TARINA OF STOCKTON

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on interviews, file review, and medication audit, the licensee did not comply with the section cited above. facility staff did not follow R1's oxycodone order and was not administered medication as noted on the controlled drug record and MAR. This posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility staff agrees to conduct a medication audit from an outside agency by POC date 12/08/2025. Facility staff agrees to email LPA an audit plan by 12/08/25

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

Official classification

Type A

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 is not met as evidenced by: Based on file reviews, interviews, and medication audit, the licensee did not comply with the section cited above. A med-tech signed off on R1's controlled drug record that medication was administered when it was not administered. The medication (10+ pills are unaccounted for). This action also resulted in controlled medication count being off. This posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility staff agrees to conduct a medication in-service by POC date 12/08/2025. Facility staff agrees to email LPA an medication in-service plan by 12/08/2025.

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

Official classification

Type B

Official code

87555(b)

Regulation authority

CCR

What the official deficiency says

The following food service requirements shall apply:(17) In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service. If this person is not a nutritionist, a dietitian, or a home economist, provision shall be made for regular consultation from a person so qualified. The consultation services shall be provided at appropriate times, during at least one meal. A written record of the frequency, nature and duration of the consultant's visits shall be secured from the consultant and kept on file in the facility. (28)All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. (29)All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by observation kitchen sink with cracks in the seams, water pooling on the floor by the sink, expired food in the walk-in refigerator and holes in the floor tiles by the ovens. This is a potential health and safety risk.

Official plan of correction

The facility will repair or replace items listed and provide the departemnt with photo evidence of the corrections. The facility will also hire a required nutritionist, a dietitian, or a home economist to complete the required evaluation of kitchen services by the POC date 12/12/2025.

Deadline recorded: Dec 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

§1569.695 Emergency Plans (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 notrequired 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 last recorded drill was 4/24/25

Official plan of correction

Licensee will submit a proof of a completed fire /disaster drill to LPA by POC due date

Deadline recorded: Dec 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(29)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement is not met as evidenced by observation multiple issues in the kitchen including, open seams in the sink, broken thermostat, equipment not operational, drainage issues resulting in puddling on the floor in front of the main oven, mirror not secured on the fireplace mantel and black smoke stains on the walls in the dining area.

Official plan of correction

The facility will repair or replace the items listed by the POC date of 10/24/2025. The facility will provide the department with documentation of the fixed items or reciepts for the replaced items via email or fax.

Deadline recorded: Oct 24, 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

This requirement is not met as evidenced by:Observation of rat droppings,missing or broken ceiling panels Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above] which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/13/2024 Plan of Correction The facility will clean rat dropping and repair or replace ceiling panels by 12/13/2024

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire safety This requirement is not met as evidenced by: Observation the fixed system/ ansul system is out of compliance and has not been serviced as required by the State fire marshal Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/26/2024 Plan of Correction The facility will repair or replace the fixed system to be in compliance with the state fire marshal requirement by the POC date 11/26/2024. The facility will submit a plan to repair the system by POC date 11/26/2024.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. Based on observation the licensee failed to secure toxins. A cabinet in a resident bathroom contained toxins. R1 took the toxin and ingested the cleaning supplies. This poses an immediate health and safety risk to residents in care.

Official plan of correction

The facility will assess residents discharge summaries for information that may have been missed. The Administrator and RCD will provide the department with a plan to review discharge paper work prior to admissions.

Deadline recorded: Jul 30, 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

87303 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 observation and photos taken. During the walk through LPA observed exposed wires not covered in the main hallways of the construction area which poses an immediate health, safety risk to persons in care.

Official plan of correction

The construction company covered the exposed wires during the safety check today. The facility will continue to monitor the construction areas to maintain the safety of all residents including visitors during the different phases of the construction project.

Deadline recorded: Jun 13, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met based on: Observation, The facility failed to maintained in conformity with the regulations adopted by the State Fire Marshal. The " Fixed System " or " Ansul System " in the kitchen, this system is scheduled for a semi-annual maintenance and was last serviced on 7/19/2023

Official plan of correction

Administrator will ensure that the fire equipment listed is inspected or a plan is made and sent to CCL by the POC date indicated. Licensee/Administrator shall send picture of the new tags as proof and submit Statement of Compliance by POC date.

Deadline recorded: Jun 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: 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...any; and disposition of the case. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not submit a written incident report to Licensing as required. Resident Care Director confirmed with LPA that an incident report was not submitted for any of the identified incidents in the report for today's visit. This poses an immediate health, safety, or personal rights risk to residents in care.

