BONITA VILLA SENIOR LIVING

Official classification

Type A

Official code

87413(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) In each facility:(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement was not met as evidenced by; Per LPA observation the facility had 4 staff during NOC shift. The medtech on duty failed to request or advise managment of the need for additional staff. This posed an immediate health and safety risk to 81 of 81 residents in care.

Official plan of correction

The licensee stated they will conduct a staff inservice by 8/22/26 and will send the itinerary and sign in log to LPA. Will rearrange schedule so that a manager is on site for every shift change.

Deadline recorded: Aug 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.695(f)(2)(A)

Regulation authority

HSC

What the official deficiency says

A facility maintains a set of keys for residence rooms, staff are not able to promptly access an occupied resident room.This requirement has not been met as evidenced by: Based on observation and interview, the only caregiver (S1) responsible for 86 residents, did not have key access to 1 of 86 resident rooms. It took approximently seven minutes to obtain the correct key. This poses an immediate health risk to 1 of 98 residents in care.

Official plan of correction

License agrees to provide direct care staff on all shifts key access to all occupied rooms by the end of the business day today.

Deadline recorded: Aug 8, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87413(a)(1)

Regulation authority

CCR

What the official deficiency says

In each facility: when scheduled regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement has not been met as evidence by: Based on observation and interview, On 8/8/26, two of five scheduled caregivers were absent from their scheduled shift and coverage by qualified personnel was not in place for 3. This poses an immediate health risk to 98 of 98 residents in care.

Official plan of correction

License agrees to provide adequate staffing on all shifts for residents in care by POC date.

Deadline recorded: Aug 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator qualifications and duties (a) when the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in section... This requirement has not been met as evidenced by: Based on observation and interview, there was not coverage by a designated substitute for the administror who has the qualifications adequate to be responsible and accountable for nanagement of the facility. This poses an immediate health risk to 98 of 98 residents in care.

Official plan of correction

Management agrees to submit to the department list of designees responsible for managing the facility in their absence, clarifying who is responsible and when by POC date.

Deadline recorded: Aug 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87611(e)

Regulation authority

CCR

What the official deficiency says

General requirements for allowable..in addition to 87465(a) and 87464(d) the license shall ensure that the resident is cared for in accordance with physician's orders, and the resident's medical needs are met. This requirement has not been met as evidenced by: Based on observation and interview, Staff did not follow the physician's orders for resident's dia This poses an immediate health risk to 1 of 98 residents in care.

Official plan of correction

Management agrees to provide training for staff to recognize the resident's that need meals prior to medications by POC date.

Deadline recorded: Aug 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review… (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)… This requirement was not met as evidenced by: Based on record review, the licensee permitted one medication technician (S1) to work in the facility on sixteen occasions from 7/12/26 through 7/30/2026 without first obtaining a background clearance transfer to the facility. This posed an immediate Health, Safety and Personal Rights Risk to 84 persons in care.

Official plan of correction

ED will review the staff schedule and check to see who is working with residents in care for Saturday – Tuesday and verify they are cleared to work with residents in care, by POC due date 08/08/26. Once ED is cleared to access Guardian, they will verify that all staff are cleared and associated to the facility prior to being scheduled to work by 08/14/2026.

Deadline recorded: Aug 8, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2: " In addition to the rights listed in Section 87468.1 [...] residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(4) To care, supervision, and services that meet their individual needs [...]. " This requirement is not met as evidenced by: Based on interviews and file review, the licensee did not comply with the section cited above in ensuring a resident's needs for feeding assistance were met, which poses an immediate health and safety risk to 1 out of 84 persons in care.

Official plan of correction

Licensee will conduct a reappraisal/redo the service plan for R1 that addresses and meets their current service needs. Licensee will submit proof to LPA by POC due date.

Deadline recorded: Aug 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87458(b)

Regulation authority

CCR

What the official deficiency says

87458(b): " The licensee shall obtain an updated medical assessment when required by the Department. " This requirement is not met as evidenced by: Based on interviews and file review, the licensee did not comply with the section cited above in ensuring an updated medical assessment was obtained as necessary for R1, which posed an immediate health and safety risk to 1 out of 84 persons in care.

