MONTEVERDE MANOR II

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

1569.605 Liability insurance; coverage requirements... Based on interview, observation and record review, This requirement is not met as evidenced by the facility did not provide a copy of the current liability insurance after several verbal and written reminders which poses a potential risk to residents in care.

Official plan of correction

The administrator/licensee stated that a copy of the current liability insurance will be provided to by the end of the day. The administrator will submit a plan of correction to ensure that this does not happen again and will provide a copy of the plan to CCL by 8/5/2026.

Deadline recorded: Aug 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator...this requirement is not met as evidenced by the administrator's certificate has expired which poses an immediate health and safety risks to residents in care.

Official plan of correction

The administrator/ licensee will develop a plan to ensure that the administrator completes the re-certification process in a timely fashion. In addition, the licensee will appoint an acting administrator for the facility while the administrator is working on the renewal process. The administrator will provide a copy of the plan of correction to CCL by 4/30/2026. The administrator will provide documents to CCL by 5/8/2026 to proof that the renewal process is completed.

Deadline recorded: Apr 30, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons 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 Based on documents reviewed, LPA observed R6 is bedridden, however, R6 was residing in a room that was not approved for bedridden resident which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction The administrator will submit a plan of correction to ensure compliance by 4/17/2026.

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 in the kitchen and the resident bathroom/shower room was measured above 150 degree F which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction The administrator will submit a plan of correction to ensure compliance by 4/17/2026.

Official classification

Type A

Official code

87412(a)(11)

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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 based on records review, LPA observed S2 did not have a health screen which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction The administrator will provide a plan of correction to CCL by 4/17/2026.

Official classification

Type A

Official code

87412(a)(13)(B)

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: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). 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 did not have criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction The administrator will provide a plan of correction to CCL by 4/17/2026.

Official classification

Type A

Official code

87613(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs. (B) Training shall be completed prior to the staff providing services to the resident. 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 S2 did not have any training prior to providing care to the residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction The administrator will provide a plan of correction by 4/17/2026 to ensure compliance.

Official classification

Type A

Official code

87219(a)

Regulation authority

CCR

What the official deficiency says

(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include: 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 upon entering the facility until the completion of the inspection, LPA did not observe any activities for the residents. LPA observed 4 residents were in bed, and 2 residents were on the couch in the living room (one was watching TV and the other one was sleeping). which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction The administrator will provide a plan of correction to CCL by 4/17/2026 indicating the actions that the facility will take to ensure facility has variety of planned activities to offer and to encourage residents to attend.

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as During the tour of the facility, LPA observed medications were unlocked and accessible to residents in care.which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction The administrator will submit a plan of correction to CCL by 4/17/2026 indicating the action(s) that the facility will take to ensure centrally stroed medication is locked and inaccessible to residents at all times.

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 based on records review, LPA observed R3 did not have a pre-placement appraisal which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction The administrator will provide a plan of correction to CCL by 4/17/2026 to ensure compliance and will provide a copy of the pre-admission appraisal to CCL by 4/27/2026.

Official classification

Type A

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 based on records review, LPA observed R1 and R4 did not have an updated reappraisal which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction The administrator will provide a plan of correction to CCL by 4/17/2026 to ensure compliance and will provide a copy of the reappraisal for R1 and R4 to CCL by 4/27/2026.

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 based on observation and record review, LPA observed R3 and R5 have half bedrails by the head of the bed 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: 04/17/2026 Plan of Correction The administrator will develop a plan of correction to ensure compliance and will provide a copy of the plan to CCL by 4/17/2026. The administrator will ensure a physician's order is obtained for R3 and R5's bed rails by 4/27/2026.

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 based on records reveiw and interview, LPA observed S1 did not have annual training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction The administrator will provide a plan of correction to ensure compliance by 4/27/2026.

Official classification

Type A

Official code

87405(d)(2)(3)

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). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. (3) Ability to maintain or supervise the maintenance of financial and other records. This requirement is not met as evidenced by: Based on observation, interview and record review, the facility has multiple repeat violations from the annual inspections from 2024, 2025 and 2026. Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as based on observation, interview and record review, the facility has multiple repeat violations from the annual inspections from 2024, 2025 and 2026 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction The administrator stated that he will be more hands-on with the facility's operation/care and supervision. The administrator will provide a plan of correction indicating the details of the " hands-on " involvement at the facility. The administrator will provide a copy of the plan of correction to CCL by 4/17/2026.

