OAKS AT PASO ROBLES, THE

Official classification

Type B

Official code

87507(f)

Regulation authority

CCR

What the official deficiency says

(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with modifications made to the level of care R1 required and was billed for which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

Administrator states they have been auditing and reviewing that all steps are conducted to communicate changes in resident services. They stated they will also conduct a formal training with the RSD and staff regarding the policy for updates on service plans and the care... tracker system and email training and staff roster to LPA by 7/23/2026.

Deadline recorded: Jul 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on record review the Licensee did not comply with the regulation above, when staff handled R1, R2 and R3 in a rough manner resulting in injury which is an immediate health, safety, and personal rights risk to residents in care.

Official plan of correction

Facility terminated S2's employment and provided other staff corrective action. Administrator states they will conduct staff training during the next all staff on 7/21/2026 regarding dignity and handling of residents and email LPA the training notes and staff roster by 7/23/2026

Deadline recorded: Jul 10, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(c)

Regulation authority

CCR

What the official deficiency says

(c) Any suspected physical abuse that does not result in serious bodily injury of an elder... adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours... This requirement was not met as evidenced by: Based on interview and record review, the Licensee did not ensure suspected physical abuse of R1 was reported as required which poses a potential health, safety, and personal rights risk to persons in care.

Official plan of correction

The facility has changed the reporting protocol. The Administrator states they conducted mandated reporter training on 6/16/2026 at the all staff meeting and will emial the LPA the training notes and roster from that training by 7/23/2026.

Deadline recorded: Jul 23, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities (a) Residents… shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interview, the Licensee did not ensure R1 was accorded dignity when staff spoke inappropriately to R1 which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Administrator states they will review residents rights and communication training with all staff at the next all-staff meeting and will submit training and signed staff roster to LPA by 4/15/2026.

Deadline recorded: Apr 15, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h)The following requirements shall apply to medications which are centrally stored:(6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:... This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above when 19 medications were not documented on resident Centrally Stored Medication Records which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 12/31/2025 Plan of Correction Administrator stated they will conduct an audit of centrally stored medictions ensuring all medications are documented on the centrally stored medication record and conduct training with all staff that are trained medication technicians on the policy of accepting and documenting newly recieved medications. Administrator will email audit documentation, staff training and signed staff roster to LPA on or before 12/31/2025.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(a)... residents...shall have all of the following personal rights: (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not ensure there was staff in sufficient numbers to meet the needs of all the resident’s in care, including R1 who sustained poor hygiene and multiple UTIs which poses an immediate Health, Safety, and Personal Rights risk to persons in care.

Official plan of correction

Administrator stated in the last month training for documenting care including toileting was conducted using their new system. Administrator will submit the signed staff training documents to LPA on or before 10/02/2025. This information is reviewed by him daily to monitor refusals and UTIs. Administrator states they have raised wages and always have job postings open. Corporate has asked the facility to have a goal to stop using agency staff by the end of last month (September), but the administrator will conitnue to use the agency staff in order to not be understaffed.

Deadline recorded: Oct 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(a)... residents...shall have all of the following personal rights: (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not ensure R1’s needs were met when R1 sustained multiple falls including one resulting in multiple broken bones which poses an immediate Health, Safety, and Personal Rights risk to persons in care.

Official plan of correction

Administrator stated in the last month the MCD started reporting falls to him on a daily bases and they impliment a fall mitigation plan after 2 falls within a month. The administrator will work with the SDRS on a written plan regarding this new policy and submit to the LPA on or before 10/08/2025. Administrator will also train staff on documenting falls and the MCD on the new policy and submit to LPA on or before 10/08/2025

Deadline recorded: Oct 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(e)(6)(B)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia (e)Licensees that use delayed egress devices on exterior doors…shall meet the following…continuing requirements: (6)For each incident of elopement…the licensee shall report the incident to: (B)The licensing agency Officer of the Day…no later than the next working day following the incident... This requirement was not met as evidenced by: Based on interview and record review, the licensee did not notify the licensing agency until nine days after the incident which poses a potential Health and Safety risk to persons in care.

Official plan of correction

Administrator states they will train lead staff on reporting requiments as outlined in this regulation and email LPA with training documents and signed roster of staff trained on or before 9/18/2025.

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

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

Staff training; legislative findings; contents (b)(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... This requirement was not met as evidenced by: Based on interview and record review, the licensee did not ensure S1 was provided dementia training prior to working in the memory care unit which poses a potential Health and Safety risk to persons in care.

Official plan of correction

Administrator states they will conduct an audit of agency staff used regularly to ensure they meet dementia training requirments and submit to the LPA via email the audit findings on or before 9/18/2025. Administrator also states moving forward they will ensure agency staff meet the dementia training.

