Admission, assessment, and evictionType A
- Official classification
- Type A
- Official code
- 87204(a)
- Regulation authority
- CCR
What the official deficiency says
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. 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 that 5 of 5 residents are non-ambulatory due to using ambulatory devices or diagnosis of major neuro-cognitive disease which poses an immediate safety risk to 5 of 5 residents in care.
Official plan of correction
POC Due Date: 07/25/2025 Plan of Correction House Manager will review facility paperwork to determine if a capacity change request has already been submitted to the Department and will either submit a copy of pending capacity change paperwork or will submit a new LIC200 and facility sketch requesting an increase is non-ambulatory clearance to the Department by POC due date of 7/25/2025.
Dementia careType A
- Official classification
- Type A
- Official code
- 87705(f)
- Regulation authority
- CCR
What the official deficiency says
(f) Licensees that lock exterior doors or perimeter fence gates shall meet the following initial and continuing requirements: 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 that the front and side gates are locked without fire clearance approval, which poses an immediate health and safety risk to 5 of 5 residents in care.
Official plan of correction
POC Due Date: 07/28/2025 Plan of Correction House Manager called repair person to remove the locking mechanisms on both gates on 7/26/2025. House Manager will provide the Department proof of scheduling by 7/25/2025 and will submit photographs of the gates without locks to the Department by POC due date of 7/28/2025.
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87633(b)
- Regulation authority
- CCR
What the official deficiency says
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: 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 that 3 of 5 residents (R1, R2, and R4) did not have hospice care plans in their records which poses a potential health risk to 3 of 5 residents in care.
Official plan of correction
POC Due Date: 08/01/2025 Plan of Correction House Manager stated that she will obtain hospice care plans for R1, R2, and R4 from their hospice providers and will send copies of the care plans to the Department by POC due date of 8/1/2025.