Official plan of correction

Licensee obtained an updated medical assessment for R1. Licensee will conduct review of all resident files to ensure that each has a current/updated medical assessment as needed. Licensee will submit proof to LPA by POC due date.

Deadline recorded: Aug 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87101(c)(3)

Regulation authority

CCR

What the official deficiency says

87101(c)(3): ' " Care and Supervision " [...] involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents. [...]. " This requirement is not met as evidenced by: Based on interviews and file review, the licensee did not comply with the section cited above in ensuring bedridden care and supervision needs for R1 were met as necessary, which posed an immediate health and safety risk to 1 out of 84 persons in care.

Official plan of correction

Licensee will conduct review of R1's care plan in collaboration with R1's hospice team and update as necessary to reflect current care needs. Additionally, Licensee will coordinate an in-service training with staff on bedridden care. Licensee will submit proof to LPA by POC due date.

Deadline recorded: Aug 7, 2026. 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

87412(f): " All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. [...]. " This requirement is not met as evidenced by: Based on interviews and file review, the licensee did not comply with the section cited above in being able to provide staff records for review, which posed an immediate health and safety risk to all persons in care.

Official plan of correction

Licensee will submit requested staff records to LPA by POC due date.

Deadline recorded: Aug 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

87202 Fire Clearance (a) All facilities shall maintain a fire clearance… Prior to…retaining any of the following types of persons, the… licensee shall obtain an appropriate fire clearance… (2) Bedridden persons This requirement was not met as evidenced by: Per LPA observations and interviews with residents and staff, 3 out of 81 residents are bedridden, which the facility does not have a fire clearance for. This poses an immediate health and safety risk to 3 of 81 residents in care.

Official plan of correction

Executive Director agreed to submit the documentation requested by the fire department to determine if a bedridden fire clearance can be granted. Executive Director will copy LPA upon submission by POC due date.

Deadline recorded: Aug 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87101(c)(3)

Regulation authority

CCR

What the official deficiency says

" Care and Supervision " means those activities which if provided shall require the facility to be licensed. It involves assistance as needed with activities of daily living and the assumption of varying degrees of responsibility for the safety and well-being of residents...This requirment was not met as evidenced by. The facility did not supervise R1 properly when they reported hitting their head. Staff did not assess R1, did not call 911 for a suspected head injury, and did not complete or document hourly monitoring checks. This posed an immediate health and safety risk to R1.

Official plan of correction

The facility will retrain all caregivers and Med-Tech staff on fall response, suspected head injury protocol, and required documentation.• Training will be completed by [POC due date].• A copy of the training agenda and staff signatures will be submitted to CCL by 4/28/26

Deadline recorded: Apr 28, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87458(b)

Regulation authority

CCR

What the official deficiency says

(b) The licensee shall obtain an updated medical assessment when required by the Department. This requirement was not met as evidenced by; R1’s last medical assessment was dated 10/1/2020. The facility did not obtain updated assessments despite repeated falls, hospitalizations, and changes in condition. This posed an immediate health and safety risk to R1.

Official plan of correction

• The facility will immediately obtain an updated medical assessment for R1.• The Administrator will implement a tracking system to ensure all residents receive timely updated assessments.• Proof of the updated assessment and tracking system will be provided to CCL by 4/28/26.

Deadline recorded: Apr 28, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87463(e)(1)

Regulation authority

CCR

What the official deficiency says

(e) The licensee shall immediately, or as soon as reasonably possible, bring any significant change in condition... to the attention of the appropriate licensed medical professional... Documentation of such communication shall be added...This requirement was not met as evidenced by; The facility did not conduct reappraisals for R1 despite nine falls, multiple injuries, and hospitalizations, all of which constitute significant changes in condition. This posed an immediate health and safety risk to R1.

Official plan of correction

The facility will complete a written reappraisal for R1.• The Administrator will create a system to ensure reappraisals are completed after any significant change in condition.• Verification of completion will be submitted to CCL by 4/28/26.

Deadline recorded: Apr 28, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(16)

Regulation authority

CCR

What the official deficiency says

Residents in all residential care facilities for the elderly shall have all of the following personal rights:(16) To receive or reject medical care or other services. This requirement was not met as evidenced by. R1 did not receive timely medical evaluation or safe and healthful care after reporting a head injury. Staff failed to provide proper assessment and supervision. This posed an immediate health and safety risk to R1.

