PACALDO LLC

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 based on the facility sketch, it indicated that there were 2 storage rooms that was divided by a wall on the 1st floor, however, during today visit, LPA observed 1 big room that was converted into a living space for 2 staff members while they were working at the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/20/2026 Plan of Correction The administrator stated that all the living items/furniture will be removed within 24 hours and the room will be converted back into a storage room, The administrator will provide photos to proof compliance to CCL by 5/20/2926.

Official classification

Type A

Official code

87355(e)(3)

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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 base on record review, observation and interview, LPA observed S1 and S2 were not associated with the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/20/2026 Plan of Correction The administrator will submit the required transfer forms to CCL by 5/20/2026.

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 R2 did not have a medical assessment which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/20/2026 Plan of Correction The administrator will provide a copy of the LIC 602 to CCL by 5/20/2026.

Official classification

Type B

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: 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 staff members staying in the storage room when they were on shift which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/26/2026 Plan of Correction The administrator will ensure these 2 staff members are no longer staying in the storage room and they will be living in their own apartment even on shift. The administrator will provide photos to ensure the storage room is no longer being used as staff room by 5/26/2026.

Official classification

Type B

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by based on observation, record review and interview, one of the room on the lower level is not included on the facility sketch and accoridng to the facility staff, it was occuped by facility staff and the facility was not able to provide any documents to proof that it was permitted which posed a potential risk for residents in care.

Official plan of correction

The administrator/licensee will provide a plan of correction including a revised facility sketch reflecting the current facility floor plan, remove all the furniture, living items, clothes, mattresses, the cabinet, etc.. and provide photos to proof that it was completed and a copy of the revised facility sketch to CCL by 5/28/2025.

Deadline recorded: May 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. 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 sharps stored in the kitchen dish rack are locked 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: 05/13/2025 Plan of Correction The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan of correction to CCL by 5/13/2025.

Official classification

Type A

Official code

87355(e)(3)

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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 S1 and S2 are transferred from the sister facility, however, the criminal records were not transferred to this facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/13/2025 Plan of Correction The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan of correction to CCL by 5/13/2025. A civil penalty of $200 is being assessed today.

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 as S2 did not have required training records in the personnel file which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/13/2025 Plan of Correction The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan of correction to CCL by 5/13/2024.

Official classification

Type A

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility did not have complete, and current record for R2 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/13/2025 Plan of Correction The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan of correction to CCL by 5/13/2024.

Official classification

Type A

Official code

87506(b)(15)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, 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 the facility did not have an admission agreement for R1 and R2 completed during the inspection which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/13/2025 Plan of Correction The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan of correction to CCL by 5/13/2024.

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 R1's pre-admission evaluation was incomplete as it was not signed by the resident and/or the responsible party; R2 was admitted on 5/12/2025 without a pre-admission evaluation which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/13/2025 Plan of Correction The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan of correction to CCL by 5/13/2024.

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 documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. 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 was admitted on 5/11/2025 and there was no medical assessment in the file which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/13/2025 Plan of Correction The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 5/13/2025.

Official classification

Type A

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. 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 was admitted on 5/12/2025 and there is no communicable TB status in the file which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/13/2025 Plan of Correction The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 5/13/2025.

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 LPA observed the facility was not able to provide any documentation to ensure 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: 05/13/2025 Plan of Correction The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 5/13/2025.

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 and R2 have bedrails without a written order which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/13/2025 Plan of Correction The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 5/13/2025.

Official classification

Type A

Official code

87411(F)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Personnel Requirements- General (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, Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed there is no TB/chest X-ray status in S1's file which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/13/2025 Plan of Correction The administrator will develop a plan of correction to ensure compliance and will provide a copy of the plan of correction to CCL by 5/12/2025.

Official classification

Type A

Official code

87405(d)(1)(2)(3)

Regulation authority

CCR

What the official deficiency says

Administrator - Qualification and Duties This requirement is not met as evidenced by: (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. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (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. Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the administrator did not ensure all the required documents are completed prior to R2 admission, all the required documents are completed for S1 and S2's personnel files, and the files are available at the facility for inspection which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/13/2025 Plan of Correction The administrator will review this regulation and provide proof after the review. In addition, the administrator will provide a plan of correction to ensure compliance and will provide a copy of the plan of correction to CCL by 5/13/2025.