SANDHILL ASSISTED LIVING LLC

Official classification

Type A

Official code

87506(A)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (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: Based on interview, record review and interviews, during the inspection, resident's records were missing from resident's files such as LIC 602 assessments, and reappraisals. Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above based on observation, record review and interviews, during the inspection, resident's records were missing from resident's files and the administrator had to retrieve them from her phone which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/02/2026 Plan of Correction The administrator will develop a plan of correction to ensure all resident records are readily available to facility staff and to licensing agency staff. The administrator will submit a copy of the plan of correction to CCL by 7/2/2026.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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 the hot water temperature was measured at 128-130 degrees F which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/02/2026 Plan of Correction The administrator will adjust the hot water temperature accordingly and will submit a plan of correction to ensure the hot water temperature is within range. The administrator will provide a copy of the plan of correction to CCL by 7/2/2026.

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 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: 07/02/2026 Plan of Correction The administrator will submit a plan to ensure drills are completed at least quarterly for each shift and will submit a copy of the plan of correction to CCL by 7/2/2026.

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed R2 has bed rails that extend the entire length of the bed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/02/2026 Plan of Correction The administrator will remove the full bed rail immediately and provide photo afterwards. The administrator will develop a plan of correction to ensure full bed rails are not being used and will submit a plan of correction by 7/2/2026.

Official classification

Type B

Official code

87355(j)

Regulation authority

CCR

What the official deficiency says

(j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file as required in Section 87412, Personnel Records. 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 LPA observed S1 did not have a copy of the criminal record maintained in the personnel file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/09/2026 Plan of Correction The administrator will develop a plan of correction to ensure criminal records are file in all staff personnel files and provide a copy of the plan to CCL by 7/1/2026.

Official classification

Type B

Official code

87458(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (5) The determination whether the person is ambulatory or nonambulatory as defined in Section 87101, Definitions, or bedridden as defined in Health and Safety Code section 1569.72. The assessment shall indicate whether nonambulatory status is based upon the resident's physical condition, mental condition, or both. 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 R3's medical assessment for Ambulatory Status was blank. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/09/2026 Plan of Correction The administrator will follow-up with R3's PCP to obtain an updated ambulatory status and the administrator will provide a copy of it to CCL by 7/9/2026.

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed R1 and R3 did not have an updated reappraisal. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/09/2026 Plan of Correction The administrator will develop a plan of correction to ensure all the residents have an updated reappraisals and will provide a copy of the plan of correction and a copy of the reappraisal for R1 and R3 by 7/9/2026.

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...The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents... This requirement was not met as evidenced by: Based on interviews, observations and records review, there was not enough staff member scheduled to cater to the resident’s care which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

On 4/10/25, LPA delivered amended LIC9099D. LPA conducted visit on 4/10/25 and observed sufficient staff. Deficiency corrected and cleared.

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

Official classification

Type B

Official code

87307(d)(7)

Regulation authority

CCR

What the official deficiency says

(7) Fireplaces and open-faced heaters shall be adequately screened. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 2 out of 2 fire places which did not have screens, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2024 Plan of Correction Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.

Official classification

Type B

Official code

87705(l)(1)

Regulation authority

CCR

What the official deficiency says

(l) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (1) Licensees shall notify the licensing agency of their intention to lock exterior doors and/or perimeter fence gates. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview of the administrator, the licensee did not comply with the section cited above in 2 out of 2 fences which were observed to have locks on them and are locked according to the administrator, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/09/2024 Plan of Correction Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.

Official classification

Type A

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in 4 out of 5 Centrally Stored Medication records(CSMR) which were missing a total of 12 medications,which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/26/2024 Plan of Correction Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.

Official classification

Type A

Official code

1569.695(a)(2)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 1 out of 1 boxes of supplies that shall be available to provide alternative resources during an outage, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/26/2024 Plan of Correction Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.

Official classification

Type A

Official code

87405(d)(1)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (d)The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not met as evidenced by: Based on records review, R1 moved in and caregivers were not given any information regarding the resident, which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee shall submit a plan on how it will address dissimenating information regarding residents to caregivers. Licensee to submit plan by POC deadline.

Deadline recorded: Feb 23, 2024. 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

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...(6)When requested by the prescribing physician or the Department, a record of dosages ... This requirement is not met as evidenced by: Based on records review, R1 does not have a Medication Administration Records (MAR) log, which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee to submit a plan to address documentation regarding MAR. Licensee to submit plan by POC deadline.

Deadline recorded: Feb 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b) The following food service requirements shall apply: (26)S upplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Based on observation, there was not enough supply of canned good and 7-day non-perishable foods, which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee to submit a plan to address the food supply in the facility. Licensee to submit photos of food supply. LIcensee to submit by POC deadline.

