A & J ASSISTED LIVING FACILITY

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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 Based on observations, resident rooms observed and second floor dining room had window screens to be in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/02/2026 Plan of Correction Licensee/administrator shall take a photo of the repaired window screens and send it to LPA by 4/2/26,

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on R1’s file reviewed, R1 has is unable to leave the facility unassisted, however, R1 was able to leave the facility on 1/1/26 without staff knowing. In addition, R1 has still not returned back to the facility and is currently missing which poses an immediate health and safety risk to residents in care

Official plan of correction

Licensee/administrator shall submit a plan in writing on how to ensure residents who are unable to leave the facility unassisted are being monitored and are being provided adequate supervision to ensure safety. A civil penalty of $250.00 is assessed for a repeat violation within the last 12 months for CCR 87464(f)(1). The same citation was issued on 11/19/25,

Deadline recorded: Jan 14, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on R1’s file reviewed, R1 has is unable to leave the facility unassisted, however, despite staff being aware that R1 was leaving, R1 still left the facility unassisted on 10/23/25. In addition, R1 did not return back to the facility the same day and although NOC shift caregivers were aware, they did not call 911 to report this incident which poses an immediate health and safety risk to residents in care

Official plan of correction

Licensee/administrator shall conduct an in-service training regarding facility's protocols for reporting requirements when a resident is missing/still has not returned from outting. Training shall include, who to contact, documentation, who is responsible for following up. A Civil penalty of $1,000.00 is assessed for a repeat violation within the last 12 months for CCR 87464(f)(1). The same citation was issued on 2/11/25 and 11/12/25.

Deadline recorded: Nov 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on R1’s file reviewed, R1 has dementia, is unable to leave the facility unassisted and is a wanderer, however on 9/24/25, R1 eloped from the facility and was brought back to the facility by police officers at around 7pm. According to the assistant administrator, the staff on the second floor did not see R1 leave the facility and are not sure how R1 left the facility which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/administrator shall conduct an in-service training with staff regarding elopement risk/wandering behavior. Sign-in sheet shall submitted to LPA. Licensee/administrator shall submit a plan in writing on how to ensure care and supervision is provided to residents who are elopement risk and have wandering behaviors. A Civil penalty of $1,000.00 is assessed for a repeat violation within the last 12 months for CCR 87464(f)(1). The same citation was issued on 2/11/25.

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

Official classification

Type A

Official code

87705(d)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia: (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors...accessible to those residents who may be at risk for elopement... This requirement is not met as evidenced by Based on observations, LPA observed 11 exit doors thoughout the facility; of which 3 doors did not have alarms, 3 doors with working alarms but were turned off, and 1 that was not working at all. According to R1's file, R1 has dementia, is a wanderer and is unable to leave the facility unassisted, however the Licensee failed to ensure the door alarms were in good working condition which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee/administrator will install and/or replace the alarms on exit on the exterior door and will provide LPA video/photos of alarms to be in good working condition. In addition, Licensee/administrator shall conduct an in-service training with staff to ensure that door alarms are turned on at all times.

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

Official classification

Type A

Official code

87507(c)

Regulation authority

CCR

What the official deficiency says

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by: Deficient Practice Statement Based on resident record reviewed, LPA observed 2/5 resident records to not have signed admission agreements which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/28/2025 Plan of Correction Licensee/administrator to submit a plan in writing on how to ensure all resident admission agreements are signed and complete.

Official classification

Type A

Official code

87555(b)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements: (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, LPA observed flies outside of the kitchen with no window or door blocking the flies from going inside the kitchen. In addition LPA observed flies in the kitchen while staff were cooking which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/28/2025 Plan of Correction Licensee/administrator shall submit a plan in writing on how to ensure flies are not going into the kitchen while food is being prepared or being served to residents.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation: (e)Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. 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 (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, water temperature throughout the facility measured between 130-135 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2025 Plan of Correction Licensee/administrator shall submit photos to LPA of water temperature being within 105-120 degrees F.

Official classification

Type B

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 Based on observations, LPA observed the door near the kitchen to be in disrepair. LPA observed the hot water faucet in one resident's room to not be working. In addition, LPA observed a cleaning supply room near the kitchen to have no door knob, and there was a hole observed in the wall. The facility put a tie through the hole in the wall into the hole in door knob hole to lock the door which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2025 Plan of Correction Licensee/administrator shall repair all of the above mentioned issues that were observed and send LPA a photo of the repair.

