ROSE GARDEN

Official classification

Type B

Official code

87205(b)

Regulation authority

CCR

What the official deficiency says

(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. This requirement was not met as evidenced by: Based on record review the Licensee did not comply with the regulation above, the Incorporation is not in good standing with the Secretary of the State and needs immediate attention which posses a potential personal rights risk to residents in care.

Official plan of correction

Administrator agreed to make contact with SoS to bring corporation into good standing and if not able will do application to change the Licensee to an individual or LLC. provide proof to CCL by 06/18/2025.

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

Official classification

Type A

Official code

87608(a)(1)

Regulation authority

CCR

What the official deficiency says

(a)...(1)Postural supports shall be limited to appliances...soft ties, used to achieve proper body position and balance,..or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc. This requirment was not met as evidenced by: Based on interviews the Licensee did not comply with the regualtion above Administrator used a gait belt to tie a resident to reclining chair which poses an immediate Health, Safety and Personal rights risk to reisdnets in care.

Official plan of correction

Administrator will not use any ties or gait belt with R1, get updated LIC 602A & Apprisal Needs and Services plan for R1 and train staff in Regulation 87608, provide proof of trianing and requested records to CCL by 06/12/2025.

Deadline recorded: Jun 12, 2025. 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

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requirement was not met as evidenced by: Based on interviews the Licensee did not comply with the regulation above, the facility will need additional staffing to take care of R1 due to change in condition and meeting R1's needs which posses a potential Health, Safety and Personnel rights risk to residents in care.

Official plan of correction

Administrator agreed to higher more staff and provide a up to date LIC 500 for current staffing working at the facility, Administrator also will do a care increase to account for a 1 on 1 for R1 while sun downing, and review regulation 87411 and provide written letter of understanding to CCL by 06/18/2025.

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

Official classification

Type B

Official code

87205(b)

Regulation authority

CCR

What the official deficiency says

(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. 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 LPA ran Barnhill & Barnhill Inc. and on the SoS showing inactive as of 03/27/2019 which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2024 Plan of Correction Administrator agreed to get Barnhill & Barnhill Inc back to active status and will provide paperwork showing Active status to CCL.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 staff where not meeting the 20 hours of annual trianing which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2024 Plan of Correction Administrator will have all staff take 20 plus hours of annual training and send proof of staff trinaing to CCL.

Official classification

Type A

Official code

1569.17(b)(1)(C)

Regulation authority

HSC

What the official deficiency says

(C) Any person who provides client assistance in dressing, grooming, bathing, or personal hygiene. Any nurse assistant or home health aide meeting the requirements of Section 1338.5 or 1736.6, respectively, who is not employed, retained, or contracted by the licensee, and who has been certified or recertified on or after July 1, 1998, shall be deemed to meet the criminal record clearance requirements of this section. A certified nurse assistant and certified home health aide who will be providing client assistance and who falls under this exemption shall provide one copy of their current certification, prior to providing care, to the residential care facility for the elderly. The facility shall maintain the copy of the certification on file as long as the care is being provided by the certified nurse assistant or certified home health aide at the facility. Nothing in this paragraph restricts the right of the department to exclude a certified nurse assistant or certified home health aide from a licensed residential care facility for the elderly pursuant to Section 1569.58. 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 one out of five staff did not have a background clerance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/16/2023 Plan of Correction Licensee immediately instructed S1 to leave the facility and return only when a background clearance is obtained. No further action needed.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interviews, the licensee did not comply with the section cited above in that documentation is not available showing proof of liability insurance which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2023 Plan of Correction Licensee will obtain documentation showing proof of liability insurance and send to CCL.

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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 is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that cleaning supplies were in an unlocked kitchen cabinet accessible to residents in care which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2023 Plan of Correction Staff immediately removed the items and placed in a locked cabinet. Licensee will conduct training on the regulation cited above and send a copy of the training sign-in sheet to LPA by due date.

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 record review and interviews, the licensee did not comply with the section cited above in S2 had an expired first aid certification which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2023 Plan of Correction Licensee will ensure that all staff have first-aid certification completed and sent copy to LPA by the due date.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interviews, the licensee did not comply with the section cited above in five out of five staff did not complete annual required training which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2023 Plan of Correction Licensee will ensure all staff complete annual required training and send proof to LPA by due date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(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 not required 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: Deficient Practice Statement Based on record review and interviews, the licensee did not comply with the section cited above in quarterly emergency drills were not completed for the past year which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2023 Plan of Correction Licensee will write a statement of understanding commiting to conducting and documenting quarterly emergency disaster drills in the future and send the statement to LPA by due date.

Official classification

Type B

Official code

87705(d)

Regulation authority

CCR

What the official deficiency says

(d) In addition to requirements specified in Section 87303, Maintenance and Operation, safety modifications shall include, but not be limited to, inaccessibility of ranges, heaters, wood stoves, inserts, and other heating devices to residents with dementia. 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 that the stove had knobs (6) allowing residents to turn on the stove which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2023 Plan of Correction Licensee has committed to installing plastic child-proof covers for stove knobs and will send a photo to LPA by due date.

Official classification

Type B

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 that knives and scissors were stored in an unlocked kitchen cabinet which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2023 Plan of Correction Staff immediately removed the knives/scissors and placed in a locked cabinet. Licensee will place knives/scissors in a locked drawer and send photo to LPA by due date.

Official classification

Type A

Official code

87468.1

Regulation authority

CCR

What the official deficiency says

87468.1 – Personal Rights. Residents have the right to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on observations, the facility failed to ensure staff were wearing face coverings which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Licensee has agreed to direct staff to change their masks two to three times in one shift. Licensee will also hold infectious control training specifically on proper PPE usage. Licensee will provide a copy of the training and staff signatures to CCL by 5/13/22.

Deadline recorded: May 13, 2022. A deadline is not proof that correction was completed.