WESTMONT OF SANTA BARBARA

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(a)... (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on observation and interviews conducted, the Licensee did not comply with the regulation above by restricting access to the Concierge's desk and/or denying freedom of choice which poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator agrees to no longer rope off areas restricting access and/or freedom of choice in common areas of the facility. Civil Penalty Assessed

Deadline recorded: Aug 12, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87633(b)(6)(B)

Regulation authority

CCR

What the official deficiency says

(b)A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:(6)Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee’s responsibilities for implementation of the hospice care plan. (B)The hospice agency will provide training specific to the current and ongoing needs of the individual resident receiving hospice care and that training must be completed before hospice care to the resident begins. This requirement was not met as evidenced by: Based on record review the Licensee did not comply with the regulation above in 2 staff provided care to Hospice Resident (R1) without Hospice training and records specific to the individual R1’s Hospice Care Plan which poses an potential safety and personal rights risk to residents in care.

Official plan of correction

Administrator agreed to read and review 87633, provide a statement of understanding, have hospice agency nurse train a facility lead staff on proper repositioning and transferring for residents on hospice services, then the lead staff can train all wellness staff -Cont. below- working with Hospice residents, provide proof of trainings and materials used with staff signatures and an up to date LIC 500 to CCL.

Deadline recorded: May 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(9)

Regulation authority

CCR

What the official deficiency says

(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (9)To have communications to the licensee from their representatives answered promptly and appropriately. This requirement was not met as evidenced by: Based on staff turnover and interviews the Licensee did not comply with the regulation above, residents responsible parties did not get responses from Administrator/Licensee which posses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator agreed to make a statement of understanding regulation, and how turnover of staffing as directors/Administrator will no longer affect communications, and will timely answers residents and family’s questions, and provide statement to CCL.

Deadline recorded: Feb 3, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(a)... (4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interviews and records the Licensee did not comply with the regulation above, Residents that pushed call buttons for care needs waited prolonged periods of time for assistance which possess a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator agreed to higher enough staffing for current residents’ care needs to be met in a timely matter. Provide proof of staffing with an LIC 500 and Call button logs over 15 minutes for the month of February 2026 showing a decrease in wait times for resident care compared to prior months logs.

Deadline recorded: Feb 3, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

(b)... (3)Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by: Based on LPA observation and interviews the Licensee did not comply with the regulations above, R1’s room was not kept clean and free from odors from incontinence which possess a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator agreed to make sure all current residents have care plans updated to reflect the current needs and services for those residents, have adequate staffing to keep residents and rooms clean and free from odors of incontinence, See below: send LIC 500, list of incontinent residents and a statement of how the facility will ensure the facility is free from odors of incontinence.

Deadline recorded: Mar 3, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87219(f)

Regulation authority

CCR

What the official deficiency says

(f)...one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities,...staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities....,This requirement was not met as evidenced by: Based on staff and resident interviews, the Activity Director quit, and it took several months to fill the position, activities were not being conducted as the calendar indicated which poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator agreed to provide LIC 500 with Activity Director name, hours working, and activity calendars for January and February 2026.

Deadline recorded: Feb 3, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(25)

Regulation authority

CCR

What the official deficiency says

(a)... (25)To protection of their property from theft or loss according to Health and Safety Code sections 1569.152, 1569.153, and 1569.154. This requirement was not met as evidenced by: Based on interview Licensee did not comply with the regulation above, R1’s package was not found after carrier delivered to the facility which possess a potential personal rights risk to residents in care.

Official plan of correction

Administrator agreed to safeguard resident’s packages delivered to the facility and log the incoming packages at the front desk when received and name of staff delivered to residents’ room. Provide a copy of the log for resident’s packages delivered to the facility for January 2026.

Deadline recorded: Feb 3, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(3)(C)

Regulation authority

CCR

What the official deficiency says

(a)…(3)…(C)Clean linen, including... The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times...The requirement was not met as evidenced by: Based on LPA observation and interviews, the Licensee did not comply with the regulation above, R1’s linens were not being changed more often to ensure R1 had clean linen to always use which possess a potential health, safety and person rights risk to residents in care.

Official plan of correction

Administrator agreed to keep enough housekeeping & maintenance staff hired to always maintain the cleanliness and sanitary conditions of the facility, resident’s rooms and bedding, make sure the housekeepers schedule Continued below: accommodated all residents bedding and maintenance, housekeeping and care staff are trained in regulation 87307, provide proof and an up to date LIC 500 to CCL.