Official plan of correction

The facility will create and implement a written fall and head injury response policy.• All staff will be trained on the new policy.• Proof of policy implementation and staff training will be submitted to CCL by 4/28/26.

Deadline recorded: Apr 28, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(b)

Regulation authority

CCR

What the official deficiency says

87202 Fire Clearance (a). All facilities shall maintain a fire clearance… Prior to … retaining any of the following types of persons, the… licensee shall notify the licensing agency and obtain an appropriate fire clearance… (2) Bedridden persons This requirement was not met as evidenced by: Based on interview and record review, the licensee retained 1 Residents (R1-) without an approved fire clearance. This posed an immediate Health, Safety and personal rights risk to 1 of 96 Residents in care.

Official plan of correction

Licensee stated they will submit an LIC200/bedridden application and facility sketch to CCL and contact the Fire Department by POC due date.

Deadline recorded: Apr 16, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (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 was not met as evidenced by: Based on observation and interview, the licensee did not ensure that two records for one resident (R1) were readily available for facility and licensing staff. This posed a potential health safety and personal rights risk to 1 of 96 residents in care.

Official plan of correction

Licensee stated they will submit the requested records by POC due date. Licensee stated in the future they will submit records on the same day or within 24 hrs.

Deadline recorded: Apr 16, 2026. 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

87412(f)All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement was not met as evidenced by: Based on observation and interview, the licensee did not ensure that staffing schedules for January, February and March of 2026 were readily available for the licensing agency to inspect. This posed a potential health safety and personal rights risk to 1 of 96 residents in care.

Official plan of correction

Licensee provided LPA with staff schedules that were previously requested. Licensee stated in the future they will provide records immediately if not within 24 hrs.

Deadline recorded: Apr 16, 2026. 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 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.” This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 94 residents (R1), Licensee did not furnish a written incident and death report to both the licensing agency and the residents’ responsible person within seven days of occurrence. This posed a potential health and personal rights risk to persons in care.

Official plan of correction

As of the date of deficiency issuance, the RO has received a copy of the pertinent LIC624 Incident Report and LIC624A Death Report for R1. During today’s visit, Licensee E-mailed copies of the same to R1’s responsible person. These actions have resolved the violation, and no further Plan of Correction was formed.

Deadline recorded: Apr 6, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87224(a)(4)

Regulation authority

CCR

What the official deficiency says

The licensee may evict a resident for one or more of the reasons listed in Section... Thirty (30) days written notice to the resident is required...If, after admission, it is determined that the resident has a need not previously identified...This requirement was not met as evidenced by: The facility refused to readmit R1 after hospitalization and did not serve any written eviction notice or provide reasons and supporting facts at least 30 days prior to the eviction date. This posed an immediate personal rights risk to 1 of 1 of 91 residents in care.

Official plan of correction

The licensee shall readmit R1 if and will issue a compliant 30 day eviction notice with reasons, facts, and relocation assistance. Staff will be trained on eviction requirements, and proof of training and policy updates will be submitted to CCL.

Deadline recorded: Mar 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1

Regulation authority

CCR

What the official deficiency says

Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidenced by: By refusing R1’s readmission and leaving them at the hospital without a lawful discharge plan or safe relocation, the facility failed to ensure safe, healthful and comfortable accommodations and continuity of care, infringing on R1’s personal rights

Official plan of correction

The licensee will create a readmission/relocation protocol ensuring residents returning from hospitals receive safe placement and proper discharge planning. Staff will receive personal rights training, and documentation of the protocol and training will be submitted to CCL by the due date.

Deadline recorded: Mar 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(b)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...A written report shall be submitted to the licensing agency and to the person responsible for the resident...Any serious injury as determined by the attending physician...This requirement was not met due to: R1 tested positive for COVID. Facility records show internal staff were notified, but RP was not informed of the diagnosis. CCL did not receive an incident report. Failure to notify RP of a significant change in condition violates reporting requirements and poses a health, safety and personal rights risk.

