JASMIN TERRACE AT YUCCA VALLEY

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors..This requirement is not met as evidenced by: The licensee did not comply with the section cited above by LPA observed the carpet in bedroom 110 was stained and soiled with dirt; which poses a potentional health, safety and personal rights risk to persons in care.

Official plan of correction

The Administrator has agreed to clean the carpet and provide photo proof by POC due date.

Deadline recorded: Aug 14, 2026. 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(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: The Licensee did not comply with section cited above by a hand saw left unlocked and unattended in the facility's dining room; which poses an immediate, health, safety, and personal rights risk to persons in care.

Official plan of correction

Correction: the hand saw was removed and placed in a locked box.

Deadline recorded: Mar 16, 2026. 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 LPAs observations, the licensee did not comply with the section cited above by kitchen knives were left unlocked and attended by staff; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/06/2025 Plan of Correction The Licensee/Administrator has acquired a locked box to store kitchen knives.

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 LPAs record review, the licensee did not comply with the section cited above staff #1 (S1) first aid/CPR training certification was expired; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2025 Plan of Correction The Licensee/Administrator shall provide proof of current first aid/CPR training for S1 by POC date.

Official classification

Type B

Official code

1569.626(a)(2)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (2) Eight hours of in-service training per year on the subject of serving residents with dementia. This training shall be developed in consultation with individuals or organizations with specific expertise in dementia care or by an outside source with expertise in dementia care. In formulating and providing this training, reference may be made to written materials and literature on dementia and the care and treatment of persons with dementia. This training requirement may be satisfied in one day or over a period of time. This training requirement may be provided at the facility or offsite and may include a combination of observation and practical application. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observations, the licensee did not comply with the section cited above by not maintaining record of annual dementia for staff #2 (S2) on file for LPA review. Last training was conducted in September 2023, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2025 Plan of Correction The Licensee/Administrator shall provide documentation of current dementia training for S2 by 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 LPAs records review, the licensee did not comply with the section cited above in by not maintaining admissions agreements that are signed and dated by resident #1, #2, and #3 or resident's representatives which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2025 Plan of Correction The Licensee/Administrator shall provided to the Licensing Agency documentation of admissions's agreements signed by resident or resident's authorized representatives by POC due date.

Official classification

Type B

Official code

87412(f)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (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. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observations, the licensee did not comply with the section cited above by Administrator's personnel file was not at the facility for LPAs to review. File is kept at the corporate office; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/24/2025 Plan of Correction The Licensee/Administrator shall provide to the licensing agency a statement of understanding on the regulation cited by POC due date.

Official classification

Type B

Official code

87506(e)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by: The Licensee/Administrator did not comply with the section cited above by not maintaining copies or orginals of R1's facility records for three years after being discharged from the facility for LPA review.

Official plan of correction

The Licensee and/or Administrator shall review the regulation cited and submit a statement of understanding to the licensing agency by POC due date.

Deadline recorded: May 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(e)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by: The Licensee did not comply with the section cited above by not maintaining copies or orginals of R1's facility records for three years after being discharged from the facility for review.

Official plan of correction

The Administrator has agreed to provide licensing with requested resident records by POC due date.

Deadline recorded: Feb 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 (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...within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident...This requirement is not met as evidenced by: The Licensee did not comply with the section cited above by not reporting incidents that threatened the health and safety of R1, R2, R3, R4, and R5; which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Administrator stated that changes have been made as to staff self-reporting incidents to the Licensing Agency. The Administrator has agreed to submit LIC624 reports to the licensing agency on the incidents by POC due date

Deadline recorded: Oct 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) The facility shall be clean, safe, sanitary and in good repair at all times...this requirement is not met as evidenced by: The Licensee did not comply with the section cited above by not maintaining resident's room and facility hallway free of odor; and not maintaining resident's floor clean; which poses a potential health, safety and personal rights risks to persons in care.

Official plan of correction

During LPA's visit, staff mopped R1's bedroom floor and odors were removed. No further action required.

Deadline recorded: Oct 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269(a)(6)

Regulation authority

HSC

What the official deficiency says

H & S:1569.269(a)(6) Enumerated rights; severability: Residents of residential care facilities for the elderly shall have all of the following rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met at evidenced by: The Licensee did not comply with the section cited by facility staff were not competent in meeting R1 needs. Facility staff failed to properly supervise R1. Following R1 leaving facility premises on December 21, 2022, R1 was struck by a vehicle and killed while attempting to cross a highway. This posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

The Licensee/Adminstrator has agreed to provide in-service staff training on regulations: 87466 Observation of the resident, 87463 reappraisals and 87461 Mental Condition as submit to proof of training to the Licensing Agency by POC due date.

Deadline recorded: Oct 23, 2024. 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

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observations, the licensee did not comply with the section cited above by not maintaining facility free of mosquitos and having roaches in room#140; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/24/2024 Plan of Correction The Licensee/Administrator shall submit a plan to prevent mosquitos in facility and submit documentation of outside pest control services by POC due date.