Official plan of correction

Licensee will have an outside agency conduct a training for Mandated reporting requirements for all staff and managers. The training schedule will be submitted to the department by the close of business on 12/5/2023. The facility will submit the list of individuals trained or the sign in sheet for the training by the plan of correction date. The facility will be responsible for finding a vendor that will conduct the training from a list of providers on the CDSS website.

Deadline recorded: Dec 5, 2023. 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(a) All Facilities shall have a qualified and currently certified administrator. This requirement was not met as evidenced by interviews with staff.

Official plan of correction

Licensee will submit to LPA an updated LIC500 and LIC200 with an employee who has a current administrator certificate and who will act in the administrator capacity until Licensee finds and updates the Administrator positions. Licensee will send to LPA by end of day on 11/14/2023

Deadline recorded: Nov 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

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 is not met as evidenced by: Based on observation and records review, the Licensee did not ensure medications ordered for residents were given as prescribed which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator will developed a plan on how the facility will follow the Physician's orders and document correctly when medications are missed. Please send the agenda along with the sign-in sheet for the in-service, by POC date or give a time when the training will take place and send that information to the department The facility will also report all incidents of medication errors, missed medication Etc.. to the resident's Primary Care Physician and to the department.

Deadline recorded: Nov 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

General. Good physical health of personnel shall be verified by a health screening, including a T.B. test, performed and signed by a physician not more than six months prior to or seven days after employment. LPA observed staff did not have a health screening and TB test results in S1's file.

Official plan of correction

Administrator to provide a health screening/TB results for staff (S1) by POC date 11/17/2023

Deadline recorded: Nov 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87628(a)

Regulation authority

CCR

What the official deficiency says

Diabetes The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement was not met as evidenced by: Based on LPA Jensen's record review of the LIC 602, LIC 624's and needs and service plan as well as LPA Jensen's interviews with 2 staff members and 1 resident, the resident has not had medication administered by a skilled professional. This poses an immediate risk to the health, safety and personal rights of residents in care.

Official plan of correction

The Licensee agrees to have an appropriately skilled professional administer medication and conduct glucose monitoring for any resident that is unable to manage their own medication as specified on the LIC 602 effective immediately. No further plan of correction is required at this time.

Deadline recorded: Aug 4, 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 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... Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by: Based on the Department's receipt of 6 incident reports that were sent more than 7 days after occurrence. This poses a potential risk to the health, safety and personal rights of residents in care.

Official plan of correction

The Licensee has implemented a new protocol for incident reporting wherein the Executive Director is immediately notified of the occurrence and an incident report is written up within 24 hours for review by upper management and their consulting group. No further plan of correction is required at this time.

Deadline recorded: Jun 29, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

Administrator Certification Requirements All facilities shall have a qualified and currently certified administrator. This requirement was not met based on: The facility's former Administrator having exited the position on or around 3/9/23 and the facility not having any evidence of a new Administrator of record. This poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Licensee agrees to submit the requested documentation for approval for a change in Administrator by Plan of Correction due date.

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

Official classification

Type B

Official code

87303(b)(1)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation ... (b) A comfortable temperature for residents shall be maintained at all times. (1) The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C). This requirement was not met as evidenced by: Based on an interview with the Executive Director there are currently 9 occupied units using portable heaters which does not allow for accurately setting a temperature in resident suites within the required range and creates a tripping and fire hazrd. This poses a potential risk to the health saftey and personal rights of residents in care.

Official plan of correction

The licensee agrees to install thermostats in the residents rooms and cease the use of the portable heaters, removed the window air conditioning units unless the resident requests otherwise and repair any broken HVAC units in resident suites.

Deadline recorded: Dec 9, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(i)

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. (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 as evidenced by: Based on LPA Jensen's test of 2 resident suite signal systems for which there was no response by staff in over ten minutes each. This poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Effective immediately the Executive Director will start reviewing signal notification reports and additional training has been conducted with staff during a shift change. Ongoing training will also be conducted. No further plan of correction is required at this time.

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

Official classification

Type B

Official code

87217(b)

Regulation authority

CCR

What the official deficiency says

87217 Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. This requirement was not met as evidenced by: Based on the facility's self reporting, a staff member used a resident's check to deposit funds in to their own account. This poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

The Licensee immediately terminated the employee. The Licensee also conducted staff training on mandated reporting. The Licensee met with the family of the resident and explained all actions that have been taken. The Licensee has made a safe available for residents to keep valuables in should they choose to do so. No other victims have been identified. No further Plan of Correction is required.

