LO-HAR SENIOR LIVING

Official classification

Type B

Official code

87307(3)(A)

Regulation authority

CCR

What the official deficiency says

87307(3)(A) …. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. This requirement was not met as in evidence: Based on observations, the licensee did not provide 3 of 68 residents in care clean and comfortable mattresses that pose a possible health risk to persons in care.

Official plan of correction

Licensee agrees to replace the mattresses by POC date and provide proof of such to LPA via email.

Deadline recorded: Oct 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 (a):(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as in evidence: Based on interviews the licensee did not assist resident with self-administratrion of medication in 1 of 66 persons in care R1 which posed a potential Safety, risk to persons in care.”

Official plan of correction

Licesee states facility staff will conduct re-medication technician training and will provide such proof to LPA by POC date.

Deadline recorded: Oct 24, 2025. 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

87468.2 a)... All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: 8)To be free from verbal, mental, physical, or sexual abuse. This requirement was not met as in evidence: Based on interviews and records collected the licensee did not protect R1 from physical abused in 1 of 57 residents in care which posed an immediate Safety risk to persons in care

Official plan of correction

Licensee had a personal rights training in May of 2025. Due to duplicate violation within 12 month, POC considered cleared.

Deadline recorded: Aug 5, 2025. 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

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) ...residents in privately operated residential care facilities for the elderly shall have ...the following personal rights:(8) To be free from neglect. This requirement was not met as evidence by: Based on interviews and record reviews the licensee did not protect resident from neglect in 1 of 67 persons in care (R1) which posed an immediate safety risk to persons in care.

Official plan of correction

Licensee will provide staff with a vendorized traiing in regards to self neglect and skin assessments. Licensee will provide proof of training scheduled within 24 hours.

Deadline recorded: May 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625(a)(1)(C)

Regulation authority

CCR

What the official deficiency says

87625 Managed Incontinence (a)The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition under the following....: (1).... managed with any of the following: (C) A program of scheduled toileting at regular intervals. Based on interviews and record reviews the licensee did not provide resident with managed incontince program in 1 of 67 persons in care (R1) which posed an potential health risk to persons in care.

Official plan of correction

Licensee will provide staff with a vendorized training in regards to incontinence care.

Deadline recorded: Jun 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(6)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by: This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, the licensee did not comply with the section cited above in 64 out of 64 residents in care which poses/posed a potential health risk to persons in care.

Official plan of correction

POC Due Date: 11/08/2024 Plan of Correction Licensee agrees to fix water fixtures including slow drainage by POC date and provide LPA with documentation.

Official classification

Type B

Official code

1569.312

Regulation authority

HSC

What the official deficiency says

1569.312 Basic Service Requirement Every facility required to be licensed under this chapter shall provide at least the following basic services: (d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement was not met as in evidence in: Based on interviews and records reviewed the licensee did not know the whereabouts of R1 which posed a potential Safety risk to persons in care.

Official plan of correction

Licensee has changed the door codes, locks and added addtional signage to prevent residents from leaving. Plan of correction has been cleared as of today's date.

Deadline recorded: Oct 10, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(c)

Regulation authority

CCR

What the official deficiency says

(c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1). This requirement was not met as in evidence in: Based on interviews and records reviewed the licensee did not report abuse to R1 which posed a Safety risk to persons in care.

Official plan of correction

Licensee agrees to provide abuse reporting AND written reporting training to all staff at facility by date and provide LPA with proof of such.

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

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements(c) All RCFE staff who assist residents with personal activities of daily living ..(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: Based on records reviewed the licensee did not provide first aid training to 13 of 16 staff which poses a potential health and safety risk to 56 persons in care.

Official plan of correction

Licensee agrees to provide training to care staff, will provide proof of training to LPA.

Deadline recorded: May 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(9)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents...shall have... the following personal rights:(9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement was not met as evidence in; Based on observations and interviews the licensee did not communicate with representatives promptly and appropriately in 1 of 65 persons in care [R1] which posed a potential Personal Rights risk to persons in care.