Official plan of correction

Licensee stated they will review title 22 regulations on reporting requirements and will conduct a staff training on reporting incidents to both CCL and residents' responsible parties. ED will submit to LPA training log by POC due date.

Deadline recorded: Mar 9, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468(a)(8)

Regulation authority

CCR

What the official deficiency says

(a)Each resident shall have personal rights which include...(8) To have his/her... responsible persons... informed by the facility of activities related to his care or services...This requirement was not met as evidenced by: Based on interviews and records review the licensee did not inform R1's responsible person of the 30 day eviction which is related to R1's care. Failure to comply presented a substantial threat to the mental health and safety of R1.

Official plan of correction

Licensee stated that they will develop and implement a procedure to properly deliver 30 day notices that can include making calls to families and mailing the notice. Licensee wil submit the new plan/procedure to LPA by POC due date.

Deadline recorded: Jan 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights... (a)In addition to… 87468.1… residents… shall have… the following… rights: (4) to care, supervision… that meet their… needs and are delivered by staff… sufficient in numbers, qualifications, and competency… This requirement was not met as evidenced by Based on interview and record review, the Licensee did not ensure that R1 received care, supervision and services required by their medical condition, resulting in their fall, fracture, and contributing to their death. This posed an immediate Health, Safety, and Personal Rights risk to 1 of 99 persons in care.

Official plan of correction

Licensee stated that they will provide a staff training regarding supervision and identifying residents needs and having a staff on call to cover shifts. Licensee will send LPA training itinerary by POC due date.

Deadline recorded: Dec 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on interview, the facility did not render housekeeping services to one resident (R1) as agreed. This posed a potential health, safety and personal rights risk to 1 of 99 residents in care.

Official plan of correction

Licensee stated that maintenance director will conduct room audits and train staff on how to report issues to management. Licensee will send training log/audit by POC due date

Deadline recorded: Jan 22, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse… this requirement was not met as evidenced by: Based on interview and records review, facility staff did not protect one resident (R2) from physical abuse by a resident with a known history of aggression (R1), which posed an immediate health, safety and personal rights risk to 2 of 99 residents in care.

Official plan of correction

Licensee stated they will conduct a staff training regarding resident on resident altercaions to prevent from occuring again. LIcensee will submit signed training log to LPA by POC dated 1/26/25. The LIC9099-D page was amended to correct deficiency type and verbiage.

Deadline recorded: Jan 26, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

...residents in ... residential care facilities for the elderly shall have all of the following personal rights:To care, supervision... that meet their individual needs and are delivered by staff that are sufficient in numbers... and competency to meet their needs. This requirement was not met as evidenced by: R1 who has mild cognitive impairment and is not permitted to leave the facility unsupervised, was able to leave the facility. R1 was located several hours later by an Officer in La Mesa. The facility did not ensure proper supervision, which posed an immediate health and safety risk to R1.

Official plan of correction

Licensee stated that after the incident R1 was placed on " care plan " and is checked on 3-4 times per shift. The Licensee will also conduct a Staff training on elopement prevention and emergency response. Facility will submit plan to LPA by POC due date. Proof of staff training and updated policies must be submitted to the Department by POC due date.

Deadline recorded: Dec 23, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident The licensee shall ensure that residents are... observed for changes in physical, mental, emotional and social functioning and that... assistance is provided... This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not assist a resident with a history of aggression, resulting in a resident-on-resident altercation causing injury to 1 resident [R1], posing an immediate health, safety, and personal rights risk to 1 of 114 residents in care.

Official plan of correction

Licensee stated that they would conduct an online training regarding resident aggression and dementia behaviors. Licensee will submit the training date and outline by 9/16/25. LIcensee stated that R1's POA is in the process of transferring R1 to a higher level of care facility.

Deadline recorded: Sep 16, 2025. 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 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... This requirement was not met as evidence by: Based on records review, staff did not submit a written report to the Department within the allotted timeframes for 1 of 127 residents in care, which which posed a potential personal rights risk to 127 of 127 residents in care.

Official plan of correction

The facility agreed to provide the RSD and the RSC training on Reporting Requirements, and submit the in-service training form to the LPA by POC due date, 08/22/2025.

