SONNET HILL

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement is not met as evidenced by: Deficient Practice Statement Based on records reviewed, the licensee did not comply with the section cited above. Based on a medication audit, resident R1 had a medication that was not listed on his/her centrally stored medication record. Resident R2 also had a medication that was not listed on their centrally stored medication record. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/08/2026 Plan of Correction ADM stated her plan of correction will be to work with the healh and wellness directors and conduct an audit. ADM stated she will work on this starting 4/2/2026. ADM stated she will send documenation of this all staff meeting. And letter of understanding regarding the regulation.

Official classification

Type A

Official code

87705(e)(5)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (e) (5) Facility staff shall ensure the continued safety of residents if they wander away from the facility ... Personal Rights of Residents in Privately Operated Facilities. This requirement was not met as evidenced by; Based on investigation, on January 11, 2026 R1, who has a neurocognitive disorder, left the facility unassisted and was found by law enforcement unattended. This poses an immediate Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Administrator stated she will send a written plan of action on how the facility ensures residents with wandering behaviors will be kept safe. ADM stated the facility conducted elopement protocol training's for all staff on 1/19/2026. ADM stated she will send LPA documentation this training has taken place. ADM stated she will send the plan of correction by POC date January 28, 2026

Deadline recorded: Jan 28, 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

87411 Personnel Requirements - General (a) Facility personnel shall at all times be...competent to provide the services necessary to meet resident needs This requirement was not met as evidenced by Based on interviews conducted, on January 2, 2026, resident R1 was administered residents R2’s M1 medication. This poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

Administrator stated the facility conducted an in-service for staff on medication training, for the medtech who made the mistake. ADM provided documentation of in-service training conducted on January 4, 2026.

Deadline recorded: Jan 21, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care(h)(6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year... This requirement was not met as evidenced by: Based on record review, interview and observation, Licensee did not ensure 4 out of 4 resident records of centrally stoed prescription medications were maintained which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator stated to submit a written plan of action understanding regulation and will ensure record of centrally stored prescription medications for each resident is maintained by POC due date. Administrator agreed and understood.

Deadline recorded: Sep 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on observation, record review and interview, the facility staff did not assist R1 with medications as needed when LIC 602A states R1 is not able to administer or store own medication which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Administrator stated to submit a written plan of action understanding regulation and will ensure R1 is assisted with medications by POC due date. Administrator agreed and understood.

Deadline recorded: Jul 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidential Medical and Dental Care (h)(4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.This requirement was not met as evidenced by: Based on observation, and record review, the facility staff did not discard R2's medication after expiration date and was still present in R1's room which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Administrator stated to submit a written plan of action understanding regulation and will ensure medications are not expired and discarded after date stated on prescription by POC due date. Administrator agreed and understood.

Deadline recorded: Jul 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h)(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: Based on observation and record review, R2 medications were accessible to R2 who is not able to store own medication which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Administrator stated to submit a written plan of action understanding regulation and will ensure centrally stored medications are kept in a safe and locked place inaccessble to residents in care by POC due date. Administrator agreed and understood.

Deadline recorded: Jul 11, 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

87309(a)... the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances...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: Based on observation and record review, laundry/cleaning solution was observed in R2's room left unattended outside of locked storage which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Administrator stated to submit a written plan of action understanding regulation and will ensure cleaning solutions are in locked storage and not left unattended by POC due date. Administrator agreed and understood.

Deadline recorded: Jul 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.2 (a)(2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not met as evidenced by: Based on record review and interview, Licensee did not make available the requested records when resident’s designated representative made a written consent which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator stated to submit a written plan of action understanding regulation and will ensure records shall reveal or made available confidential information upon the resident’s and/or resident’s designated representative’s written consent by POC due date. Administrator agreed and understood.

Deadline recorded: May 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was not met as evidenced by, based in interviews & records review, R1 was left outside the balcony of the facility for a long period of time exposing R1 to high temperatures, which poses an immediate health, safety, or personal rights risk to clients in care.

Official plan of correction

Licensee has already corrected this deficiency by updating the needs and services plan of the R1 refelecting minimal sun exposure during the day. Licensee has also advised and reminded staff to be aware of R1s whearabouts inside the facility.

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

Official classification

Type A

Official code

87467(a)

Regulation authority

CCR

What the official deficiency says

87467 Resident Participation in Decisionmaking (a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility. This was not met as evidenced by: Based on records review, 7 out of 7 resident files reviewed does not have a needs and services plan, which poses an immediate health, safety, or personal rights risk to clients in care.

Official plan of correction

Licensee has already updated all needs and services plans of residents when the new ED took over.

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

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (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 conducted & evidence reviewed, R1 care plan states R1 requires status checks every 2 hours at night. R1 was last seen on 08/12/24 at 11:21pm and was check on again on 08/13/24 at 3:47am the following day. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

ADM stated she will send a written letter of understanding, explain how she will ensure the facility will ensure it will meet the care, supervision and services that meet the needs of the residents.

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

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in that 2 out 3 caregivers were observed without valid first aid certificate which poses/posed a potential health, safety risk to persons in care.

Official plan of correction

POC Due Date: 05/16/2024 Plan of Correction ADM stated to submit the plan of correction by POC due date to have staff to obtain first aid training and certificate

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in that staff were unable to provide 5 out 5 resident central stored medications forms in the resident files poses/posed a potential health, safety risk to persons in care.

Official plan of correction

POC Due Date: 05/16/2024 Plan of Correction ADM stated to submit a plan of correction by the POC due date to maintain resident file accurate and update to date.

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: (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not being met as evidenced by: Based on record review, facility stopped giving R1’s medication without a doctor’s order to stop when R1 was not eating for 48 hours. This poses an immediate risk to the health and safety of resident in care.