Official plan of correction

Licensee agrees to provide staff with customer service training and working phones by 5/31/2024.

Deadline recorded: May 31, 2024. 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

87611 General Requirements for Allowable Health Conditions (e) … the licensee shall ensure that the resident is cared for in accordance with the physician’s orders and that the resident’s medical needs are met. This requirement has not been met as evidenced by: Based on interviews and records review, the licensee did not ensure that R1’s physician’s order for assistance with feeding and oxygen use was followed, resulting in hospitalization for R1. This posed an immediate health risk to R1.

Official plan of correction

R1 no longer resides at the facility or receiving care from the facility. The Wellness Director is currently implementing in-service training for following physician's orders for care and medications. The Wellness Director will submit copies of staff sign in sheet for physician's order training to the Department by POC due date of 4/29/2024.

Deadline recorded: Apr 29, 2024. 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 resident needs. This requirement has not been met as evidenced by: Based on interviews and records reviewed, the licensee did not comply with the above section as staff were not able to meet resident care needs. This poses a potential health risk to 64 of 64 residents in care.

Official plan of correction

Wellness Director is currently reassessing residents and their care plans to determine necessary staff levels. Staff have also been hired and Wellness Director is currently interviewing new hires. Wellness Director will submit a list of staff hired in March and April 2024 and will submit copies of updated staffing schedule for April 2024 to the Departmentby POC due date of 4/29/2024.

Deadline recorded: Apr 29, 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 Maintenance and Operation (a) the facility shall be clean, safe, sanitary, and in good repair at all times… This requirement has not been met as evidenced by: Based on observation and interviews, the licensee did not comply with the section above as the facility was observed to be cluttered and dirty on multiple occasions. This poses a potential health risk to 64 of 64 residents in care.

Official plan of correction

Staff have also been hired and Wellness Director is currently interviewing new hires. The Wellness Director will conduct refresher housekeeping training and implement a housekeeping log for resident rooms and submit copy of training sign in sheet and housekeeping log to the Department by POC due date of 4/29/2024.

Deadline recorded: Apr 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(f)(5)

Regulation authority

CCR

What the official deficiency says

87303(f)(5) Maintenance and Operation (f)(5) Solid waste… shall be maintained in a clean and sanitary condition. This requirement has not been met as evidenced by: Based on observation and interviews, the licensee did not comply with the above section as soiled incontinence briefs were not emptied frequently enough to prevent odors. This poses a potential health risk to 64 of 64 residents in care.

Official plan of correction

Staff have also been hired and Wellness Director is currently interviewing new hires. The Wellness Director will conduct refresher housekeeping training and implement a housekeeping log for resident rooms and submit copy of training sign in sheet and housekeeping log to the Department by POC due date of 4/29/2024.

Deadline recorded: Apr 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

87625 Managed Incontinence (b)… the licensee shall be responsible for… (3) ensuring that incontinent residents are kept clean and dry. This requirement has not been met as evidenced by: Based on interviews and records review, the licensee did not comply with the section above as R1 was not assisted with incontinence services to remain clean and dry. This poses a potential health risk to 64 of 64 residents in care.

Official plan of correction

Staff have also been hired and Wellness Director is currently interviewing new hires. Wellness Director will conduct an inservice training for staff on incontinence care and submit sign in sheets to the Department by POC due date of 4/29/2024.

Deadline recorded: Apr 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f)(4) Personal assistance and care as needed by the resident… with those activities of daily living such as… bathing… This requirement has not been met as evidenced by: Based on interviews and records review, the licensee did not comply with the above section as R1 was not assisted with bathing services as needed. This poses a potential personal rights risk to 64 of 64 residents in care.

Official plan of correction

Staff have also been hired and Wellness Director is currently interviewing new hires. The Wellness Director will be conducting an inservice training on the physical requirements of caregiving and providing assistance with ADLs to residents. Wellness Director will submit sign in sheets to the Department by POC due date of 4/29/2024.