Deadline recorded: Sep 30, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(b)(2)

Regulation authority

CCR

What the official deficiency says

The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement was not as evidenced by: Based on LPAs temperature readings of the upstairs hallway and 3 resident rooms that were above 85 degrees. This poses an immediate safety, health and personal rights risk to residents in care.

Official plan of correction

Licensee made adjustments to a portable air conditioner unit in the room of a resident on the second floor during the course of the visit which lowered the temperature by 4 degrees within 30 minutes and the room continues to cool. Licensee agrees to add a hydration table to the hallway of the second floor by 7pm on 9/9/22. Maintenance will add two floor blowers to second floor and email or text temperature readings to LPA by 9/10/22. Staff will check on residents on the upper floor every two hours over the course of the 24 hours.

Deadline recorded: Sep 10, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

874119(c)(1)

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 shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (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 of personnel file for S2 which contained a first aid/CPR certificate that had expired on 12/12/21, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/13/2022 Plan of Correction Licensee agrees to have any staff needing first aid/CPR training complete the necessary training and email proof of certification to LPA by May 13, 2022.

Official classification

Type A

Official code

87309(a)(1)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs observation of multiple toxins in an unlocked storage room next to the elevator on the second floor, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2022 Plan of Correction Licensee agrees to replace the storage room door handle with a locking handle and keep the door locked when the room is unoccupied. Licensee will send photos of the locking door handle by email to the LPA by 4/19/22

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, 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 This requirement is not met as evidenced by: Based on LPAs observation of an unlocked sliding door on the second level with access to a portion of the roof that was unstable with a high fall risk and tripping hazards, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2022 Plan of Correction Licensee agrees to submit a plan to secure the access to the roof by email by 4/19/22.

Official classification

Type A

Official code

87303(i)(A)(B)(C)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation (i) Facilities shall have signal systems which shall...(1)All facilities licensed for 16 or more...shall:(A)Operate from each resident's living unit.(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. (C) Identify the specific resident living unit. This requirement is not met as evidenced by: Based on observation and interview, it was determined that R1s facility's signal system did not function. This poses an immediate health, safety, and resident rights risk to residents in care.

Official plan of correction

Licensee will submit plan to ensure resident needs are met with alternative signal system until current system is repaired or replaced. Plan to be submitted to LPA by POC due date. POC visit to be planned. Licensee will repair or replace current signal system to meet regulatory requirements. A time frame for repair or replacement to be submitted to LPA by POC due date.

Deadline recorded: Mar 31, 2022. 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

A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources This requirement was not met as evidenced by based on observationa and record review of R3, R4 and R5 hourly check log did not reflect that residents were being checked hourly therefore residents did not receive the required care. This poses a potential health and safety risk to residents R3, R4 and R5

Official plan of correction

Administrator agrees to review all hourly check logs and conduct care and supervision training for all care staff and med techs. Administrator agrees to submit training documentation to LPA by email by POC date 3/11/22

Deadline recorded: Mar 11, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87208(a)(7)(B)

Regulation authority

CCR

What the official deficiency says

Plan of Operation87208(a)(7)(B) Each facility shall have and maintain a current, written definitive plan of operation...Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval..Sketches, showing dimensions, of the following: The grounds showing buildings, driveways, fences, storage areas, pools, gardens, recreation area and other space used by the residents.This requirement was not met as evidenced by based on observation resident room 119 is being utilized as an office for staff. This poses a potential health and safety risk for residents in care.

Official plan of correction

The Administrator agrees remove the office and revert this space back to a resident room by 3/11/22.

Deadline recorded: Mar 11, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(i)(1)(A)

Regulation authority

CCR

What the official deficiency says

87303 i(1)(A) Maintenance and Operation 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 was not met as evidenced by based on observation call button page alert displaying misinformation. This posed a potential threat to the Health, Safety, and Personal Rights of all residents in care.

Official plan of correction

Administrator agrees to repair the

Deadline recorded: Mar 11, 2022. 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): Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidence by: Based on observartion, facility did not comply with the section cited above. LPAs observed unlocked tools and chemicals accessible to residents which is an immediate health and safety risk to residents in care.

Official plan of correction

Facility agreed to lock it tools and chemicals. Facility will submit proof to CCLD by POC date.

Deadline recorded: Jan 25, 2022. 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): Maintence and Operation :(a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met as evidence by: Based on observation, Facility did not comply with the section cited above in 87303(a). LPAs observed debris and cob webs throughout the facility, which is a potential health and safety risk to residents in care.

Official plan of correction

Facility agreed to clean up debris and cob webs and submit proof to CCLD by POC date.

Deadline recorded: Jan 28, 2022. A deadline is not proof that correction was completed.