Deadline recorded: Feb 3, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

(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..., cooking, house cleaning, laundering, and maintenance...This requirement was not met as evidenced by: Based on interviews and records the License did not comply with the regulation above due to insufficient staffing did not perform timely care, activities, food service and housekeeping to residents in care which possess a potential health & safety risk to residents in care.

Official plan of correction

Administrator agreed to update care plans and higher enough staff in each department to meet the needs of the residents. Provide an up-to-date LIC 500 with a list of vacancies and staff schedules for January and Februaryto CCL, continued below. after each month is completed send an up to date schedule of staff actually worked.

Deadline recorded: Dec 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(i)

Regulation authority

CCR

What the official deficiency says

(i)When there is significant change in condition,...or once every 12 months,...the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's rep,... facility staff,...,Resident Participation.... This requirement was not met as evidenced by: Based on records and interviews the licensee did not comply with the regulation above Staff conducted a reappraisal Service Plan and did not make contact with R1’s RP to go over or have a meeting to discuss, letting R1 sign and putting the new fees in effect which poses a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator agreed to read, review and train staff doing pre-appraisals, re-appraisals, generating new LIC 602A to the doctor and updating Service plans on Regulation 87463, provide proof of training with a list of staff to CCL.

Deadline recorded: Dec 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

...residents are regularly observed for changes in physical,...social ...functioning...assistance is provided...observation reveals unmet needs.... attention of the resident's physician and the resident's person responsible,... This requirement was not met as evidenced by: Based on interview and record review the Licensee did not comply with the regulation above Staff did not report to R1’s RP several dates and incidents that were faxed to the physician which possess a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator agreed to train the staff that notifies doctors and RP’s in regulation 87466 and the facility policy and procedures for notifications, send proof of training and provide a current list of those staff to CCL.

Deadline recorded: Dec 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.655(a)

Regulation authority

HSC

What the official deficiency says

(a) ...increases the rates of fees for residents or makes increases in any of its rate structures for services,...90 days’ prior written notice to the residents or the residents’ representatives...amount of the increase and the reason or reasons for the increase,,...This requirement was not met as evidenced by: Based on interview and record review the Licensee did not comply with the H & S code above. Facility mailed out notices, not all notives were received by the RP’s and some notices were not a full 60days notice which possess a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator agreed to train staff that handle rent and care increases in H & S code 1569.655, provide proof of training and list of staff who do the increases at the facility.

Deadline recorded: Dec 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.69(a)(1)

Regulation authority

HSC

What the official deficiency says

(a)...:(1)...the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training,...and 8 hours of other training or instruction,...which shall be completed within the first four weeks of employment. This requirement was not met as evidenced by: Based on record review the Licensee did not comply with the regulation above staff did not take initial /or annual medication training which possess a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator agreed to hold training for all staff on H & S code 1569.69 and provide staff missing any of these requirements with medication training, provide proof of training and an up to date LIC 500 with all staff and positions listed to CCL.

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

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

(a)...(4)To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interviews and records the Licensee did not comply with the regulation above, staff were not competent in handling the centrally stored medications and assistance to residents, without errors which possess a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator agreed to hold personal rights training with all staff to include regulations 87468.1 and 87468.2. Provide proof of training and an up-to-date LIC. 500 for all staff to CCL.

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

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

(a)...(1)...(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 was not met as evidenced by: Based on incident reporting the Licensee did not comply with the regulation above The facility did not report any medication errors or discrepancies for R1 which possess a potential Health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator agreed to train all staff in reporting requirements 87211 and send proof of training with an up to date LIC 500 will all staff to CCL.

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

Official classification

Type B

Official code

87506(c)

Regulation authority

CCR

What the official deficiency says

87506(c) Residents Records: (c) All information and records obtained from or regarding residents shall be confidential. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as a confidential document of one resident was found in another resident's record which poses a potential safety and personal rights risk to residents in care.

Official plan of correction

Administrator immediately removed the confidential document from the file. Deficiency cleared at the time of the visit.

Deadline recorded: Sep 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

Type A: 87465(c)(2) Incidental and Medical Care: ....Once ordered by the physician the medication is given according to the physician's directions. 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 when R1 was administered Hydromorphone 2mg on 6/15/2025 at 5:50 am by one staff member and again at 6:00 am by another staff member which poses an immediate health and safety risk to residents in care.

Official plan of correction

POC Due Date: 08/28/2025 Plan of Correction Administrator agrees to conduct a staff in-service to include proper procedure in administering medications and properly documenting transactions. Administrator will provide in writing the date in-service was conducted including description of the training, first and last names of attendees, and attendees’ signatures.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times… This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as the carpet in a resident’s room was observed to be stained and soiled which poses/posed a potential health, safety, or personal rights risk to persons in care.

