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 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

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

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.