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 R2 and R3 did not have documentation to proof that their annual training was completed in 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/16/2025 Plan of Correction The administrator/licensee will develop a plan to ensure compliance and will provide a copy of training records for R2 and R3 by 4/16/2025.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons 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 based on the LIC602, R5 bedridden is but residing in room #1 that is not approved for bedridden which poses an immediate health, safety or personal right risk to persons in care.

Official plan of correction

POC Due Date: 04/02/2025 Plan of Correction The administrator will develop a plan to ensure compliance and if the plan is to convert room 1 into a bedridden room, the administrator shall indicate it in the plan of correction and LPA will assist with the process. The administrator will submit a plan to CCL by 4/2/2025.

Official classification

Type A

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

(a) 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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed the garage has been converted into a non-functioning garage as evidenced by 2 beds for staff to sleep/rest, many storage boxes, every cluttered the garage door is no longer working which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/02/2025 Plan of Correction The administrator will develop a plan to ensure compliance and will submit a copy of the plan to CCL by 4/2/2025. The compliance date to clean up the garage shall be no later than 4/8/2025.

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 R4 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: 04/02/2025 Plan of Correction The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 4/2/2025. The administrator shall have a copy of the completed pre-admission appraisal by 4/8/2025.

Official classification

Type A

Official code

87507(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. 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 R4's admission agreement was blank which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/02/2025 Plan of Correction The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 4/2/2025. The administrator shall have a copy of the completed admission agreement by 4/8/2025.

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 administrator did not have documents to proof that drills were conducted accordingly which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/02/2025 Plan of Correction The administrator will develop a plan to ensure compliance and provide a copy of the plan to CCL by 4/2/2025. The administrator shall provide proof to conduct an emergency drill no later than 4/8/2025.

Official classification

Type A

Official code

1569.695(d)

Regulation authority

HSC

What the official deficiency says

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. 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 administrator was not able to provide document to proof that this was completed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/02/2025 Plan of Correction The administrator will develop a plan to ensure compliance and provide a copy of the plan to CCL by 4/2/2025.

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 R1, R4 and R5 have bed rails without a written order from the physician which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/02/2025 Plan of Correction The administrator will develop a plan to ensure compliance and provide a copy of the plan to CCL by 4/2/2025. The administrator will obtain a copy of written order for the residents who have a bedrail no later than 4/8/2025.

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 R1, R2 and R3 did not have an updated appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/07/2025 Plan of Correction The administrator will develop a plan to ensure compliance and provide a copy of the plan to CCL by 4/7/2025. The administrator will complete a reappraisal for R1, R2, and R5 by 4/8/2025.

Official classification

Type A

Official code

87202(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons 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 resident #1 (R1) is deemed to be bedridden and is residing in a room that is not approved for bedridden person which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/18/2024 Plan of Correction The administrator will developed a plan to ensure residents are residing in a room that is approved by the fire marshal based on their medical condition. In the plan, it shall include what action is the facility taken to ensure R1 is residing in an appropriate room. The administrator will provide a copy of the plan to CCL by 4/18/2024.

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed facility garage has been altered into living space for 2 staff members which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/18/2024 Plan of Correction The administrator will remove all the livable supplies, items, toiletries, etc. in the garage and submit proof of completion to CCL by 4/18/2024. LPA administrator will develop a plan to ensure compliance and how to handle the living space situation for the facility staff and submit a copy of the plan to CCL by 4/18/2024

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed toxins and chemicals in the garage were unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/18/2024 Plan of Correction The administrator will develop a plan to ensure compliance and will provide copy of photos to CCL by 4/18/2024.

Official classification

Type A

Official code

87412(a)(11)

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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 3 out of 4 staff files did not contained completed health screening which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/18/2024 Plan of Correction The administrator will develop a plan to ensure compliance and on the plan, it shall indicate when these 3 staff will complete their health screening. The administrator will provide a copy of the plan to CCL by 4/18/2024.

Official classification

Type A

Official code

87412(a)(13)

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: (13) For employees that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: 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 one staff did not have criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/18/2024 Plan of Correction The administrator will develop a plan to ensure all staff are criminally background cleared prior to employment and will provide a copy of the plan to CCL by 4/18/2024.

