PENINSULA SENIOR LIVING MAGNOLIA LLC

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

POSTURAL SUPPORTS A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met, as residents in rooms #2, #3, #7, #8, #9, #15, #17, #18, #19, #20 have half bed rails on beds, which poses a potential health, safety or personal rights risk to clients in care.

Official plan of correction

MD orders for half bed rails for clients in rooms #2, #3, #7, #8, #9, #15, #17, #18, #19, #20 will be sent to CCLD BY DUE DATE

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

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

REAPPRAISALS The pre-admission appraisal, as specified in Section 87457... shall be updated in writing as frequently as necessary or once every 12 months... to note significant changes in condition...and to keep the appraisal accurate. This requirement is not met, as appraisals for clients #2, #7, #9 are dated over 12 months ago. Licensee failed to ensure that written appraisals are updated annually, which poses a potential health safety or personal rights risk to clients in care.

Official plan of correction

Written appraisals for clients #2, #7, #9 will be updated and sent to CCLD BY DUE DATE

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

Official classification

Type B

Official code

87463(h)(1)

Regulation authority

CCR

What the official deficiency says

REAPPRAISALS The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every 12 months, either in person or by video appointment...documentation of the annual routine visit...shall be added to the resident's record. This requirement is not met, as MD reports for clients #2 and #9 are dated more than 12 months ago. Licensee failed to ensure that MD reports are completed annually, which poses a potential health, safety or personal rights risk to clients in care.

Official plan of correction

MD reports for clients #2 and #9 will be sent to CCLD BY DUE DATE

Deadline recorded: Jan 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(a)(1)(A)

Regulation authority

CCR

What the official deficiency says

ADMISSION AGREEMENTS The licensee shall complete an individual written admission agreement...text of the admission agreement, including any attachments and modifications, shall be printed in black type of not less than 12-point type size, on plain white paper. The print shall appear on one side of the paper only. This requirement is not met, as original signed admission agreement for client #9 is printed on both sides of paper, which poses a potential health, safety or personal rights risk to clients in care.

Official plan of correction

Plan of correction to be sent to CCLD BY DUE DATE.

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

Official classification

Type B

Official code

1569.695(f)(1)

Regulation authority

HSC

What the official deficiency says

EMERGENCY PLANS A facility shall have...the following in place: An evacuation chair at each stairwell, on or before July 1, 2019. This requirement is not met, as there are no evacuation chairs in 3 stairwells. Licensee failed to ensure that evacuation chairs are installed in each stairwell, which poses a potential health, safety or personal rights risk to clients in care.

Official plan of correction

Evacuation chairs will be installed in each of 3 stairwells, and proof of correction to be sent to CCLD BY DUE DATE

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

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

PERSONNEL REQUIREMENTS - GENERAL Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met, as there is no evidence that staff #1 and #2 have current first-aid training, which poses a potential health, safety or personal rights risk to clients in care. Licensee failed to ensure that all caregivers have current first-aid training.

Official plan of correction

Proof of current first aid training for staff #1 and #2 will be sent to CCLD BY DUE DATE

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

Official classification

Type B

Official code

87412(a)

Regulation authority

CCR

What the official deficiency says

PERSONNEL RECORDS The licensee shall ensure that personnel records are maintained on... each employee. Each personnel record shall contain...Employee's full name, Social Security number, Date of employment, Written verification that the employee is at least 18 years of age, including...a copy of his/her birth certificate or driver's license, Home address and telephone number, Educational background, Past experience, including...former employers... position for which employed...health screening.... REcords for staff #1 do not include job application and health screening

Official plan of correction

Job application and health screening for staff #1 sent to CCLD on 12/10/25. Deficiency corrected and cleared

Deadline recorded: Jan 5, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

MAINTENANCE AND OPERATION Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F . This requirement is not met, as hot water temperature tested at 140 degrees in room 12 on 2nd floor. Licensee failed to ensure that hot water temperature is within range of 105 to 120 degrees F., which poses an immediate health and safety risk to clients in care. This deficiency was cited on 12/8/25, but not corrected.

Official plan of correction

Hot water temperature will be lowered and maintained within range of 105 to 120 degrees F. Proof of correction to be submitted to CCLD BY DUE DATE

Deadline recorded: Jan 6, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

MAINTENANCE & OPERATION Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F . This requirement is not met, as hot water temperature tested at 124 degrees in room 12 on 2nd floor. Licensee failed to ensure that hot water temperature is within range of 105 to 120 degrees F., which poses an immediate health and safety risk to clients in care.

Official plan of correction

Hot water temperature to be lowered and maintained within range of 105 to 120 degrees F. Proof of correction to be submitted to CCLD BY DUE DATE

Deadline recorded: Dec 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(g)(2)

Regulation authority

CCR

What the official deficiency says

PERSONNEL REQUIREMENTS GENL Prior to employment or initial presence in the facility, all employees...subject to a criminal record review shall obtain a CA clearance...as required by law or Dept regulations or request a transfer of a criminal record clearance...This requirement is not met, as agency caregivers are present, but their criminal record clearances are not associated to facility. Licensee failed to ensure that caregivers maintain criminal record clearance & association to facility, which poses an immediated health, safety or personal rights risk to clients.

Official plan of correction

Proof that criminal record clearances for agency staff #3 and #6 are associated to facility will be sent to CCLD BY DUE DATE

Deadline recorded: Dec 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87608(a)

Regulation authority

CCR

What the official deficiency says

POSTURAL SUPPORTS Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met, as full bed rails are observed on beds of nonhospice clients, which poses an immedicate health, safety or personal rights risk to clients. Licensee failed to ensure that full bed rails are only used for hospice clients when included in hospice care plans. Clients #6 & #7 have full bed rails

Official plan of correction

Plan of correction to be submitted to CCLD for use or non-use of full bed rails for clients #6 and #7

Deadline recorded: Dec 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not ensure hot water temperature at the sink faucet is in the range of 105 - 120 degree F. The hot water temperature was measured between 136.3°F - 162.5°F in 4 of 4 bathroom sink faucets, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/03/2024 Plan of Correction The manager stated that they would fix the high hot water temperatures. The manager will submit the evidence that hot water temperature is within the range of 105°F - 120°F to CCLD by 12/03/2024.

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 record review, the licensee did not ensure that the emergency drills are conducted on quarterly basis which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/09/2024 Plan of Correction The manager stated that they will conduct Energency Drill soon and the manager will submit evidence of the completed drill log to CCLD by 12/09/2024.

Official classification

Type A

Official code

87468.1(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities:(a)... residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in...qualifications, and competency to meet their needs. This requirement was not met as evidenced by: R1 was not provided care and supervision to meet R1's needs wherein R1 left the facility unassisted while facility staff were unaware which poses an immediate Health, Safety, or Personal Rights risk to persons in care.

Official plan of correction

Licensee will submit a written plan of action to ensure resident's safety and provide in-service training by POC date. Licensee agreed and understood.

Deadline recorded: Mar 22, 2024. A deadline is not proof that correction was completed.