Official classification

Type A

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 LPAs observations, the licensee did not comply with the section cited above by maintaining hot water temperature above 105 degrees F in four (4) resident bathrooms; which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/24/2024 Plan of Correction The Licensee/Administrator shall submit to the Licensing Agency documentation of water within regulation temperatures by POC due date.

Official classification

Type B

Official code

87307(a)(3)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observations, the licensee did not comply with the section cited above by not having a required chair in room#115; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/06/2024 Plan of Correction The Licensee/Administrator shall submit to the Licensing Agency documentation of a chair in resident's room by POC due date.

Official classification

Type B

Official code

87219(f)

Regulation authority

CCR

What the official deficiency says

(f) In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities. The program of activities shall be written, planned in advance, kept up-to-date, and made available to all residents. The responsible employee shall have had at least one year of experience in conducting group activities and be knowledgeable in evaluating resident needs, supervising other employees, and in training volunteers. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observations, the licensee did not comply with the section cited above by not having an up-to-date activity plan on file; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/06/2024 Plan of Correction The Licensee/Administrator shall submit to the Licensing Agency a current written activity plan 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: Deficient Practice Statement Based on LPAs record review, the licensee did not comply with the section cited above by resident#6(R6's) physicians report was not signed by the resident and/or legal representative; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/06/2024 Plan of Correction The Licensee/Administrator shall submit to the Licensing Agency proof of signed physicians report by POC due date.

Official classification

Type B

Official code

87507(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observations, the licensee did not comply with the section cited above by not maintaining record of (R1s),(R2s),(R3s),(R4s),(R5s) admissions agreements on file;which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/06/2024 Plan of Correction The Licensee/Administrator shall submit to the Licensing Agency documentation of admissions agreement for R1, R2, R3, R4, and R5 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 LPAs record review, the licensee did not comply with the section cited above by not maintaining a current disaster drill conducted with staff on file; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/06/2024 Plan of Correction The Licensee/Administrator shall submit to the Licensing Agency a current disaster drill with staff by POC due date.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space(a) Disinfectants, cleaning solutions, poisons...and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients..this requirement is not met by: Based on LPA observations the Licensee/Administrator did not comply with the section cited above by having a Raid insecticide spray next to resident's bed; which poses an immedicate health, safety and/or personal rights risk to persons in care.

Official plan of correction

The Administrator removed the can from resident's bedroom and placed inaccessible to residents.

Deadline recorded: Aug 22, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

REPORTING REQUIREMENTS (a)Each licensee shall furnish to the licensing agency…(1)A written report…within seven days...(D)Any incident which threatens the welfare, safety or health of any resident…This requirement is not met by: The licensee did not provide the licensing agency with written reports regarding R1 injuries which occurred on 6/11/23 and 6/15/23 with 7 days; which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Administrator has agreed to provided the SIR for the altercation between R1 and R2 by the POC 12/10/23

Deadline recorded: Dec 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPA observed roaches and insects on several areas of the kitchen; Which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/03/2023 Plan of Correction Administrator to provide proof of treatment by POC date

Official classification

Type A

Official code

87705(h)

Regulation authority

CCR

What the official deficiency says

(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. The outdoor space for Dementia residents is not completely enclosed with open access to the street. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/03/2023 Plan of Correction Administrator/Licensee to provide proof of correction that the area is completely enclosed by POC 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 observation and record review, the licensee did not comply with the section cited above. LPA found two (2) resident files with missing admissions agreements; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2023 Plan of Correction Administrator/Licensee to provide copies of admissions agreement for Resident #1 and Resident #2 to licensing agency by poc 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 record review, the licensee did not comply with the section cited above in. LPA observed missing admissions agreements which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/15/2023 Plan of Correction Administrator shall submit a statement of understanding of the above regulation by due date.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. T Deficient Practice Statement This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. Staff#1 did not have required health screening; which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/11/2023 Plan of Correction Licensee/Administrator to submit health screening records for staff #1 to the licensing agency by POC date.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

Criminal Record Clearance (e)All individuals subject to a criminal record review...prior to working...in a licensed facility shall...(1)Obtain a California clearance or a criminal record exemption...This requirement is not met as evidenced by: Facility records and staff interviews reveal, Licensee did not ensure a criminal record clearance was obtained for Staff #1 (S1) prior to employment, which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Administrator stated S1 is no longer employed at the facility. Administrator to submit a statement of understanding that the facility will ensure that all staff and/or volunteers are criminally cleared prior to start date and submit statement to the Licensing agency by POC date.

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

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

Incidental Medical & dental care (a) A plan..shall be by compliance with the following: (1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions & needs of residents. This requirement is not met as evidenced by: Based on interviews and record review, R1 had multiple physical injuries between 4/28/23 and 6/11/23 that required follow-up medical care. However, it was not until 6/15/23, when R1 sustained subsequent injuries that R1 was sent to the hospital, which poses and immediate health, safety and personal rights risks to residents in care.

