IRENE'S BOARD & CARE

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

The licensee shall ensure that residents are regularly observed for changes in physical, mental... When changes... are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician... This requirement was not met as evidenced by: Based on interview and record review, the licensee did not report R1's changes in condition to their physician until the LPA requested they do so which poses a potential health and safety risk to persons in care.

Official plan of correction

Licensee states they will create a policy on reporting and documenting changes in condition and train the staff on the policy. Licensee will email the policy and staff training tot he LPA on or before 6/30/2026.

Deadline recorded: Jun 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87219(b)

Regulation authority

CCR

What the official deficiency says

87219(b) Planned Activities (b) Residents served shall be encouraged to contribute to the planning, preparation, conduct, clean-up and critique of the planned activities. This requirement was not met as evidenced by: Based on observation, interview, and record review, the licensee did not involve resident in planning activites and provide the activities listed on their calendar which poses an potential health and personal rights risk to persons in care.

Official plan of correction

Licensee states they will get resident input prior to creating each months calendar. Licensee will email LPA the July activity calendar and a letter of understanding on the importance of involving residents in activity planning on or before 6/30/2026.

Deadline recorded: Jun 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (4)The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on observation, interview and record review, the licensee is not providing residents their medications as prescribed, which poses an immediate Health, Safety, Personal Rights risk to persons in care.

Official plan of correction

Licensee obtained an updated physician order for the memantine during the LPA visit and is working to obtain the updated seroquel order by tomorrow. Licensee will email LPA the updated seroquel order when received and a statement of understanding of this regulation by 6/17/2026.

Deadline recorded: Jun 17, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (4)The licensee shall assist residents with self-administered medications as needed.This requirement was not met as evidenced by: Based on observation, interview and record review, the licensee is not providing reisdents their medications as prescribed, which poses an immediate Health, Safety, Personal Rights risk to persons in care.

Official plan of correction

Licensee removed and will destroy the mixed medications and they will write a procedure on using one bottle at a time and properly documenting start dates, email this to LPA by 3/12/2026. Additional Licensee will sign up for vendored medication training and email LPA confirmation for all three staff.

Deadline recorded: Mar 12, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

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 was not met as evidenced by: Based on observation, interview, and record review, the licensee tansffered medications into three different medication bottles which poses an immediate Health, Safety, and Personal Rights risk to persons in care.

Official plan of correction

Licensee states they will no longer mix medication and will incldue this in the procedure for the above plan of correction and email to LPA by 3/12/2026.

Deadline recorded: Mar 12, 2026. 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

Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement was not met as evidenced by: Based on observation, the licensee did not ensure two electrical outlets were covered with faceplates which poses a potential Health and Safety risk to persons in care.

Official plan of correction

Licensee will have the outlets covered with faceplates and email LPA pictures by 3/25/2026.

Deadline recorded: Mar 25, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. 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 when nine resident medications were not documented on the (CSMR) and five expired medications were observed in resident current stock of medications which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 12/26/2025 Plan of Correction During LPA visit Licensee recorded the nine medications on the resident CSMR and documented the destruction of the five expired medications. Licensee will email LPA on or before 12/26/2025 a policy created to ensure medications are documented upon reciept to the facility and centrally stored medciations are audited regularly to check for expiration.

Official classification

Type B

Official code

87463(b)

Regulation authority

CCR

What the official deficiency says

(b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in 4 out of 4 resident reappraisals not up to date or complete per regulation which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 01/02/2026 Plan of Correction Licensee will review the full regulation 87463 and document up to date reappraisals for each of the four residents. The up dated reappraisals will be emailed to the LPA on or before 1/3/2026.

Official classification

Type B

Official code

87625(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (8) Privacy shall be afforded when care is provided. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above when R1 was not provided privacy when recieving care from staff allowing other residents and visitors to see R1 while indicposed which poses a personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/26/2025 Plan of Correction Licensee will conduct staff training with all staff ensuring residents are provided privacy during care and email the LPA the training documentation and signed staff roster on or before 12/26/2025.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

Storage Space and Access (a) ...the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives,...sharp objects,... and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidenced by: Based on observation, the licensee did not follow this regulation when they left disinfectants, cleaning solutions, knives, and sharp objects out and accessible to residents in care which poses an immediate Health and Safety risk to persons in care.