Official plan of correction

Administrator agrees to have carpets cleaned in five (5) resident's rooms no later than POC due date (11/15/2024). Administrator agrees to provide photographs of cleaned carpets via email on or before POC due date (11/15/2024).

Deadline recorded: Nov 15, 2024. A deadline is not proof that correction was completed.

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 record review and observation, the licensee did not comply with the section cited above as staff trainings do not include a minimum of four hours per year of training in postural support, restricted health conditions, and hospice care which poses an immediate health, safety or personal rights risk to persons in care..

Official plan of correction

POC Due Date: 07/30/2024 Plan of Correction Acting Executive Director agrees to conduct all-staff trainings no later than due date (7/30/2024). Acting Executive Director agrees to submit proof of training via email to LPA no later than 7/30/2024. Proof of training to LPA via email to include first and last name and signature of trainee, descriptions of training, dates completed, and duration of training.

Official classification

Type A

Official code

87506(b)(17)(A)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal; This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interview, the licensee did not comply with the section cited above when a Pre-Appraisal was not conducted for Resident 10 (R10) prior to admission into the facility on or before 3/27/2023 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/27/2024 Plan of Correction Acting Executive Director agrees to provide an updated appraisal for R10 no later than POC due date of 7/27/2024.

Official classification

Type A

Official code

87465

Regulation authority

CCR

What the official deficiency says

87465(c)(2) Incidental Medical and Dental Care: Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited when residents did not receive their medication as prescribed, which posed an immediate health and safety risk to residents in care.

Official plan of correction

POC Due Date: 07/27/2024 Plan of Correction Acting Executive Director stated S1 is no longer employed with the facility. Acting Executive Director agrees to submit a written plan to ensure residents will receive their medication as prescribed.

Official classification

Type A

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

87465(h)(4) Incidental Medical and Dental Care: All centrally stored medications shall be labeled and maintained in compliance with state and federal laws… This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited when Resident 1’s IR1’s) Centrally Stored Medication Record did not list two prescribed medications.

Official plan of correction

POC Due Date: 07/27/2024 Plan of Correction Acting Executive Director agrees to provide proof that R1’s Centrally Stored Medication Record reflects all prescribed medications.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) Maintenance and Operation: 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 and interview conducted, the licensee did not comply with the section cited above when the outside patio areas between Assisted Living and Memory Care were observed to be unclean and not sanitary due to birds nesting in the area.

Official plan of correction

POC Due Date: 07/30/2024 Plan of Correction Acting Executive Director agrees to provide proof via email that the patio areas have been cleaned.

Official classification

Type B

Official code

87211(g)(1-3)

Regulation authority

CCR

What the official deficiency says

87211(g)(1-3) Reporting Requirements: The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. The notification shall include the following: (1) Name and residence and mailing addresses of the new administrator. (2) Date he/she assumed his/her position. (3) Description of his/her background and qualifications, including documentation of required education and administrator certification. 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 as previous Administrator was no longer employed on or about May 10, 2024; Licensee has not provided information to CCLD to name the previous Interim Administrator and/or current Acting Executive Director as Facility Administrator which poses a potential health and safety risk to residents in care.

Official plan of correction

POC Due Date: 07/30/2024 Plan of Correction Licensee shall submit required paperwork to CCLD via email naming Administrator to the facility. Required paperwork to be submitted no later than the POC due date (7/27/2024).

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident. When changes…are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited when R1’s missed medications were not communicated to their physician, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Interim Administrator agrees to provide a written plan to ensure residents’ physicians are notified of medication refusals promptly and appropriately. Interim Administrator agrees to conduct in-service with staff to include procedures to follow with residents' medications refusals. Interim Administrator will inform CCLD as to date(s) in-services will be conducted.

Deadline recorded: Jul 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited when multiple residents did not receive their medication as prescribed, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Acting Executive Director agrees to provide proof S1 was retrained in mediation procedures. Acting Executive Director agrees to submit a written plan to ensure residents will receive their medication as prescribed.

Deadline recorded: Jul 3, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements. A written report shall be submitted to the licensing agency…Any incident which threatens the welfare, safety, or health of any resident… This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above when they failed to report a bus accident involving residents and medication errors, which posed a potential health and safety risk to residents in care.

Official plan of correction

Acting Executive Director agrees to provide a written incident reports, as well as a written statement of understanding of 87211 Reporting Requirements.

Deadline recorded: Jul 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Personnel Requirements. 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…cooking… This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the section cited when they did not employ sufficient dining staff, which posted a potential health and safety risk to residents in care.

