FIVE STAR CARE HOME II

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

(c) All window screens shall be clean and maintained in good repair. 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 as LPA observed the screen sliding door in one of the private room has 2 holes on it which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2026 Plan of Correction The administrator will provide photo to CCL by 6/18/2026 to proof that the screen is fixed.

Official classification

Type B

Official code

87412(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: 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 as during the inspection, LPA observed some records were not available for inspection such as the emergency drills, and staff education resulting in the caregiver contacting the administrator who sent proof to LPA via email of the missing documents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2026 Plan of Correction The administrator will submit a plan of correction to CCL by 6/18/2026 to ensure all personnel records shall be available to the licensing agency to inspect.

Official classification

Type A

Official code

87355(a)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve..or employment, .. Based on observation, interview and record review, LPA observed S1 caring for resident but criminal record clearance was incomplete which poses an immediate health and safety risks for residents in care.

Official plan of correction

The administrator will develop a plan to ensure all staff have a completed the criminal record clearance process prior to working. The administrator will provide a copy of the plan of correction to CCL by 7/4/2025.

Deadline recorded: Jul 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed water temperature in the kitchen and the resident bathroom were measured at 139-143 F which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2025 Plan of Correction The administrator will develop a plan to ensure water temperature is within the range of 105-120 and will take daily temperature for the next 10 days and record the result. The administrator will submit a copy of the plan of correction to CCL by 6/18/2025.

Official classification

Type A

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed S1 and S2's CPR/Fire aid training expired May 2024 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2025 Plan of Correction The administrator will develop a plan to ensure at least one staff member has CPR and First aid training on duty and will submit a copy of the plan to CCL by 6/18/2025. The administrator will ensure one of the two staff members obtains their CPR/First aid training no later than 7/2/2025. The facility was cited on this deficiency during last's annual visit.

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above LPA observed 2 out of 2 staff did not have their training records which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2025 Plan of Correction The administrator will develop a plan of correction to ensure required training is completed for all staff and will submit the plan to CCL by 6/18/2025. The plan shall indicate the date that the training shall be completed for all staff and the date shall be no later than 7/2/2025. The facility was cited on this deficiency during last's annual visit.

Official classification

Type A

Official code

1569.696(a)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: 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 LPA observed 2 out of 2 staff did not have their training records which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2025 Plan of Correction The administrator will develop a plan of correction to ensure required training is completed for all staff and will submit the plan to CCL by 6/18/2025. The plan shall indicate the date that the training shall be completed for all staff and the date shall be no later than 7/2/2025. The facility was cited on this deficiency during last's annual visit.

Official classification

Type A

Official code

87465(c)(3)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. 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 as LPA observed R4 was admitted in May 2025 and there is no medication record which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2025 Plan of Correction The administrator will develop a plan of correction to ensure the facility maintains a medication record for all the residents and the plan shall indicate the date that this will be completed for R4 and the date shall be no later than 7/2/2025. The administrator will submit a copy of the plan to CCL by 6/18/2025.

Official classification

Type A

Official code

87456(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. 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 as LPA observed R4 was admitted in May 2025 and there is no pre-admission appraisal which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2025 Plan of Correction The administrator will develop a plan of correction to ensure the facility maintains a pre-admission appraisal for all the residents and the plan shall indicate the date that this will be completed for R4 and the date shall be no later than 7/2/2025. The administrator will submit a copy of the plan to CCL by 6/18/2025. The facility was cited on this deficiency during last's annual visit.

Official classification

Type A

Official code

87456(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. 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 as LPA observed R4 was admitted in May 2024 and the facility did not have a copy of the recent medical assessment which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2025 Plan of Correction The administrator will develop a plan of correction to ensure the facility maintains a recent medical assessment for all the residents and the plan shall indicate the date that this will be completed for R4 and the date shall be no later than 7/2/2025. The administrator will submit a copy of the plan to CCL by 6/18/2025.

Official classification

Type A

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility was not able to provide proof that the emergency drills were completed accordingly which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2025 Plan of Correction The administrator will develop a plan of correction to ensure the facility is conducting emergency drills accordingly and the plan shall indicate the date that this will be completed and the date shall be no later than 7/2/2025. The administrator will submit a copy of the plan to CCL by 6/18/2025.

