GRACIOUS LIVING

Official classification

Type A

Official code

1569.269(a)(29)(E)

Regulation authority

HSC

What the official deficiency says

Enumerated rights; severability... (a) Residents of residential care facilities for the elderly shall have all of the following rights:... (29) To manage their financial affairs. A licensee shall not require residents to deposit their personal funds with the licensee. Except as provided in approved continuing care agreements, a licensee, or a spouse, domestic partner, relative, or employee of a licensee, shall not do any of the following:...(E) Enter into a loan or promissory agreement or otherwise borrow money from a resident This requirement was not met as evidenced by: Based on interviews, record review, the Licensee received personal funds from R1 for lifetime services and supplies that facility is not licensed to provide. Licensee also entered into a loan agreement with R1. This posed an immediate Health, Safety, or Personal Rights risk to residents in care.

Official plan of correction

The Licensee has agreed to read over regulation 1569.269(a)(29)(E) and provide LPA with a signed acknowledgement acknowledging and understanding the regulation. The Licensee will also provide LPA with the revoking process of the loan agreement dated 4/25/2025, along with the lifetime service contract. Furthermore, the Licensee will provide LPA with a repayment plan or the process of repaying back R1 by POC date: 6/15/2026.

Deadline recorded: Jun 15, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(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 and record review, the licensee did not comply with the section cited above by not ensuring a centrally stored medication log was updated and completed for Resident #1 (R1) and Resident #2 (R2), which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/15/2026 Plan of Correction Administrator stated to send updated and completed centrally stored medication log by 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 and record review, the licensee did not comply with the section cited above by not ensuring R1 and R2 have a completed needs and services plan, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/15/2026 Plan of Correction Administrator stated to send LPA updated needs and services plan for R1 and R2 by POC due date.

Official classification

Type B

Official code

87468.2(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not being met as evidenced by: R2, R3, R4's information was given to R1's representative whom is not a legal repesentative of R2, R3, and R4. This poses a potential health and safety risk.

Official plan of correction

Licensee will ensure each document for a resident that is requested that it will be sent to the legal representative and conduct a secondary check prior to sending requests with management. Licensee will review regulation and email LPA a self-certifying statement of understanding and compliance of the regulation by POC due date.

Deadline recorded: Nov 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements : (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not being met as evidenced by: Facility did not report to CCLD that 911 was called for R2 and was taken to the hospital. This poses a potential health and safety risk.

Official plan of correction

Licensee will report any incidents involving residents within the time frame as required, document and maintain records of confirmation of incidents sent to CCLD. Licensee will review regulation and conduct training and submit copy by email to LPA by POC due date.

Deadline recorded: Nov 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

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 observation, interview and record review, the licensee did not comply with the section cited above by not making the personnel records available to the licensing agency to inspect, and audit which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/16/2024 Plan of Correction Licensee stated to submit Signed Statement of Understanding on CCR 87421(f) to LPA Brown on Plan of Correction (POC) due date.

Official classification

Type A

Official code

87355(e)

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: 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 obtaining a ciminal record clearance for Staff #3 before allowing S3 to work at the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/16/2024 Plan of Correction Licensee stated to obtain S3 criminal record clearance and submit proof to LPA Brown on Plan of Correction (POC) due date. Licensee removed S3 at the facility during the visit. Plan of Correction (POC) cleared.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 regulating the hot water in residents' shared bathroom between 105 degrees Fahrenheit to 120 degrees Fahrenheit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2024 Plan of Correction Licensee resgulated the hot water temperature to residents shared bathroom to 119 degrees Fahrenheit during the visit. Plan of Correction (POC) cleared.

Official classification

Type B

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(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. 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 identifying tap water that delivers water above 125 degree F by warning signs which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2024 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 Brown on PLan of Correction (POC) due date.

Official classification

Type B

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 maintaining all personnel records at the facility which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2024 Plan of Correction Licensee stated to submit signed statement of understanding on CCR 87412(g) to LPA Brown at Plan of Correction (POC) due date.

Official classification

Type B

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, record review, the licensee did not comply with the section cited above by not transferring Staff #1 (S1) criminal record clearance to the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2024 Plan of Correction Licensee stated to transfer S1 criminal record clearance to the facility and submit proof to LPA Brown at Plan of Correction (POC) due date.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 staffs receive appropriate training in first aid from persons qualified by such agencies as teh American Red Cross which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2024 Plan of Correction Licensee stated to submit proof of staffs completed First Aid/CPR Trainings to LPA Brown at Plan of Correction (POC) due date.

Official classification

Type B

Official code

87507(c)

Regulation authority

CCR

What the official deficiency says

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by not signing the Admission Agreement issued to one (1) resident which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2024 Plan of Correction Licensee stated to submit Signed Statement of Understanding on CCR 87507(C) to LPA Brown at Plan of Correction (POC) due date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

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

Official plan of correction

POC Due Date: 04/26/2024 Plan of Correction Licensee stated to conduct fire drill and eathquake drill and submit proof to LPA Brown at Plan of Correction (POC) due date.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and (record review, the licensee did not comply with the section cited above by allowing two (2) residents with half bed rail but no written order from their physician indicating the need for half bed rail for mobility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/30/2024 Plan of Correction Licensee stated to obtain written order from two (2) residents physician indicating the need for half bed rail for mobility and submit copy to LPA Brown at Plan of Correction (POC) due date.

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing one (1) resident to have full bed rail who's not on hospice and without approved exception from CCLD which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/30/2024 Plan of Correction Licensee stated that they will submit exception request for full bed rail to CCLD and submit to LPA Brown on Plan of Correction (POC) due date.

Official classification

Type B

Official code

87705(c)(3)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: (A) Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living; 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 providing the required dementia trainings to staffs at the facility which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/26/2024 Plan of Correction Licensee stated to train all staff on the required Dementia Training and submit proof to LPA Brown on Plan of Correction (POC) due date,

Official classification

Type A

Official code

1569.695(a)

Regulation authority

HSC

What the official deficiency says

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 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 completed and maitained at the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/16/2024 Plan of Correction Licensee created and posted the facility's Emergency Disaster Plan during the visit. Plan of Correction (POC) cleared.