Deadline recorded: Apr 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(4)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (f)Basic services shall at a minimum include:(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing. These requirements were not met as evidence by:Based on interviews and observations the licensee did not provide basic services in 3 of 62 persons in care ([R1/R2/R3]) which posed a potential Health risk to persons in care.

Official plan of correction

Licensee agrees to provided outside training for Parkinsons residents and activities of daily living by 2/28/2024.

Deadline recorded: Feb 28, 2024. 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 Incidental Medical and Dental Care (c)(2)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 interviews and observations licensee did not issue medication as prescribed in five of 65 persons in care which posed a potential health risk to persons in care.

Official plan of correction

Licensee agrees to conduct vendorized training to staff by December 20, 2023 and provide proof of scheduled training by December 4, 2023.

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

Official classification

Type B

Official code

87411

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living ….(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 record review the licensee did not comply with the section cited above in 3 of 5 persons which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/04/2023 Plan of Correction Will conduct a first Aide/CPR certified training to facilitate a training for updated First aide/CPR for all care staff.

Official classification

Type B

Official code

87303e5

Regulation authority

HSC

What the official deficiency says

This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, the licensee did not comply with the section cited above in 2 of 6 showers which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/04/2023 Plan of Correction Executive Director agreed to purchase and place Non-Skid mats strips in shared room showers with the exception of shower rooms.

Official classification

Type B

Official code

87219(a)

Regulation authority

CCR

What the official deficiency says

87219 Planned Activities (a)Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. This requirement was not met as evidenced by: Based on observations and interviews the licensee did not provide planned activities to 65 of 65 persons in care which posed a potential health risk to persons in care.

Official plan of correction

Licensee has created/provided a monthly calendar of activites and has agreed to provide daily activities to residents in care.

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

Official classification

Type B

Official code

87465(a)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment: “(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.” This requirement was not met, as evidenced by: Based on records and interviews, for 1 of 63 residents (R1), prior to their acceptance as a resident, licensee did not obtain and keep on file, documentation of a medical assessment, signed by a physician, which posed a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee agreed to coordinate with R1’s physician to obtain a current LIC602 Physician’s Report for R1. Licensee agreed to retrain its marketing/admissions staff and management team on required documents for every resident, by time of move-in. Licensee agreed to E-mail a copy of R1’s LIC602 and the training sign-in sheet, to LPA by the POC due date.

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

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3)To be free from...abuse. This requirement was not met as evidenced by: Based on interviews the licensee did not protect resident's personal right to be free from abuse in 1 of 57 persons in care ([R1]) which posed an immediate Safety risk to persons in care.

Official plan of correction

Licensee agrees to terminate S1 and request agency staff not to return to facility.

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

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities...shall have all of the following personal rights:(1)to be accorded dignity in their personal relationships with staff. This requirement was not met as evidenced by: Based on interviews the licensee did not accord resident dignity in their personal relationship with staff in 1 of 57 persons in care ([R1]) which posed a potential personal rights risk to persons in care.

Official plan of correction

Licensee agrees to terminate S1 and request agency staff not to return to facility.

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

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 When changes such as..deterioration of mental ability or a physical health condition are observed... licensee shall ensure that changes are... brought to the attention of the resident's physician. This requirement was not met as evidenced by: Based on records reviewed and interviews, the licensee did not report metal or physical health conditions in 2 of 56 persons in care ([R1/R2]) which posed a potential Health risk to persons in care.

Official plan of correction

Wellness Director has implemented a new reporting system for all staff and will provide documentation to new system to LPA Strong by 8/9/2023.

Deadline recorded: Aug 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(l)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia: “(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2) The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates.” This requirement was not met, as evidenced by: Based on observation, in areas of the facility where 30 of 55 residents (R1 through R30) resided, licensee locked exterior doors and perimeter fence gates, but did not ensure that its fire clearance included approval of locked exterior doors or locked perimeter fence gates, which posed an immediate safety risk to persons in care.