Deadline recorded: Feb 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(d)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication...(2) The date and time of each contact with the physician, and the physician's directions... This requirement is not met as evidenced by: Based on records review, two medications, Lasix & Tylenol, were given to R1 with no proper documentation that it was requested from the doctor, which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee to submit a plan to address documentation of PRN medications to residents. Licensee to submit plan by POC deadline.

Deadline recorded: Feb 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by: Based on interview, S1 stated that there were no logs for activities of daily living, which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee to submit a plan to address documentation of activities of daily living. Licensee to submit plan by POC deadline.

Deadline recorded: Feb 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(d)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements –General (d)All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance. This requirement is not met as evidenced by: Based on interviews from witnesses, there are staff that are not qualified and not trained, which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee to submit a plan where staff are provided adequate on-the-job training. Licensee to submit plan by POC deadline.

Deadline recorded: Feb 23, 2024. 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 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... (4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on records review, there was one day where R1 was given twice the dosage of the medication and no other documentation stating that it was approved by R1s physician, which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee to submit a plan to address medication administration to residents. Licensee to submit plan by POC deadline.

Deadline recorded: Feb 22, 2024. A deadline is not proof that correction was completed.

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... Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. ... This requirement is not met as evidenced by: Based on interviews and records review S3 was not able to help R1 due to another resident being assisted and the personnel report schedule have no specific days on when staff is scheduled, which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee to submit a plan to provide adequate staffing in the facility. Licensee to submit updated LIC 500. Licensee to submit plan by POC deadline.

Deadline recorded: Feb 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(14)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b)The following food service requirements shall apply (14) If food is prepared off the facility premises, the preparation source shall meet all applicable requirements for commercial services... This requirement is not met as evidenced by: Based on interviews, lunch is prepared in a different facility and placed in plastic containers and transported by another staff member by car, which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee to submit a plan regarding food preparation in the facility. Licensee to submit plan by POC deadline.

Deadline recorded: Feb 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses... This requirement is not met as evidenced by: Based on interviews, the facility is not able to provide any records regarding R1s weight loss, which poses an immediate health, safety, and personal rights risk to persons in care.

Official plan of correction

Licensee to submit a plan addressing documentation and resident observation. Licensee to submit plan by POC deadline.

Deadline recorded: Feb 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211(a) Each licensee shall furnish... such reports... including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency...(D)Any incident which threatens the welfare...or unexplained absence of any resident. This requirement is not met as evidenced by: Based on record reviews licensee did not comply with the section cited above due an incident where there is a change in condition of R1 not reported to CCLD which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit a plan in order to address reporting requirements to CCLD. Licensee to submit plan by POC due date.

Deadline recorded: Nov 7, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 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.. The requirement is not met as evidenced by facility dog presented aggression toward a family member and bit the family member which posed an immediately health risk for resident in care.

Official plan of correction

The administrator/licensee will develop a plan to ensure this does not happen again and the plan shall include what actions that the facility shall take to ensure a comfortable, safe, healthful environment is provided environment is provided for resident, family members, visitors, etc.

Deadline recorded: Aug 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on 2 Personnel Files are not on file in the facility and is not readily available for checking which poses an immediate health and safety risk to residents..

Official plan of correction

POC Due Date: 07/25/2023 Plan of Correction Submit plan of action to ensure that files are readily to available for checking. Make the files available in the facility.

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 record review, the licensee did not comply with the section cited above because 2 staff members doesn't have valid CPR training which poses an immediate health and safety risk to residents or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/25/2023 Plan of Correction Submit a plan on how the 2 staff members will get the training required.

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 2 personnel records were not readily available in the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/25/2023 Plan of Correction Submit a plan on how to make staff records readily available in the facility.

Official classification

Type A

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 record review 2 personnel records were not readily available in the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/25/2023 Plan of Correction Submit plan of action to ensure that files are readily to available for checking. Make the files available in the facility.

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 interview no emergency drill logs are available in the facility. Drills in the facility were done every 6 months instead of quarterly which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/25/2023 Plan of Correction Submit a plan on action on when this drills are going to be scheduled and ensure that staff sign for the in service training.

Official classification

Type B

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 record review, the licensee did not comply with the section cited above due to 2 out 3 doesn’t have signature of Licensee/Administrator in the admission agreement. One resident doesn’t have signature on LIC 603 (Needs & Appraisals), another resident doesn’t have signature on LIC 621 (Personal Property & Valuables) which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/28/2023 Plan of Correction Have all necessary documents signed by either party.

Official classification

Type A

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by: Based Deficient Practice Statement Based on interview, a resident mentioned that he/she fell several times. No report was submitted to licnesing. The licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/25/2023 Plan of Correction Provide a plan of action as to how to address incident reports.