Official plan of correction

Administrator agrees to submit a plan to ensure sufficient dining staff and decrease resident wait times for food. Administrator will submit by 6/24/2024.

Deadline recorded: Jun 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(i)

Regulation authority

CCR

What the official deficiency says

87303(i) Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria… This requirement was not met as evidenced by: Based on records review, the licensee did not comply with the section cited above when staff did not answer calls timely, which posed a potential health and safety risk to residents in care.

Official plan of correction

Administrator agrees to provide training to all staff of call button response time expectations. Administrator will submit by 6/24/2024.

Deadline recorded: Jun 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(c)

Regulation authority

CCR

What the official deficiency says

87411(c) Personnel Requirements. 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… This requirement was not met as evidenced by: Based on record reviews, the licensee did not comply with the section cited above when staff did not have adequate training in 2022, which posed a potential health and safety risk to residents in care.

Official plan of correction

Administrator agrees to provide a plan to ensure all staff receive adequate training going forward. Administrator will submit plan by 6/24/2024.

Deadline recorded: Jun 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(19)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(19) Personal Rights. To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days…This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above when they did not provide R1’s responsible party access to all of R1’s records, which posed a potential personal rights risk to residents in care.

Official plan of correction

Administrator agrees to provide R1’s responsible party a complete copy of R1’s records by 6/24/2024.

Deadline recorded: Jun 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidenced by: Based on interview and observation, the licensee did not comply with the section cited above when the facility had a mal odor and feces on R1’s wall, which posed a potential health risk to residents in care.

Official plan of correction

R1’s wall has been cleaned. Administrator agrees to provide proof of deep cleaning in memory care by 6/24/2024.

Deadline recorded: Jun 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87218(a)(2)

Regulation authority

CCR

What the official deficiency says

87218(a)(2) Theft and Loss: A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. This requirement was not met as evidenced by: Based on interview, the licensee did not comply with the section cited above, as they were unable to properly safeguard resident property, which poses a potential personal rights risk to residents in care.

Official plan of correction

Administrator agrees to reimburse residents for damaged items. Administrator agrees to submit a written statement of understanding of 87218 to CCL by 6/24/2024.

Deadline recorded: Jun 24, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(2)

Regulation authority

CCR

What the official deficiency says

87465(a)(2) Incidental and Medical Care: A plan for incidental medical and dental care shall be developed by each facility. The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when not asking for R1’s refills timely, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Administrator agrees to develop a written procedure/plan for staff to ensure refills are obtained timely. Administrator will submit plan to CCL by 6/19/2024.

Deadline recorded: Jun 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

878468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(1) Personal Rights. Residents…have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above when staff spoke inappropriately to residents, which posed a potential personal rights risk to residents in care.

Official plan of correction

Administrator agrees to conduct personal rights training with all staff and provide proof of training by 6/20/2024. Administrator agrees to submit proof of training via email including description of training, first and last name(s) of trainer(s) and trainees. Trainee signatures required.

Deadline recorded: Jun 20, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.312(a)

Regulation authority

HSC

What the official deficiency says

Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above when they failed to respond to R1’s call button for assistance, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Administrator agrees to provide staff training on call button response expectations. Administrator will provide proof training is scheduled by 6/14/2024, and administrator will provide proof of training by 6/21/2024.

Deadline recorded: Jun 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211(a)(1) Reporting requirements. 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 requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above when they did not notify R1’s RP of a fall in writing, which posed a potential health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator agrees to provide R1’s responsible party a copy of the incident report. Administrator stated a copy of the report will be sent via USPS Certified Mail with Return Receipt.

Deadline recorded: Jun 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465(c)(2) Incidental Medical and Dental Care: Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above when a medication inventory revealed out of 24 medications reviewed, 7 medications were not administered per Doctor's orders which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/15/2023 Plan of Correction Administrator agrees to provide written proof of medication administration in-service to all staff who are responsible for administering medications. Written proof to include date of in-service, sign-in sheet of attendees (first and last name w/signature), description of in-service, and plan of action to adhere to regulation as stated above.

Official classification

Type A

Official code

87506(c)

Regulation authority

CCR

What the official deficiency says

87506(c) Resident Records: All information and records obtained from or regarding residents shall be confidential. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above as Residents' records were exposed when the Resident Service Director office door was observed to be fully open which poses an immediate health and safety risk to residents in care.

Official plan of correction

Administrator agrees to conduct an in-service with facility staff to maintain compliance with HIPAA regulations and will keep the residents' records confidential. Administrator will provide in-service training documents to LPA via email no later than 7/19/2023.

