OUR HOUSE

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

PERSONNEL REQUIREMENTS GENERAL 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 all staff have expired first-aid training. Licensee failed to ensure that staff providing care maintain valid first-aid training, which poses a potential health and safety risk to clients in care.

Official plan of correction

Proof of current first aid training for ALL staff will be sent to CCLD BY DUE DATE

Deadline recorded: Mar 17, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.696

Regulation authority

HSC

What the official deficiency says

HEALTH AND SAFETY CODE RCFEs shall provide training to direct care staff on postural supports, restricted conditions or health services, hospice care...training shall include...4 hours of training on the care, supervision, and special needs of those residents... Four hours of training thereafter of in-service training per year on the subject of serving those residents. This requirement is not met, as there is no proof of this annual training for staff #2, #4 and #5. Licensee failed to ensure that all direct care providers have this annual training, which poses a potential health, safety or personal rights risk.

Official plan of correction

Proof of postural supports, restricted health conditons and hospice care training for staff #2, #4 and #5 will be sent to CCLD BY DUE DATE

Deadline recorded: Mar 17, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

PERSONNEL RECORDS The licensee shall maintain documentation that an administrator has met... recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met, as there is no evidence that administrator has met the RCFE administrator recertification requirements. Licensee failed to ensure that there is certified RCFE administrator overseeing facility operations, which poses an immediate health, safety or personal rights risk to clients in care.

Official plan of correction

Proof that there is a certified RCFE administrator overseeing facility operations will be sent to CCLD BY DUE DATE

Deadline recorded: Mar 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

HEALTH AND SAFETY CODE A facility shall conduct a drill at least quarterly for each shift... type of emergency covered in a drill shall vary... 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, type of emergency ... names of staff participating in the drill. This requirement was not met, as there is no record that facility has conducted emergency disaster drills.

Official plan of correction

Plan for implementation and performance of quarterly disaster drills will be sent to CCLD BY DUE DATE. In addition, upon completion of emergency disaster drill, documentation to be submitted to CCLD.

Deadline recorded: Mar 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.69(b)

Regulation authority

HSC

What the official deficiency says

HEALTH AND SAFETY CODE Each employee who received training and ...who continues to assist with the self-administration of medicines, shall also complete 8 hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement is not met, as there is no evidence that staff have received 8 hours of annual medication training. Licensee failed to ensure that staff who manage clients' medications received annual medication training, which poses a potential health, safety or personal rights risk to clients in care.

Official plan of correction

staff will receive at least 8 hours of annual training on medications. Proof of corrction to be sent to CCLD BY DUE DATE.

Deadline recorded: Mar 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

HEALTH AND SAFETY CODE ...after July 1, 2015, all RCFEs... shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.This requirement is not met, as there is no evidence that facility maintains liability insurance, as required. Licensee failed to maintain required liability insurance coverage, which poses a potential health, safety or personal rights risk to clients.

Official plan of correction

Proof of required liability insurance coverage --including policy dates--will be sent to CCLD BY DUE DATE

Deadline recorded: Mar 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above 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: Plan of Correction

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type B

Official code

1569.69(b)

Regulation authority

HSC

What the official deficiency says

(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. 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/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type A

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above 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: Plan of Correction

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: Plan of Correction

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type B

Official code

1569.69(b)

Regulation authority

HSC

What the official deficiency says

(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. 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/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type A

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above 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: Plan of Correction

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: Plan of Correction

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type B

Official code

1569.69(b)

Regulation authority

HSC

What the official deficiency says

(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. 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/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type A

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above 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: Plan of Correction

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: Plan of Correction

Official classification

Type B

Official code

1569.605

Regulation authority

HSC

What the official deficiency says

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type B

Official code

1569.69(b)

Regulation authority

HSC

What the official deficiency says

(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. 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/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type B

Official code

1569.696(a)(1)

Regulation authority

HSC

What the official deficiency says

(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on staff record review, the licensee did not comply with the section cited above, as there is no evidence that all staff have received at least 4 hours of training on hospice care, restricted health conditions and postural supports. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/22/2024 Plan of Correction All staff shall receive at least 4 hours of training on hospice care, restricted health conditions and postural supports. Proof of correction to be sent to CCLD BY DUE DATE

Official classification

Type B

Official code

1569.695(f)(2)(D)

Regulation authority

HSC

What the official deficiency says

(f) A facility shall have both of the following in place: (2) A set of keys available to facility staff on each shift for use during an evacuation that provides access to all of the following: (D) All facility cabinets and cupboards or files that contain elements of the emergency and disaster plan, including, but not limited to, food supplies and protective shelter supplies. This requirement is not met as evidenced by: Deficient Practice Statement (A) All occupied resident units. (B) All facility vehicle (C) All facility exit doors. Based on observation, the licensee did not comply with the section cited above, as an emergency set of keys is not maintained, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/22/2024 Plan of Correction An emergency set of keys will be maintained and include all occupied resident units, all facility vehicles, all facility exit doors, all facility cabinets and cupboards or files that contain elements of the emergency and disaster plan, including, but not limited to, food supplies and protective shelter supplies. Proof of correction to be sent to CCLD BY DUE DATE.