Official classification

Type A

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. 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 as LPA observed R2 and R4 have bed rails without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2025 Plan of Correction The administrator will develop a plan of correction to ensure the facility obtains a written order from a physician indicating the need for the postural support and the plan shall indicate the date that this will be completed for R2 and R4 and the date shall be no later than 7/2/2025. The administrator will submit a copy of the plan to CCL by 6/18/2025.

Official classification

Type A

Official code

87618(b)(3)(B)

Regulation authority

CCR

What the official deficiency says

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. 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 LPA did not observed any " No Smoking - Oxygen in Use " signs inside and outside of the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2025 Plan of Correction The administrator will post signs in the appropriate areas by 6/18/2025 and will send photos to CCL by 6/18/2025.

Official classification

Type A

Official code

87633(a)(1)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (1) The licensee has received a hospice care waiver from the department. 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 as the facility has an approved hospice waiver for 1 but currently has 2 residents who are on hospice which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2025 Plan of Correction The administrator shall develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/18/2025.

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as during the tour, LPA observed strong urine odor in resident rooms, a layer of black dust on top of the kitchen vent, dirty floor edges in the kitchen and around the facility, resident rooms were cluttered, etc. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2025 Plan of Correction The administrator will develop a plan of correction to ensure the facility is clean, safe and in good repair at all times and the plan shall indicate the date that the facility will complete the plan of correction and the date shall be no later than 7/2/2025. The administrator will provide a copy of the plan to CCL by 6/24/2025.

Official classification

Type B

Official code

87618(b)(3)(A)

Regulation authority

CCR

What the official deficiency says

(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at 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 as LPA observed 2 residents with Oxygen in their room and the facility was not able to provide proof that the local fire jurisdiction was notified which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2025 Plan of Correction The administrator will provide proof that the local fire jurisdiction was notified and provide copy of such proof to CCL by 6/24/2025.

Official classification

Type A

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 2 out of 2 staff did not have a valid First Aid Certification which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2024 Plan of Correction The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/18/2024.

Official classification

Type A

Official code

87456(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. 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 as 4 out of 6 residents did not have a pre-admission appraisal which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2024 Plan of Correction The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/18/2024.

Official classification

Type A

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility was not able to provide proof that emergency drills were completed accordingly which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/18/2024 Plan of Correction The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/18/2024.

Official classification

Type B

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed a hold in the wooden deck which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2024 Plan of Correction The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/24/2024. The administrator will provide photo to proof that the wooden deck has been fixed by 6/24/2024

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 2 out of 2 staff did not have documents to proof that required training was completed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2024 Plan of Correction The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/18/2024 along with a copy of the training records.

Official classification

Type B

Official code

1569.625(d)(1)

Regulation authority

HSC

What the official deficiency says

(1) A licensed or certified health professional with valid certification shall receive eight hours of training on resident characteristics, resident records, and facility practices and procedures prior to providing direct care to residents. 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 as 2 out of 2 staff members did not have documents to proof that this training was completed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2024 Plan of Correction The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/24/24 and a copy of the training records.

Official classification

Type B

Official code

1569.696(a)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: 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 as 2 out of 2 staff did not have documents to proof that this training was completed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2024 Plan of Correction The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/24/24 and a copy of the training records.

Official classification

Type B

Official code

1569.696(a)(1)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. 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 2 out of 2 staff members did not have training records to proof that this was completed which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2024 Plan of Correction The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/24/24 and a copy of the training records.

Official classification

Type B

Official code

87468(d)

Regulation authority

CCR

What the official deficiency says

(d) Licensees shall post the personal rights, nondiscrimination notice, and complaint information specified above in English, and, in any other language in which at least five (5) percent of the residents can only read that other language. 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 as LPA did not observe the personal rights were posted which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2024 Plan of Correction The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/24/24. The administrator will provide photos to proof compliance.

Official classification

Type B

Official code

87457(c)(1)

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 his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall include, at a minimum, an evaluation of the prospective resident's functional capabilities, mental condition and an evaluation of social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factors. 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 as 4 out of 6 residents did not have a completed appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2024 Plan of Correction The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/24/24 and a copy of the completed appraisal.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by:87307 Personal Accommodations and Services Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed a bed that was blocking the outdoor passageway which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2024 Plan of Correction The administrator will develop a plan to ensure compliance and the plan shall include staff training. The administrator will provide a copy of the plan and staff training records to CCL by 6/24/2024.