Deadline recorded: Aug 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident The licensee shall ensure that residents are... observed for changes in physical, mental, emotional and social functioning and that... assistance is provided... This requirement was not met as evidenced by: Based on interview and record review, the licensee did not assist a resident with a history of aggression, resulting in a resident-on-resident altercation with injuries for 2 residents [R1 and R2], posing an immediate health, safety, and personal rights risk to 2 of 127 residents in care.

Official plan of correction

The facility plans to schedule a care conference with the family to update R1's plan of care, and aggreed to make a PCP appointment for an updated LIC602. The facility will inform LPA the scheduled dates by POC due date, 08/22/2025. The updated plan of care and LIC602 will be submitted to LPA once they are complete. This is an amended version to an original report delivered on 08/08/2025.

Deadline recorded: Aug 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation: " (a) The facility shall be clean...sanitary and in good repair at all times. " This requirement was not met, as evidenced by: Based on manager interview and LPA observation, pertaining to the bedroom of 1 of 126 residents (R1), Licensee did not ensure that the facility was clean, sanitary, and in good repair at all times. This posed a potential personal rights risk to persons in care.

Official plan of correction

Licensee agreed to use its carpet shampoo machine to thoroughly clean the carpet inside Apartment #211, and once complete, to send LPA a video of the carpet post-cleaning, by the POC due date. In the event the machine is not successful in removing all stains, Licnesee agreed to coordinate with R1's responsible person to make arrangements for the carpet to be replaced with new flooring material, at no additional charge to R1.

Deadline recorded: May 8, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(i)(1)(B)

Regulation authority

CCR

What the official deficiency says

shall have signal systems which shall meet the following criteria: 1) All facilities licensed for 16 or more a....shall have a signal system which shall: (B)Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This requirement was not met in evidence as: Based on interviews and observations the licensee did not provide a working pendant for 2 of 120 persons in care which posed a potential Health, Safety, or Personal Rights risk to persons in care

Official plan of correction

Licensee has already begun daily pendant checks and alarm clearing, Maintanance team has also initiated monthly random checks of pendants to verify working conditions. Adminsitrator stated they are updating the system and getting outside company quotes. Adminsitrator will provide a written letter to LPA to confirm such continous checks.

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

Official classification

Type B

Official code

87611(e)

Regulation authority

CCR

What the official deficiency says

In addition to Sections 87465(a) and 87464(d), the licensee shall ensure that the resident is cared for in accordance with the physicians orders and that the resident's medical needs are met. Based upon staff and outside agency interviews. The facility did not ensure that one out of 128 residents in care (R1) have their medical equipment transferred to their room. This posed a potential health risk to 1 of 1 of 128 persons in care.

Official plan of correction

Executive Director stated that she will conduct an inserivce training focusing on protocol for transferring residents to temporry rooms. Proof of traning will be provided to Community Care Licensing by the POC due date 2/18/25.

Deadline recorded: Feb 18, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.317

Regulation authority

HSC

What the official deficiency says

1569.317 Absentee Notification Plan for Missing Residents: “Every residential care facility for the elderly…shall…develop and comply with an absentee notification plan…The plan shall include…a requirement that an administrator of the facility, or his or her designee, inform the resident’s authorized representative when that resident is missing from the facility…and the circumstances in which [they] shall notify local law enforcement.” This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 117 residents (R1), the licensee did not comply with its absentee notification plan. This posed a potential safety risk to persons in care.

Official plan of correction

Executive Director will ensure that a staff training on elopment procedures is conducted and will email sign in sheet to LPA by POC due date.

Deadline recorded: Jul 21, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625(b)

Regulation authority

CCR

What the official deficiency says

Managed Incontinence - Licensee shall be responsible for ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Facility records show that residents often wake up with soiled diapers and linen.

Official plan of correction

Administrator shall retrain staff on proper incontinence care and hold them responsible for complying with these requirements. A copy of this training shall be provided to CCL by POC date indicating the date, topic, and attendees.

Deadline recorded: May 2, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (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:(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement was not met as evidenced by: Based on review of records and interviews, the licensee did not make arrangements to ensure transportation to medical appointments, which posed a potential health, safety, and personal rights risk to 130 of 130 in care.