Official plan of correction

Licensee agrees to submit a plan to train staff on adminstering medications and PRNs according to doctor's orders and to notify the physician if resident is unable to take medications. This plan is to be submitted to CCL by POC date. Once trainings are completed, the Licensee shall submit copies of trainings to CCLD.

Deadline recorded: Jun 23, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(d)(1)

Regulation authority

CCR

What the official deficiency says

87224(d)(1) Eviction Procedures: (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. (1) The notice to quit shall include the following information: (B) to (D) This requirement is not being met as evidenced by: Based on record review, the eviction notice dated 2/10/22 did not have information on resources, the right to file a complaint, and unlawful detainer language.

Official plan of correction

Licensee agrees to train relevent staff on proper eviction procedures, especially as specified in Title 22 Regulation 87224. Once trainings are completed, the licensee shall submit copies of training records to CCLD.

Deadline recorded: Jun 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(a)

Regulation authority

CCR

What the official deficiency says

87507(a) Admission Agreements: (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 being met as evidenced by: Based on interview and record review, the licensee did not complete a written admission agreement with R1’s representative which poses a potential risk to the health of the resident in care.

Official plan of correction

Licensee agrees to train relevant staff on ensuring residents have completed individual admission agreements and ensuring the admission agreements are kept in the resident record. Once training is completed, the licensee shall submit training records to CCLD.

Deadline recorded: Jun 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87224(f)

Regulation authority

CCR

What the official deficiency says

87224(f) Eviction Procedures: (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement was not met as evidenced by: Based on record review, CCL did not receive a copy of R1’s eviction notice in February.

Official plan of correction

Licensee agrees to train relevent staff on properly documenting eviction notices to CCLD. Once training is completed, the licensee shall submit training records to CCLD.

Deadline recorded: Jun 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(g)(3)(B)(2)

Regulation authority

CCR

What the official deficiency says

87507 Admission Agreements (g)(3)(B)(2): (g) Admission agreements shall specify the following: (3) Payment provisions, including the following: (B) Rate for additional items and services, including: 2. A separate charge for an item or service may be assessed only if that charge is included in and authorized by the admission agreement This requirement is not being met as evidenced by: Based on interview and record review, facility failed to complete the admission agreement for R1 during the entire time of admission. Without the admission agreement, the separate charge for incontinent care was not authorized due to lack of admission agreement. This poses a potential risk to the health and safety of the resident in care.

Official plan of correction

Licensee agrees to train relevant staff on signing and completing admission agreement and all intake forms at the time of admission. Once training is completed, the Licensee agrees to submit copies of the training records to CCLD.

Deadline recorded: Jun 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(12)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(12) Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (12) To receive in the admission agreement a comprehensive description of the method for evaluating residents’ service needs and the fee schedule for the items and services, and to receive written notice of any rate increases according to Health and Safety Code sections 1569.655 and 1569.884. This requirement is not being met as evidenced by: Based on interview and record review, R1 was not given a copy of admission agreement that listed the fee schedule but a reservation agreement which did not list the fee for incontinent care. This poses a potential risk to the health and welfare of the resident in care.

Official plan of correction

Licensee agrees to train relevant staff on providing newly admitted residents with a fee schedule for the items and services for which the resident will be charged. Once training is completed, the Licensee agrees to submit copies of the training records to CCLD.

Deadline recorded: Jun 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition 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 being met as evidenced by: Based on interview and record review, there was no documentation that facility brought to the attention of R1’s physician prior to stopping R1’s medications when R1 was not eating. Facility also did not inform R1’s responsible person when R1 was not eating for 48 hours. This poses an immediate threat to the health and safety of the resident in care.

Official plan of correction

Licensee agrees to create a plan to train staff reporting changes in resident conditions to resident's primary care physician and responsible party by POC date. Once trainings are completed, training records shall be submitted to CCLD.

Deadline recorded: Jun 23, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87668.2(a)(20)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents for reasons other than those permitted by state law or regulations and shall comply with all eviction and relocation protections for residents. For purposes of this paragraph, " involuntary " means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident. This requirement is not being met as evidenced by: Based on interview and record review, facility initiated the involuntary discharge of R1 by refusing to take R1 back from the hospital without a proper eviction notice and without discussion with all parties involved. This poses a potential risk to the personal right of the resident in care.

Official plan of correction

Licensee agrees to submit a plan to train relevant staff on reasons for issuing an eviction notice to residents that are permitted by state laws and regulations by POC date. The training records shall be submitted to CCLD once completed.

Deadline recorded: Jun 29, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(d)(2)

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. This requirement was not being met as evidenced by: Based on interview and record review, Admin failed to have knowledge of and ability to conform to Title 22 on eviction procedures, personal rights and admission agreement as R1 was not given the proper eviction notice, the eviction notice was not sent to licensing agency, admission agreement was not completed, involuntary discharge and unprofessionalism in dealing with a family member. This poses an immediate risk to the health and safety of residents in care.

Official plan of correction

Licensee agrees to train relevent facility staff on proper eviction procedures and eviction notices to residents and families, interpersonal professionalism training, and proper admission procedures and agreements. These training plans shall be submitted to CCL by POC date. Once trainings are completed, training records shall be submitted to CCL.

Deadline recorded: Jun 23, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidenced by: Licensee did not report 4 COVID positive cases at the facility, which posed a potential safety risk to residents in care.

Official plan of correction

Licensee agrees to submit an incident report for the four positive COVID cases within 24 hours and submit a statement of understanding regarding reporting requirements, especially pertaining to reporting of epidemic outbreaks, to CCL by POC date.

Deadline recorded: Jun 9, 2022. A deadline is not proof that correction was completed.