Official plan of correction

Administrator to provide proof of R1 follow-up visit with primary physician's to the licensing agency by POC date.

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

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

REPORTING REQUIREMENTS (a)Each licensee shall furnish to the licensing agency…(1)A written report…within seven days...(D)Any incident which threatens the welfare, safety or health of any resident…This requirement is not met by: The licensee did not provide the licensing agency with written reports regarding R1 injuries which occurred on 6/11/23 and 6/15/23 with 7 days; which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The Administrator provided LPA with one (1) incident report. Administrator provide the additional incident report by shall provide by POC date.

Deadline recorded: Aug 7, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(f)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records(f)All personnel...shall be in good health...Good physical health shall be verified by a health screening...performed by a physician not more than six (6) months prior to or seven (7) days after employment. This condition is not met by: The facility did not ensure that staff 1 (S1) and staff 2 (S2) had a verifiable health screening that indicates whether the person is physically qualified to perform the duties to be assigned. Which poses health, safety, and personal rights risk to residents in care.

Official plan of correction

Licensee shall provide community care licensing documentation of S1 & S2 completed health screening by POC date. .

Deadline recorded: Apr 7, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements(a)Each licensee shall furnish...reports...including ...(1)A written report shall be submitted to the licensing agency within 7 days.. of the occurrence of...(D)Any incident which threatens the welfare, safety or health...of resident. This requirement was not met by

Official plan of correction

Licensee provided LPA with incident report on 4/3/23. Licensee will provide training to all staff regarding reporting requirements, overview of regulation and submit proof of training to Community Care Licensing by POC date

Deadline recorded: Apr 7, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working...(1) Obtain a California 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 allowing Staff #5 to work at the facility without criminal background clearance since 06/07/2021 which pose immediate health, safety and personal rights risk to resident in care.

Official plan of correction

Licensee stated to submit Signed Statement of Understanding on CCR 87355(e)(1) to LPA Brown by POC due date. The licensee stated to remove S5 from the facility and not allow S5 to work at the facility until S5 has a criminal background clearance.

Deadline recorded: Jan 13, 2023. 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...(2) Request a transfer of a criminal record clearance as specified... 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 failure to associate Staff # 4 to the facility which pose immediate health, safety and personal rights risk to resident in care.

Official plan of correction

Licensee stated to submit signed Statement of Understanding on CCR 87355(e)(2) and submit to LPA Brown by POC due date. Licensee associated/transferred S4 Criminal Background clearance to the facility last 08/09/2022, POC cleared.

Deadline recorded: Jan 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall... (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually...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 failure to ensure that R2 have annual medical assessment and reappraisal done annually which pose immediate health, safety and personal rights risk to resident in care.

Official plan of correction

Licensee stated to train all staff on CCR 87705(c)(5) and submit Training Log to LPA Brown by POC due date. Licensee stated to submit signed Statement of Understanding on CCR 87705(c)(5) to LPA Brown by POC due date

Deadline recorded: Jan 13, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(9)

Regulation authority

CCR

What the official deficiency says

87555.General Food Service Requirements. (b)The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by having expired dry food in the kitchen panty. LPA found expired peanut butter, expired soup base chicken, and expired sauerkraut in the kitchen pantry which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2022 Plan of Correction The licensee has agreed to read regulation 87555 entirely and send LPA self-certify letter that the regulation was read and understood. The license has agreed to train kitchen staff on how to check for expired food. The licensee has agreed to send LPA signed and dated confirmation that each kitchen staff has been trained in food safety.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355.Criminal Record Clearance. (e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above by allowing S1 to work at the facility for four (4) months without a criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/10/2022 Plan of Correction The licensee has agreed to read regulation 87355 entirely and send LPA self-certify letter that the regulation was read and understood. The license has agreed to remove S1 from the facility and not allow S1 to work at the facility until S1 has a criminal background clearance.

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 and sanitary and in good repair at all times. Maintenance shall include ... This requirement is not met as evidenced by: Based on observations and interviews, the Licensee did not comply with the section cited above by having a pull button/cord in room 116 near the resident bed in disrepair which poses an immediate health, safety and personal rights risks to residents in care.

Official plan of correction

Licensee stated to replace and/or repair pull button/cord near resident bed at room 116 and submit proof to LPA Brown by POC due date. Also, LIcensee stated to check all residents room that the pull button/cord near resident beds and bathrooms are working and submit proof to LPA Brown by POC due date.

Deadline recorded: Apr 26, 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, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven ... Based on observations, interviews and record review, the Licensee did not comply with section cited above by not reporting incidents of unwitnessed fall of Resident 1 (R1) at the facility to Community Care Licensing Division (CCLD) which poses potential health, safety and personal rights risk to resident in care.

Official plan of correction

Licensee stated to report all incidents at the facility to CCLD and train staff on CCR 87211(a)(1) Reporting Requirements and submit Training Log to LPA Brown by POC due date. Also, Licensee stated to submit Statement of Understanding on CCR 87211(a)(1) to LPA Brown by POC due date.

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