Official classification

Type A

Official code

87456(h)(2)

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: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, LPA observed the second floor nurses' station that has medication in the room to have the key attached to the door knob with no staff present which poses an immediate health, safety or personal rights risk to persons in care. A CIVIL PENALTY OF $250.00 IS ASSESSED ON 3/27/25 FOR REPEAT VIOLATION WITHIN LAST 12 MONTHS. Deficiency was assessed on 10/30/24

Official plan of correction

POC Due Date: 03/28/2025 Plan of Correction Licensee/Administrator to conduct an in-service training with staff regarding the importance of locking medication and ensuring the key is not attached to the door.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on file reviewed, Based on R1's physician's report, R1's physician's report dated 11/14/23 indicated R1 has a diagnosis of traumatic brain injury with cognitive dysfunction and can't leave the facility unassisted. According to administrator, staff did not observe R1 leave the facility. R1 did not have a staff escort R1 when leaving the facility.

Official plan of correction

Licensee/Administrator will provide in-service training to all staff members regarding checking to ensure residents who are signing-out have a staff member escorting them if required. A repeat civil penaty is assessed today for a repeat violation within 12 months. Same violation was cited on 10/30/24. $1,000.00 civil penalty is provided on 2/11/25.

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

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on interviews, due to the absence of supervision, R1 left the facility again unassisted on 10/19/24 and facility staff failed to check to see if R1 returned back to the facility knowing R1 left in the morning which poses an immediate health risks for residents in care. R1 did not return back to the facility till 10/29/24.

Official plan of correction

The Licensee/Administrator will develop a plan to ensure residents are being supervised at all times. Administrator/licensee will provide a copy of the plan to CCL by 10/31/24. Immediate Civil Penalty of $500.00 is being assessed today 10/30/24 for absence of supervision.

Deadline recorded: Oct 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c) Violation of this regulation is not met as evidenced by: Based on file reviewed, Based on R1's physician's report, R1 has Mild Cognitive Impairment (MCI) and can't leave the facility unassisted. According to interviewes, on 9/23/24, R1 did not have a staff escort R1 to his/her doctor's appointment. According to the administrator, it was not till 9:15pm when a staff noticed that R1 was not at the facility and not until 11:15pm when staff called the police for a missing person's. Facility failed to ensure required parties were called immediately after noticing R1 was not at the facility.

Official plan of correction

Licensee/Administrator will provide in-service training to all staff members regarding checking to ensure residents who are signing-out have a staff member escorting them if required.

Deadline recorded: Oct 21, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

CRIMINAL RECORD CLEARANCE All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility, obtain a CA clearance or a criminal record exemption as required by the Department. This requirement was not met, as staff #1 has been employed as caregiver since 1/2023, but there is no evidence of criminal record clearance. Licensee failed to ensure that staff with direct contact with clients maintain criminal record clearance prior to contact with clients, which poses an immediate health, safety or personal rights risk to clients in care. LIC421 issued to assess immediate $500 civil penalty=5 days at $100/day .

Official plan of correction

Staff #1 cannot be on premises with contact with clients unless and until he has been fingerprinted and obtain criminal record clearance and association with facility. Proof of correction to be sent to CCLD BY DUE DATE

Deadline recorded: Apr 26, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

Prohibited Health Conditions - Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:(1) Stage 3 and 4 pressure injuries. This regulation has not been met as evidenced by: It was discovered that the facility accepted and retained a resident with Stage 3 pressure sore without prior approval by the Department to allow the resident to be accepted into the facility.

Official plan of correction

The facility shall ensure that the a plan will be implemented in order to prevent this situation from happening in the future. A written plan shall be received outlining the understanding of this regualtion and actions the facility will take before accpeting any residents with conditions requiring an exception. POC to be received by due date

Deadline recorded: Feb 1, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87455(a)

Regulation authority

CCR

What the official deficiency says

Acceptance and Retention Limitations - Acceptance or retention of residents by a facility shall be in accordance with the criteria specified in this article 8 and Section 87605, Health and Safety Protection, and the following. This regulation has not been met as evidenced by: It was discovered that the facility accepted and retained a resident with Stage 3 pressure sore without prior approval by the Department to allow the resident to be accepted into the facility.

Official plan of correction

The facility shall ensure that the a plan will be implemented in order to prevent this situation from happening in the future. A written plan shall be received outlining the understanding of this regualtion and actions the facility will take before accpeting any residents with conditions requiring an exception. POC to be received by due date

Deadline recorded: Feb 1, 2023. A deadline is not proof that correction was completed.