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Official classification

Type B

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, record review, and staff interview, the licensee did not comply with the section cited above in that the Administrator did not have an up to date Administrator's Certificate which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/30/2026 Plan of Correction Licensee stated designated staff will obtain a Administrator's Certificate and submit to LPA by POC due date.

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, the licensee did not comply with the section cited above in 4 out of 4 residents did not have medications stored in originally received container which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 04/30/2026 Plan of Correction Licensee stated that staff will immediately cease placing medications in weekly containers. Staff will take a training on medication administration and provide LPA proof of training by POC due dtae.

Official classification

Type B

Official code

87506(d)

Regulation authority

CCR

What the official deficiency says

All resident 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 was not met as evidence by: Based on a records request the Licensee did not provide resident records to the Department. This posed a potential health and safety risk to 1 out of 5 residents in care.

Official plan of correction

Licensee McEvoy will conduct an audit on resident records to ensure complete and accurate information. Licensee will organize records and house them in an accessible area. POC due date is 4/24/2023.

Deadline recorded: Apr 24, 2023. A deadline is not proof that correction was completed.