PRN CARE HOME LLC

Official classification

Type A

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, LPA observed mice droppings in the garage where facility stores their non-perishables which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/29/2025 Plan of Correction Licensee/administrator shall clean the mice droppings from the shelves and send LPA a photo. Licensee/administrator shall submit a plan in writing to ensure facility is free from pests. Plan should include hiring third party pest control services to treat the facility.

Official classification

Type A

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 records reviewed and interviews, 3/4 staff were observed to not have the required training which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/29/2025 Plan of Correction Licensee/administrator shall develop a plan in writing on how to ensure staff complete annual training. The plan shall include conducting audits and ensuring all training is logged and maintained in each staff file.

Official classification

Type A

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(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 4/4 staff records reviewed, 4/4 staff did not have their first aid/CPR training which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/29/2025 Plan of Correction Licensee/administrator to enroll all staff in first aid/CPR training and provide LPA confirmation of enrollment and the date of enrollment. Once completed, Licensee/administrator shall submit LPA a copy and ensure cards are maintained in each staff file.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(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 R1's prescribed insulin unlocked and accessible in the refrigerator which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/29/2025 Plan of Correction Licensee/administrator shall lock R1's insulin and provide LPA a photo of medication being locked and inaccessible.

Official classification

Type A

Official code

87463(h)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This requirement is not met as evidenced by: Deficient Practice Statement Based on 4/6 resident records reviewed, LPA did not observe any documentation to show that 4/6 of the residents have received an annual routine visit with a licensed professiona oncel every year which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/29/2025 Plan of Correction Licensee/administrator shall schedule annual routine appointments with a licensed medical professional for the 4 residents. Licensee/administrator shall ensure documentation of the appointment is maintained in the resident's files.

Official classification

Type A

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, LPA observed R1's bed to have a full bed rail. Based on interviews and records reviewed, R1 is not on hospice which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/29/2025 Plan of Correction Licensee/administrator shall remove the full bed rail from R1's bed and provide LPA a photo.

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) 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 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, the water temperature throughout the facility measured between 127-131 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/04/2025 Plan of Correction Licensee/administrator shall adjust the water heater and ensure water temperature is between 105-120 degrees F. Licensee/administrator to submit LPA video/photo of water temperature being within regulatory requirements.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on staff record review, Administrator was unable to provide a complete file for Staff 1 (S1) which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/04/2025 Plan of Correction Licensee/administrator shall ensure S1's file is complete and signed and maintained at the facility. Licensee/administrator shall submit a copy of S1's file to LPA by 11/4/25.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on 6/6 resident records reviewed, the files were not complete which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/04/2025 Plan of Correction Licensee/administrator shall audit all resident files and ensure all required documents under CCR87506 are signed and completed and maintained in each resident's file.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Deficient Practice Statement Based on 6/6 resident records reviewed, 3/6 resident files did not have a pre-admission appraisal in their files which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/04/2025 Plan of Correction Licensee/administrator shall complete pre-admission appraisals for the 3 residents and ensure it is maintained in the residents files.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on 6/6 resident record, 5/6 resident records did not have a service plan and/or had an outdated service plan which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/04/2025 Plan of Correction Licensee/administrator shall complete service plan/reappraisals for all residents to ensure it's being updated once every 12 months.

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 records reviewed and interview, Administrator was unable to provide LPA documenation to show that emergency drills are being conducted at least quarterly which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/04/2025 Plan of Correction Licensee/administrator shall begin documenting emergency drills quarterly and maintain a log at the facility. Licensee/administrator shall conduct an emergency drill by 11/4/25 and provide LPA a sign in sheet.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement is not met as evidenced by: Based on interviews and file reviews, on 12/11/24, there were six residents at the facility, all which have dementia. According to the administrator, he went to get groceries for the facility when R1 eloped and S1 was the only one present providing care to all six residents. Nevertheless, due to the lack of staffing, R1 was able to elope from the facility twice on 12/11/24 which poses an immediate health and safety risk to residents in care.

Official plan of correction

Facility shall submit a new LIC500 and submit a plan to ensure staffing is sufficient throughout the day/night. Facility shall submit a plan on how to ensure residents needs are being met, including hiring additional staff if required

Deadline recorded: Dec 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: (e) 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: (1)Obtain a California clearance or a criminal record exemption as required by the Department or.... Violation of this regulation is not met as evidenced by: Based on observations, LPAs observed S1 to providing care and supervision to clients in care however, based on record review, S1 was obseved to not have any fingerprint clearance. According to the administrator, S1 has been working at the facility for more than a year.

Official plan of correction

Licensee/Administrator shall ensure S1 does not work and/or is present at the facility until S1 is fingerprint cleared or has an exemption

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

Official classification

Type A

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, the licensee constructed an office room in the garage which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/19/2024 Plan of Correction Licensee/Administrator shall submit a plan in writing on how to address this deficiency by the POC due date.