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 facility was not able to provide documents for the drills which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/18/2024 Plan of Correction The administrator will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 4/18/2024

Official classification

Type B

Official code

87355(e)(4)

Regulation authority

CCR

What the official deficiency says

(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: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present 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 out of 4 staff were not associated which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/24/2024 Plan of Correction The administrator will associate both staff and provide proof to CCL by 4/24/2024 that it has been completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: 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 3 out of 4 residents files did not contained pre-admission appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/24/2024 Plan of Correction The administrator will develop a plan to ensure compliance and a copy of each resident's completed pre-admission and/or appraisal service needs to CCL by 4/24/2024.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above since this facility only has an approved bedridden fire clearance to accept and retain (1) bedridden resident in Room #4 only. This Licensee currently has (2) bedridden residents in care at the time of this annual visit which posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/16/2023 Plan of Correction The facility Administrator stated that the proper forms and documents will be completed and submitted into CCL requesting the increase in the bedridden status to be able to accept and retain up to (2) bedridden residents. A statement of correction, along with all relevant forms and documents, will be completed and submitted into CCL by the due date.

Official classification

Type A

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. 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 that the hot water that was measured in the resident restrooms were found to be at 122.2 degrees which posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2023 Plan of Correction The facility Administrator stated that the hot water heater will be turned down and the hot water will be measured on a daily basis for (1) week. A statement of correction, along with the hot water temperature readings for (1) week, will be completed and submitted into CCL by the due date.

Official classification

Type A

Official code

87412(a)(11)

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: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 [3] out of [4] staff persons did not have a completed health screening report which posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/16/2023 Plan of Correction The facility Administrator stated that the proper forms and documents will be completed and submitted into CCL detailing the completion of the updated health screenings for all facility personnel. A statement of correction, along with all relevant forms and documents, will be completed and submitted into CCL by the due date.

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 record review, the licensee did not comply with the section cited above in [1] out of [4] staff persons did not have updated and certified First Aid training which posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/16/2023 Plan of Correction The facility Administrator stated that the proper forms and documents will be completed and submitted into CCL detailing the completion of the updated First Aid training for all facility personnel. A statement of correction, along with all relevant forms and documents, will be completed and submitted into CCL by the due date.

Official classification

Type A

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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 [1] out of [5] facility resident files did not have an annually updated medical assessment as required for residents diagnosed with dementia which posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/16/2023 Plan of Correction The facility Administrator stated that the proper forms and documents will be completed and submitted into CCL detailing the completion of the updated medical assessment for all facility residents. A statement of correction, along with all relevant forms and documents, will be completed and submitted into CCL by the due date.

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above since it was learned that medications were pre-poured for 48 hours in advance with incomplete documentation of medications when dispensed to the residents. This posed an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/16/2023 Plan of Correction The Administrator stated that all medications will no longer be pre-poured and taken out of the original containers until the actual administration of the medications to the residents. A statement of correction, along with proof of in-service for all facility staff handling and dispensing the medications for no less than (1) hour in duration, will be completed and submitted into CCL by the due date.

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, the licensee did not comply with the section cited above in that there were cracks in the kitchen and restroom flooring. Unused building materials and items were left in the exterior of this facility blocking side exits as well which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2023 Plan of Correction The facility Administrator stated that all of the flooring will be repaired/replaced to remove any cracks or breaks within the flooring throughout this facility. All unused building materials and items will be cleaned up and removed. A statement of correction, along with photos of the repaired/replaced flooring and exterior grounds, will be completed and submitted into CCL by the due date.

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, the licensee did not comply with the section cited above in that there were missing window screens and other screens that were in need of repair/replacement which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2023 Plan of Correction The facility Administrator stated that all of the window screens will be repaired/replaced. A statement of correction, along with photos of the repaired/replaced window screens, will be completed and submitted into CCL by the due date.

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 record review, the licensee did not comply with the section cited above in [3] out of [5] facility personnel files were missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2023 Plan of Correction The facility Administrator stated that an audit of all facility personnel files will be conducted. Any missing required forms and documents will be updated and filed appropriately in all facility personnel records. A statement of correction, along with copies of all updated forms and documents, will be completed and submitted into CCL by the due date.

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 record review, the licensee did not comply with the section cited above in [3] out of [5] facility resident files were missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/22/2023 Plan of Correction The facility Administrator stated that an audit of all facility resident files will be conducted. Any missing required forms and documents will be updated and filed appropriately in all facility resident records. A statement of correction, along with copies of all updated forms and documents, will be completed and submitted into CCL by the due date.