Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(f)
- Regulation authority
- CCR
What the official deficiency says
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above. Licensee stated she did not have staff files available for LPA to review. which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/22/2026 Plan of Correction Licensee / ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send to LPA by POC due date, January 22, 2026
Background checksType B
- Official classification
- Type B
- Official code
- 87355(e)(3)
- 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: (3) 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 record review, the licensee did not comply with the section cited above. Facility Administrator is not associated with the facility. which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/22/2026 Plan of Correction Licensee / Administrator will associate the Administrator to the facility. Licensee/ Administrator will send letter of understanding regarding the regulation.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87456(a)(2)
- Regulation authority
- CCR
What the official deficiency says
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview, the licensee did not comply with the section cited above. Licensee stated she did not preform a pre admission appraisal for R3. This poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/22/2026 Plan of Correction ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will send to LPA by POC due date.
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87463(a)
- Regulation authority
- CCR
What the official deficiency says
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. 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. Resident R2's Needs and services plan is dated August 10, 2024, is blank. Resident R3's Needs and Services Plan is blank. This poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/22/2026 Plan of Correction ADM / Licensee stated she will send LPA a copy of R2 and R3's updated Needs and services plan by POC due date. ADM / Licensee stated she will send a letter of understanding regarding the regulation.
Fire safety and emergency preparednessType B
- 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, the licensee did not comply with the section cited above. Licensee stated she and the Administrator have not conducted quarterly drills. This poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/22/2026 Plan of Correction ADM stated she will conduct a disaster drill and will ensure the Documentation of the drill shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. ADM stated she will send documentation a drill has taken place to LPA by POC due date.
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87618(b)(3)(B)
- Regulation authority
- CCR
What the official deficiency says
(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. located between 2 residents bedroom, LPA noted, oxygen was being used. ADM confirmed the resident that was residing in that bedroom does use oxygen. LPA noted that the door to the bedroom does not have a, " oxygen in use, no smoking. " This poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/22/2026 Plan of Correction ADM stated she will send a letter of understanding regarding the regulation. ADM stated she will put a " oxygen in use, no smoking " sign in the room that is using oxygen and send photo documentation showing the sign is in place. ADM stated she will send to LPA by POC due date.
Medication handling and storageType B
- 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 interview and record review, the licensee did not comply with the section cited above. Resident R1's centrally stored medication record did not have 5 of R1's medications listed. Resident R4 did not have 2 medications that were not listed in his/her centrally stored medication record. Resident R3 did not have his/her medications listed on his/her centrally stored medication record. This poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 01/22/2026 Plan of Correction ADM stated she will send an updated Centrally stored medication record for residents R1, R3 and R4. ADM stated she will send to LPA by POC due date.