Deadline recorded: Jul 19, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355(e)(2) Criminal Record Clearance. (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as prior to being present and/or working in the facility, one staff member was not associated to the facility which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agrees that staff will not work or be present in this facility without an appropriate transfer to the facility. Staff 1 (S1) was associated at the time of the visit. This page has been amended. Civil Penalty assessed in the amount of $3,000.

Deadline recorded: May 17, 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(a)(2) Personal Rights of Residents in All Facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on LPA observation, Licensee failed to ensure all staff wore face coverings properly at all times while in the facilities. Staff 1, Staff 2, Staff, 3, Staff 4 were not wearing a mask at the time LPA conducted a tour of the facility which poses an immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Administrator agrees notify all staff to wear masks at all times in the facility. Administrator agrees to conduct an infectious control training, review and train staff on all recent PIN’s released for 2022, ncluding mask-wearing mandates, and provide copy of training and staff signatures to CCL by 12/22/2022. List of attendees with signatures to include first and last name of each attendee shall be provided to LPA via email.

Deadline recorded: Dec 22, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355(e)(2) Criminal Record Clearance. (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as prior to being present and/or working in the facility, 18 home care agency staff, 3 nursing consultants, 1 corporate regional director were not associated to the facility which poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agrees that staff members, home care agency staff, nurse consultants, and corporate staff will not work or be present in this facility without an appropriate transfer to the facility. Civil Penalty assessed in the amount of $12,600.

Deadline recorded: Dec 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(1)(2)

Regulation authority

CCR

What the official deficiency says

87355(e)(1) Criminal Record Clearance. (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or criminal record exemption... or (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Deficient Practice Statement This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above as eight (8) facility staff were not associated to work in the facility and one (1) facility staff did not receive a fingerprint clearance and/or background check prior to working in the facility which poses an immediate health and safety risk to residents in care.

Official plan of correction

POC Due Date: 08/05/2022 Plan of Correction Licensee agrees that staff members will not work at this facility without an appropriate transfer and/or receiving a criminal background/fingerprint clearance. Civil Penalty assessed in the amount of $4,750.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) Maintenance and Operation: 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 was not as evidenced by: Based on interviews, the licensee failed to ensure that R1’s door was functioning, which posed a potential health and safety risk to persons in care.

Official plan of correction

Administrator stated that the door was fixed in January 2022. The POC was cleared during the visit.

Deadline recorded: Aug 4, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate... This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above. R1’s Services Plan dated 07/24/2021 was not updated after R1 sustained multiple falls requiring hospitalization, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee will submit plan how you will ensure Reappraisals are conducted in a timely manner when there is a change in resident condition. Submit to CCL by 4/1/22

Deadline recorded: Apr 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87207

Regulation authority

CCR

What the official deficiency says

87207 False Claims. No...employee of a licensee shall make or disseminate any false or misleading statement...This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above.The Facility Resident Services Director stated she faxed incident report to the Regional Office on 08/11/2021, however, the Investigator learned that a substitute nurse filled in for the Director at the facility on 08/10/2021 and 08/11/2021, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee has agreed to do the following: 1. Schedule a training on conduct inimical and false claims. Training must be conducted by an approved vendor. 2. 2. Submit a letter to CCLD indicating the vendor's name, address, phone number, and date of the training. Training must take place by

Deadline recorded: Apr 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(B)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1)(B) Any serious injury...occurring while the resident is under facility supervision. This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above. R1 had a fall on 08/07/2021 and 08/16/2021 sustaining injuries which required hospitalization, no incident reports were received for the incidents, which posed a potential health and safety risk to residents in care.

Official plan of correction

Licensee will review 87211 Reporting Requirements regulation and submit a memo of understanding regarding submitting incident reports timely to appropriate parties. Submit to CCL by 4/5/22

Deadline recorded: Apr 5, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)

Regulation authority

CCR

What the official deficiency says

87464(f)(1) Basic Services. (f) Basic services shall at a minimum include: (1) Care and supervision... This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. (R1) was not provided the proper supervision to ensure R1’s safety. R1 had a history of falls, which led to multiple falls causing R1 to sustain injuries requiring hospitalization, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee will submit a written action plan regarding proper resident care and supervision to CCL by 4/1/22

Deadline recorded: Apr 1, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

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: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in 3 counts which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/16/2022 Plan of Correction Administrator removed staff from the facility and schedule. Administrator will hold an in-service for directors and submit training log to LPA by 2/16/22

Official classification

Type A

Official code

87355(e)(2)

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: (2) 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 interview and record review, the licensee did not comply with the section cited above in 4 counts which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/16/2022 Plan of Correction Administrator removed staff from the facility and schedule. Administrator will hold an in-service for directors and submit training log to LPA by 2/16/22