by not maintaining a pre-admission appraisal on file for resident #1 (R1) on file; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2024 Plan of Correction The Licensee shall submit to the Licensing Agency documentation of a resident appraisal for R1 and R2 by 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 LPA document review, the licensee did not comply with the section cited above by not having documentation of a drill 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: 04/19/2024 Plan of Correction The Licensee shall submit to the Licensing Agency proof of drill conducted with staff by POC due date.