Official plan of correction

By the POC due date, Licensee agreed to E-mail to the CCLD San Diego Regional Office’s (RO's) main intake E-mail address, and to cc’ LPA: a) an LIC200 Application which indicates a request for use of secured perimeter, and b) a Waiver Request from Regulation 87468(a)(6), to prevent residents from leaving the facility. These actions will prompt the RO to request a subsequent fire authority re-inspection for the facility.

Deadline recorded: Jul 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident: “The licensee shall ensure that residents are regularly observed…” This requirement was not met, as evidenced by: Based on records and interviews, the licensee did not ensure that 1 of 55 residents (R1) was observed, which posed a potential safety risk to persons in care.

Official plan of correction

Licensee agreed to formally retrain its direct care staff at large (to include both facility staff and outside agency caregivers), teaching that: a) all memory-impaired residents must be accompanied by staff when outdoors, and b) staff must ensure that the facility’s perimeter doors and gates fully close and latch after being opened.

Deadline recorded: Aug 4, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

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 be responsible for ensuring the following: (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, both of which shall include a reassessment of the resident’s dementia care needs.” This requirement was not met, as evidenced by: Based on records and interviews, licensee did not ensure that 1 of 55 residents (R1), who was diagnosed with a dementia, had a medical assessment performed within the last year, which posed a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee agreed to coordinate with R1’s physician, responsible party, and/or case manager, as needed, to obtain a new/updated LIC602 Physician’s Report for R1, and to place it in R1’s resident file. Licensee agreed to mark their internal calendar to remind them that for every resident diagnosed with dementia, Licensee will need to facilitate a new LIC602 within the next 12 months. Licensee agreed to E-mail LPA a copy of R1’s new/updated LIC602, by the POC due date.

Deadline recorded: Aug 4, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(3)(C)

Regulation authority

CCR

What the official deficiency says

Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets…The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not provide clean linen to residents on a weekly basis. This posed a potential health and personal rights risk to 56 of 56 residents in care.

Official plan of correction

Administrator agreed to provide in service training for all current and new staff. Administrator is in the process of hiring new staf to bring staffing levels up to the numbers sufficient to meet the needs of the residents. Documentation of training and updated staffing plans will be submitted to CCL by POC date of 5/19/2023.

Deadline recorded: May 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(d)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services (d)... if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs... providing the other basic services... either directly or through outside resources. This requirement was not met as evidence by; Based on interviews and records reviewed the licensee did not identify how facility would meet the resident's needs in 1 in 56 of persons in care which posed a potential Health, Safety, and Personal Rights risk to persons in care.

Official plan of correction

Administrator agrees to create a detailed plan of care for R1 and provide to LPA by 4/21/2023.

Deadline recorded: Apr 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87207

Regulation authority

CCR

What the official deficiency says

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidenced by: Based upon LPA’s record review, licensee documented false information in records maintained for 1 of 55 residents in care. This posed a potential health and safety risk to residents in care.

Official plan of correction

Executive Director offered to conduct training and ensure that outside vendor training is provided to all med techs and caregivers to ensure that accurate and timely charting is completed. Proof of training is to be provided to Cmmunity Care Licensing by the POC due date of 10/14/2022.

Deadline recorded: Oct 14, 2022. 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)(1)(D)Reporting Requirements: (a)licensee shall furnish to the licensing agency (1)A written report shall be submitted..in any of the events specified... D)Any incident which threatens the welfare, safety or health of any resident... such as an unexplained absense. This requirement is not met as evidence by; Based on record reviews and interviews the licensee did not report an unexplained absense of R1 to the Department which poses a potential Health and Safety risk to persons in care.

Official plan of correction

Administrator states she will obtain reporting requirement training for herself along with any designated staff and provide proof as plan of correction to the Deparrment by 7/1/2022.

Deadline recorded: Jun 21, 2022. A deadline is not proof that correction was completed.