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

Official classification

Type B

Official code

87307(a)(3)(D)

Regulation authority

CCR

What the official deficiency says

Personal Accommodations and Services (a)…The following provisions shall apply: (3)...supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident....if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (D) Hygiene items of general use such as soap and toilet paper. This requirement was not met as evidenced by: Based on observation, interviews, and information obtained, the licensee did not ensure soap and toilet paper necessary for maintenance of adequate hygiene practice...

Official plan of correction

Administrator will work with corporate on a plan to ensure supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident in care. Administrator will submit a written plan to LPA via email on or before 9/10/2025. were readily available to each resident, which poses a potential Health, Safety, Personal Rights risk to persons in care.

Deadline recorded: Sep 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(a)... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above when 6 of 7 residents stated they wait for staff to respond, 130 call response times were

Official plan of correction

Administrator stated they will move a screen that displays resident calls at the concierge station on 7/24/2025 more in view of the concierge to provide staff reminders, two weeks ago new staff devices were purchased to receive emergency resident alerts, and will train staff and provide LPA via email training and signed roster on or before 8/6/2025. over 10 minutes, and when staff stated the system does not always work which poses a potential health, safety, and personal rights risk to clients in care.

Deadline recorded: Aug 6, 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

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: Based on interviews and record review, the licensee did not comply with the section cited above when 7 rooms had stained/soiled linens, and when LPA noted R3's room with an odor and in disrepair which poses a potential health, safety, and personal rights risk to clients in care.

Official plan of correction

Administrator states the facility has hired additional housekeeping staff, they will schedule housekeeping in memory care daily, create a quality control check to ensure residents are provided clean linens, and schedule R3's room to be repaired. Administrator will email housekeeping schedule, quality control check docmuent and date(s) of scheduled repair to LPA on or before 8/6/2025.

Deadline recorded: Aug 6, 2025. 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

87465(a)(4) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when S1 gave R1 the wrong medications, which posed an immediate health and safety risk to residents in care.

Official plan of correction

S1 was temporarily suspended until further investigation was conducted, upon return to work S1 will not handle medications. S1 gave facility notice of resignation with last day of 04/06/2025. Administrator will create a checklist for med-techs to conduct the 6 medication rights and 3 checks to follow for each medication pass. Administrator will email the checklist to LPA by 3/27/2025. Administrator will train the staff handling medications on how to use the new checklist. Administrator will personally shadow each medication technician.

Deadline recorded: Mar 27, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465(h)(6) Incidental Medical and Dental Care. The following requirements shall apply to medications which are centrally stored: The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained... This requirement was not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when R2's lorazepam and oxycodone were not centrally stored on the Centrally Stored Medications Record.

Official plan of correction

Administrator will create a written protocol for trained staff to centrally stored medications and directors to review received medications on a daily bases by 04/09/2025. Administrator will email LPA the protocol by 04/09/2025.

Deadline recorded: Apr 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87265(b)(3)

Regulation authority

CCR

What the official deficiency says

87625 Managed Incontinence (b)…Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met by evidence of “ammonia like smell” in R1’s room and poses a potential risk to residents in care.

Official plan of correction

Administrator will email LPA (Garrett.Haner-Tomasko@dss.ca.gov) a copy of facilities emergency cleaning policy and statement of facility procedure to address emergency sanitation protocols no later than 03/07/2025.

Deadline recorded: Mar 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care ... (1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. The requirement was not met by evidence of R1 missing hundreds of medication passes which puts the Resident in immanent danger.

Official plan of correction

The Administrator shall conduct a comprehensive medication audit, with all residents in care to ensure that medications are in sync with Physicians orders, CSMR, MAR and physical medication count with a summary plan for audit submitted to LPAs emails by 02/28/2025. And audit completed with in two weeks on or before 03/14/2025. And submit proof of audit in CSMR, MAR, Physician Prescription Order and physical medication count to LPA by email on or before 03/14/2025.

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

Official classification

Type A

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (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. By evidence of S1 stating that R1's Centraly Stored Medication Records (CSMR) had been shreeded, which poses in immanent danger to Resident in care.

Official plan of correction

The Administrator shall have all staff who distribute medications and staff that manage the staff who distribute medication completed a comprehensive medication training of no less than 2 hours by a authorized vender of Department of Social Serviced, State of California. Administrator will provided LPA by email a list of employees who will take that class and the vender and class subject title by email on 02/28/2025 and will have all staff completed the training by 03/14/2025. And submit proof of training to LPA by email on or before 03/14/2025.

Deadline recorded: Feb 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87458(b)(1)

Regulation authority

CCR

What the official deficiency says

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met by evidence of Administrator allowing F1 to circumvent COVID-19 screening for two months or more, which posed a potential health risk to all residents in care.

Official plan of correction

Administrator who broke COVID-19 screening protocols is no longer at this facility, additionally the COVID-19 screening has been rescinded, therefore the POC is cleared at this visit,,

Deadline recorded: Aug 10, 2023. A deadline is not proof that correction was completed.