Official plan of correction

Memory Care Director (MCD) agreed to hire a driver as soon as possible. Director will coordinate with staff, residents, and sister facility to arrange transportation medical appointments. MCD agreed to provide the LPA proof of facility advertising for a driver, by 02/22/24.

Deadline recorded: Feb 21, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(5)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 6 out of 8 bathrooms which poses a safety risk to persons in care.

Official plan of correction

POC Due Date: 03/01/2024 Plan of Correction Licensee will conduct an inpection of all rooms and place non-skid stips in showers. Licensee agreed to LPA cite inspection to assure non-skid strips are in place.

Official classification

Type B

Official code

87303(i)(1)(A)

Regulation authority

CCR

What the official deficiency says

(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 2 of 8 rooms inspected which posed a safety risk to persons in care.

Official plan of correction

POC Due Date: 03/01/2024 Plan of Correction Licensee will conduct an inpection of all rooms and ensure all pull cords signal system in bathrooms are operational. Licensee agreed to LPA cite inspection to assure opperation of signal system are in place.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review the licensee did not comply with the section cited above in 6 of 6 persons which poses a potential and safety risk to 111 of 111 (R1-R111)

Official plan of correction

POC Due Date: 03/01/2024 Plan of Correction Licensee agrees to complete CPR training and first aid training to appropriate care staff to ensure at least one staff member on duty has CPR traiing as well as first aid by POC date. Licensee agreed to cite/record inspection to ensure appropriate staff have first aid certificates and CPR certificates.

Official classification

Type B

Official code

87415(a)

Regulation authority

CCR

What the official deficiency says

(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency: 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 in 6 of 6 persons which poses a potential and safety risk to 111 of 111 (R1-R111)

Official plan of correction

POC Due Date: 03/01/2024 Plan of Correction Licensee agrees to have care staff members on night supervision 10:00pm to 6:00 am complete first aid training by POC date. Licensee agreed to LPA cite inspection to assure night staff have first aid certificates.

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 interview and record review the licensee did not comply with the section cited above in 6 of 6 persons which poses a potential and safety risk to 111 of 111 (R1-R111)

Official plan of correction

POC Due Date: 03/01/2024 Plan of Correction Licensee agrees to complete first aid training to appropriate care staff to ensure all care staff has as first aid by POC date. Licensee agreed to LPA cite inspection of records to ensure all care staff have first aid.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. 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 in 1 of 1 identifiers which poses potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 03/01/2024 Plan of Correction Licensee agrees to rotate emergency food supply and dispose of expired food. Licensee agrees to replenish nonperishable foods to allow for minimum of one week supplies. Licensee agreed to a cite inspection to ensure compliance

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 interview and record review, the licensee did not comply with the section cited above in 6 of 6 persons which poses/posed a potential safety risk to persons to 111 of 111 (R1-R111) in care.

Official plan of correction

POC Due Date: 03/01/2024 Plan of Correction Licensee agrees to complete first aid training to appropriate care staff and provide First aid certicates by POC date. Licensee agrees to cite inspections of records to ensure all care staff have first aid

Official classification

Type B

Official code

87303(i)(1)

Regulation authority

CCR

What the official deficiency says

Facilities shall have signal systems...All facilities licensed for 16 or more...shall have a signal system which shall:Operate from each resident's living unit.Transmit a visual and/or auditory signal to a central staffed location...loud enough to summon staff. This requirement was not met as evidenced by: Based on LPA direct observation the licensee did not have a functional signal system for R1 [1] of [1] of 109 persons in care which posed a potential health and safety risk to persons in care.

Official plan of correction

Licensee agreed to do " pendant checks " every week and will conduct a managment training regarding pendant system and will provide proof of training to LPA by POC due date of 12/8/23

Deadline recorded: Dec 8, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

97555(b)(15)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b) The following food service requirements shall apply: (15) All persons engaged in food preparation and service shall observe personal hygiene and food services sanitation practices which protect the food from contamination. This requirement was not met as evidenced by: Based on observations, interviews with staff, and records review, the licensee did not ensure employees engaged in food preparation were wearing the appropriate personal protective equipment to prevent food cross-contamination. This posed a potential health risk to 110 residents in care.

