FIVE STAR SENIOR LIVING

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. During the course of the inspection, LPA noted multiple instances where cleaning products, were acessilbe to residents in care. LPA also noted insect killer and lighter fluid acessible in the garage. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/28/2026 Plan of Correction ADM stated he will send a plan of action on how he will ensure disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended. ADM stated he will send to LPA by POC due date.

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. While reviewing R2's and R6's medications, LPA observe both medication containers had several loose medications not inside their original container. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/28/2026 Plan of Correction ADM stated he will send a plan of action on how he will ensure Each resident's medication shall be stored in its originally received container. ADM stated he will send the plan of correction to LPA by POC due date.

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and records reviewed, the licensee did not comply with the section cited above. while reviewing R2's medications, S1 informed LPA that the facility has Tums and Tylenol medications that they use for all the residents in the home. LPA asked S1 if all the residents have a prescription for the Tums and tylenol. S1 stated the facility does not have a prescription. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/28/2026 Plan of Correction ADM stated he will send a plan of action on how he will ensure every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) 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, the licensee did not comply with the section cited above. LPA noted cigarettes scattered on the floor in the backyard. LPA also noted tree foileage on the ground. LPA also noted stains in the hallway bathroom. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction ADM stated he will send a plan of action on how he will ensure the facility will remain clean, safe, sanitary and in good repair at all times. ADM stated he will send his plan to LPA by POC due date.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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. LPA requested to review staff S1's health screening. S1 stated he/she did not have it and was going to get one. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction ADM stated staff S1 will get a new health screening and send LPA documenation showing S1 has completed his/her health screening by POC due date.

Official classification

Type B

Official code

87412(c)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above. LPA requested to review staff S1-S3's training records. LPA was provided a sheet with 1 training, for April 1, regarding medication training, for staff S1 and S2. This which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction ADM stated he will send a letter of understanding regarding the reguation. ADM stated he will send documenation showing S1-S3's training to LPA by POC due date.

Official classification

Type B

Official code

87506(b)(16)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables. 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. LPA also noted R3 did not have a personal property log. R5 had a personal property log that was blank. R6 has a personal property log from his/her previous form, but does not have one for this facility, dated from his/her move in. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction ADM stated he will create a new personal property log for R3, R5 and R6. ADM stated he will send a copy to LPA by POC due date.

Official classification

Type B

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 interview and record review, the licensee did not comply with the section cited above. LPA requested to review the facility emergency drill log. LPA was not provided documentation showing drills have taken place. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction ADM stated he will conduct a drill and send documenation showing a drill has taken place. ADM stated he will send a letter of understanding regarding the regulation.

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 record review, the licensee did not comply with the section cited above. Resident R2 and R3 had medications that were not listed on the centrally stored medicatoin record. S1 stated R2 does not have his/her medications listed on the 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: 03/06/2026 Plan of Correction ADM stated he will send a letter of understanding regarding the regulation. ADM stated he will send a copy of the updated centrally stored medicaton records for Rw and R3 to LPA by POC due date.

Official classification

Type B

Official code

87455(b)(8)

Regulation authority

CCR

What the official deficiency says

87455 Acceptance and Retention Limitations (b)(8) Persons who are under 60 years of age whose needs are compatible with other residents in care, if they require the same amount of care and supervision as do the other residents in 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. During a review of residents files 4 (R1, R2, R5, R6) Out of 6 residents are under the age of 60. The facility has a census of 6 and the facility did not request an exception request for the residents who are under the age of 60 years. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/06/2026 Plan of Correction ADM stated he will send an age exception request for at least 3 residents under the age of 60. ADM stated he will send the plan of correction to LPA by POC due date.

Official classification

Type A

Official code

87468.1(a)(1)

Regulation authority

CCR

What the official deficiency says

**This LIC9099-D page is amended to remove the deficiency issued on 08/22/2025. The allegation finding was amended to be changed from Substantiated to Unsubstantiated.**

Deadline recorded: Aug 23, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. 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 S1 works for the facility more than one month and staff S2 works for the facility more than 6 months, both wiout health screen forms. which poses/posed a potential health, safety risk to persons in care.

Official plan of correction

POC Due Date: 03/20/2025 Plan of Correction ADM stated to send plian of correction by the POC due date to ensure all staff have health screening forms ready.

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 of 3 staff without health screen forms which poses/posed a potential health, safety.

Official plan of correction

POC Due Date: 03/20/2025 Plan of Correction ADM agreed to send plan of correction by the POC due date to ensure all staff have the health screen forms.

Official classification

Type B

Official code

87465(h)(1)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: 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 3 out of 3 residents' central stored medication forms without started date which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/20/2025 Plan of Correction ADM stated to submit plan of correction by the POC due date to ensure all residents' centrally stored medication forms are maintained accurate and up to date.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in that 2 out of 3 residents physician reports are more than 1 year which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/20/2025 Plan of Correction ADM stated to send plna of correction by the POC due date to maintain residents' physician reports up to date.

Official classification

Type B

Official code

87463(i)

Regulation authority

CCR

What the official deficiency says

(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making. 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 of 3 residents' appraisal needs and service plan are over than one year which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/20/2025 Plan of Correction ADM stated to send plan of correction by the POC due date to ensure residents' appraisal needs and service plans are done annually.

Official classification

Type B

Official code

87555(b)(7)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b) The following food service requirements shall apply:(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirements was not met as evidenced by: Based on the interviews and record reviews, the facility did not provide the special diet prescribed by resident R1's physician, this poses a potential health, safety or personal rights risk to a person in care.

Official plan of correction

Administrator stated to submit a plan of correction by the POC due date to ensure the facility follows residers' doctors prescribed special diets.

Deadline recorded: Oct 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468(c)(1)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities shall be posted as applicable to the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that the personal rights posters were not observed in the main entrance which poses an personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2024 Plan of Correction ADM stated to send a plan of correction by the POC due date to post the personal rights posters at main entrance.

Official classification

Type B

Official code

87468(b)(1)(A)

Regulation authority

CCR

What the official deficiency says

(b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. (A) The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on records review, the licensee did not comply with the section cited above in that 1 out of 3 resident files did not have personal rights policy which poses a personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/18/2024 Plan of Correction ADM stated to submit a plan of correction by the POC due date to provide the personal rights policy to residents for resident files.

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 1 out 3 resident centrally stored medication record was observed inaccurate and not up to date, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/18/2024 Plan of Correction ADM stated to submit a plan of correction by the POC due date to make resident files accurate and up to date.