Official classification

Type A

Official code

87307(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, LPAs observed a closet room right across from the garage, located next the dining room table to have a bed and personal belongings which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/19/2024 Plan of Correction Licensee/Administrator indicated that he will remove beds and perosnal belongings from the closet by the POC due date.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, the garage passageway was observed to be blocked with clutter. In addition, LPAs observed the exit route area from Bedroom #4 to the patio in the backyard to have suitcases, covered furniture, wheelchair and a desk chair blocking the exit route passeway which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/19/2024 Plan of Correction Licensee/Administrator shall remove all items blocking the passeway in the garage and the backyard patio to ensure it is not a fire safety hazard and provide LPAs the photo of the correction by the POC due date.

Official classification

Type A

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 observations, LPAs observed chemicals, and sharps unlocked and accessible to residents in the kitchen and in the bathroom which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/19/2024 Plan of Correction Licensee/Administrator shall ensure locks on kitchen cabinets are repaired and provide LPA photos of locked chemicals and sharps. Licensee/Administrator shall provide staff training regarding the importance of locking sharps and chemicals.

Official classification

Type A

Official code

87412(g)

Regulation authority

CCR

What the official deficiency says

(g) All personnel records shall be maintained at the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, no personnel records were present at the facility for review which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/19/2024 Plan of Correction Licensee/Adminstrator shall ensure personnel records are complete and ensure it is maintained at the facility at all times.

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, LPAs observed a gallon of expired milk in the refrigerator. In addition, LPAs observed frozen milk in the garage freezer to also be expired which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/19/2024 Plan of Correction Facility staff immediately threw away the expired milk. Deficiency is cleared and corrected.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(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, LPAs observed medication cabinet to be unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/19/2024 Plan of Correction Medication cabinet was immediately locked in LPAs presence. Deficiency cleared and corrected.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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, Bedroom #4 bathroom was observed to have water on the floor, faucet was observed to be in disrepair, power strip locatedi n bedroom #4 was observed partially burnt. In addition, LPAs observed Bedroom #3 with mold on the ceiling which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/19/2024 Plan of Correction Licensee/administrator shall submit a plan in writing to indicate how to fix/address the issues mentioned above by 9/19/2024.

Official classification

Type B

Official code

87303(d)

Regulation authority

CCR

What the official deficiency says

(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, LPAs toured bedroom #3 and observed a table light that does not provide sufficienct lighting for resident which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/19/2024 Plan of Correction Licensee/administrator shall purchase new lighting fixture for resident and provide LPA with a copy of the receipt to show fixture has been bought. In addition, provide LPAs photos that fixture is installed.

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, no emergency drill log was provided and/or available to LPAs during the visit. Based on interviews, staff indicated she/he has not heard of any drills being conducted at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/19/2024 Plan of Correction Licensee/Administrator shall conduct an emergency drill and provide a copy of the drill log to LPA.

Official classification

Type A

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations, Bedroom #4 has a resident with dementia. Bedroom #4 has an exit door leading from the room to the patio area in the backyard. The door alarm was observed to not be in working condition which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/19/2024 Plan of Correction Licensee/administrator shall fix the door alarm and send LPAs a video/photo to ensure door alarm is in good working condition.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on 5 resident records reviewed, 1/5 resident does not have a file at all and 1/5 resident record does not have physician's report, needs and service plan, ermegency contact sheet which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/25/2024 Plan of Correction Licensee/Administrator shall complete and maintain updated resident records at the facility.

Official classification

Type B

Official code

87465(i)(1-4)

Regulation authority

CCR

What the official deficiency says

INCIDENTAL MEDICAL CARE Prescription medications which are... otherwise to be disposed of shall be destroyed in the facility by the facility administrator & one other adult who is not a resident. Both shall sign a record, to be retained for at least 3 years, which lists...: Name of the resident, Rx number, name of pharmacy, drug name, strength, quantity destroyed, date of destruction. This requirement is not met, as medications included on 3 clients' Medication Administration Records were stopped or discarded, per staff, but there is no documentation maintained of the MD orders or destruction. Licensee failed to ensure that records are maintained for med destruction, which poses a potential risk.

Official plan of correction

Plan of correction to be submitted to CCLD BY DUE DATE This shall include explanation of whereabouts for 6 medications for client #3, and 1 medication each for clients #1 and #2.

Deadline recorded: Mar 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: facility failed to ask screening questions; failed to post COVID-19 signage throughout the facility; failed to maintain a 30-Day PPE supply; failed to have paper-towels in the bathroom; failed to have trash cans with bins. 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/posed a potential health, safety or personal rights risk to persons in care. Facility failed to ask screening questions upon arrival to the facility, keep an appropriate amount PPE, have COVID signage posted throughout the facility, and have bathrooms equipped with paper-towels.

Official plan of correction

POC Due Date: 10/28/2021 Plan of Correction The administrator/licensee will review the Department's Provider Information Notices (PINs) regarding the daily COVID-19 screening for residents and staff members, masking guidance, COVID-19 protocol signage, and maintaining an adequate amount of PPE supply.

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Albert Liu, staff member, is not listed on the LIC500 or the LIC555. 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/posed a potential health, safety or personal rights risk to persons in care. According to Licensing records, Albert Liu is not associated with the facility or has received background clearance.

Official plan of correction

POC Due Date: 10/25/2021 Plan of Correction This is a Type A definiciency. Facility will associate staff member with the facility immediately.