Official plan of correction

Licensee agreed to conduct additional training with food handling employees to ensure personal protective equipment is worn. Documentation of in service training will be submitted to CCL by POC date of 10-27-2023

Deadline recorded: Oct 27, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs. This requirement was not met as evidenced by: Based on interviews and observations, the licensee did not ensure the facility was adequately staffed to meet the needs of 110 residents. This posed a potential health and safety risk to 110 residents in care.

Official plan of correction

Licensee agreed to review their personnel/staffing requirements and update plan of operations to ensure facility personnel are sufficient in number and compentency to meet residents needs. Licensee will submit a revised plan of operations to CCL by POC date 10-27-2023.

Deadline recorded: Oct 27, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(C)(2)

Regulation authority

CCR

What the official deficiency says

87465(C)(2) Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on observations, interviews, and records review, facility staff did not administer medications in accordance with the physician’s orders for R1, which posed a potential health risk to 1 of 110 persons in care.

Official plan of correction

Licensee agreed to conduct in service training on medication administration. Documentation of completion of training should be submitted to CCL by POC date of 10/13/2023

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

Official classification

Type B

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care: “(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.” This requirement was not met, as evidenced by: Based on records and interviews, during the incident, the licensee did not keep centrally stored medication in a safe and locked place not accessible to persons others than employees responsible for the supervision of centrally stored medication, which affected 1 of 109 residents (R1) and posed a potential safety risk to persons in care.

Official plan of correction

Based on staff interview and training records: following the incident, licensee conducted remedial training with both S1 and other med-trained staff. Staff were taught to not “pre-pour” medications, but to instead fill only one cup with pills at a time, before moving on to the next resident. Licensee agreed to further train its med-trained staff to: a) keep the drawers of the med cart in a closed position as much as possible, opening such drawers only to withdraw medications, then closing them immediately; and, b) locking the med cart's drawers before taking their gaze away. Licensee agreed to conduct this updated “med cart procedures” training and submit the staff sign-in sheet to LPA, by the POC due date.

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

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Personal Rights of Residents in Privately Operated Facilities (a)(4) 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 was not met as evidence by: Based on interviews, records review, and observations, facility did not provide sufficient staff to meet resident’s care needs. This posed a potential personal rights risk to [R1] 1 of 97 residents in care.

Official plan of correction

Facility will be hiring one extra personal care assistant for each shift and will submit a care staff assignement sheet to verify the onboarding of additional staff to LPA by POC due date, 6/07/23.

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

Official classification

Type B

Official code

1569.652(c)

Regulation authority

HSC

What the official deficiency says

H & SC 1569.652(c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual… within 15 days after the personal property is removed. This requirement was not met as evidenced by: Based on interviews and records reviewed the licensee did not did not issue a refund within 15 days after personal property was removed for 1 in of 99 persons in care [R1] which posed a potential health and safety risk to persons in care.

Official plan of correction

Administrator agrees to read and train all management staff regarding refunds and communicate regulation to accounting department by 4/25/2023. Administrator will submit proof of such training and communication to LPA.

Deadline recorded: Apr 25, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.317

Regulation authority

HSC

What the official deficiency says

1569.317 Absentee Notification Plan for Missing Residents: “Every residential care facility for the elderly…shall, for the purpose of addressing issues that arise when a resident is missing from the facility, develop and comply with an absentee notification plan…” This requirement was not met, as evidenced by: Based on records and interviews, the licensee did not comply with its absentee notification plan for 1 of 97 residents (R1), which posed a potential safety risk to persons in care.

Official plan of correction

Per training records and staff interviews, on 03-24-2023, licensee retrained its staff on the facility's AWOL policy and performed an Elopement Drill with them. These actions resolve the deficiency.

Deadline recorded: Apr 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia: “(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.” This requirement was not met, as evidenced by: Based on LPA observation, licensee did not have an auditory device or other staff alert feature on one exit door accessible to residents for whom exiting presents a hazard, which posed a potential safety risk to persons in care.

Official plan of correction

Licensee agreed to install either an auditory alert device or other staff alert feature on the perimeter door located within the facility's Assisted Living " Stairwell 1 Exit Route, " and to notify LPA (via E-mail or phone) of the installation completion before the POC due date.

Deadline recorded: Apr 28, 2023. A deadline is not proof that correction was completed.