Official plan of correction

Licensee states they will re-train the staff on this regulation and create log sheets to record the date, time and reason for every time staff unlock and lock any locked cabinets containing disinfectants, cleaning solutions, poisonous substances, knives, and sharp objects. Licensee will email LPA training documents and signed staff roster on or before 9/26/2025 and the log on or before 10/03/2025.

Deadline recorded: Sep 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

Fire Clearance(a)...Prior to...retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city,...fire department,...or the State Fire Marshal. (2)Bedridden persons. This requirement was not met as evidenced by: Based on observation and interview, the licensee did not follow their fire clearance a bedridden resident, R1, resides in a non bedridden room and fire extinguisher not serviced annually which poses an immediate Health and Safety risk to persons in care.

Official plan of correction

Licensee will submit an LIC200, LIC9054, and the facility sketch to the LPA by 8/13/2025 to see if the fire marshal will update the fire clearance to meet the needs of the resident in care. Provide LPA with proof of fire extinguisher service or purchase by 8/26/2025.

Deadline recorded: Aug 13, 2025. 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

Storage Space and Access (a) ...the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances,... and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidenced by: Based on observation, the licensee did not follow this regulation when they left bug spray and cleaning solutions out and accessible to residents in care which poses an immediate Health and Safety risk to persons in care.

Official plan of correction

Backup Administrator removed and locked up the items at time of LPA observation. Licensee will email LPA a statement of understanding on this regulation by 8/13/2025. Licensee will conduct staff training on this regulation and email LPA documentation of the training on or before 8/26/2025.

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

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. ... This requirement is not met as evidenced by: Based on interview and not being able to produce evidence of quarterly drills, the licensee did not comply with the section cited above during the facility visit which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will conduct an emergency disaster drill on each shift and show proof to LPA by 08/26/2025 via email. Licensee will also create a written plan to ensure the required drills are conducted quarterly and email the plan to LPA on or before 8/26/2025.

Deadline recorded: Aug 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows:(2)...Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F... This requirement is not met as evidenced by: Based on observation the licensee did not meet this regulation when LPA tested the resident shower temp reaching a maximum of 97.9 degree F which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will adjust water heater to meet the regulation and create a written plan to ensure the water temperature at all resident used faucets deliver water within regulation. Licensee will email the plan to LPA on or before 8/26/2025.

Deadline recorded: Aug 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

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 was not met by evidence of W1, W2, and LPA observing Resident Room's exits being blocked by obstacles, which poses a potential risk to residents in care.

Official plan of correction

Licensee/Administrator, Angelita O. Maravillas, agrees to provided 2 hours of Fire Safety training from a CCLD authorized vendor to all staff by 12/27/2024 and email proof of training to LPA by 12/27/2024.

Deadline recorded: Dec 25, 2024. A deadline is not proof that correction was completed.

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 not being able to produce evidence of quarterly drills, the licensee did not comply with the section cited above during the annual facility inspection which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/09/2024 Plan of Correction Licensee/Administrator will conduct emergency disaster drill on each shift and show proof to LPA by 12/09/2024. via email or text picture on cell phone.

Official classification

Type A

Official code

1569.269(1)(a)(10)

Regulation authority

HSC

What the official deficiency says

Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons.(10) To be free from neglect, ... punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. Based admission the licensee did not comply with the section cited above by tying and allowoing S2 to tie R1 to the bed with a sheet, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee agrees to have all facility employees take 4 hours of Personal Rights, and Mandated Reporting Training conducted by and authorized vender of CCLD. Licensee must identify vender by 10/11/2024 and communicate with LPA in a timely manor as completion of all staff for all 4 hours of training required by this POC.

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

Official classification

Type B

Official code

87468.2(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents…(a)In addition to the rights listed in Section 87468.1, …shall have all of the following personal rights: (1)To have a reasonable level of …communications…This requirement was not met based on Staff admission of aggressive verbal interactions with Resident, which poses an potential health, safety and personal rights risk to residents in care.

Official plan of correction

All staff will receive 1 hour of resident personal rights training by an approved vendor. Licensee will submit proof of training to LPA Jeffries by email on or before 08/31/2022.

Deadline recorded: Aug 31, 2022. A deadline is not proof that correction was completed.