VACAVILLE MEMORY CARE

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care: (a)A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement not met by licensee as evidenced by: Based on record reviews facility failed to administer correct medication during the medication pass. This poses immediate health and safety concerns for the residents in care.

Official plan of correction

Executive Director Agrees to conduct in-service training regarding medication pass and submit proof of self-certification to CCL by plan of correction days 07/17 2026.

Deadline recorded: Jul 17, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(3) Personal Rights of Residents in All Facilities: (a)(3) To be free from punishment,humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’... This requirement was not met as evidenced by: Based on interviews conducted, records reviewed, and observations made, the facility failed to ensure resident’s rights and protection from abuse. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Executive Director agrees to provide all staff training regarding abuse, de-escalation and crisis training. ED will submit proof of correction by Plan of Correction (POC )due date 04/10/2026.

Deadline recorded: Apr 10, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

Plan of Operation 87208(a) Licensee shall have and maintain a current, written definitive plan of operation for the facilit…Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. This requirement was not met as evidenced by: Licensee failed to submit Admissions Agreement for review to ensure changes were not made that required approval by CCL. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee to submit Admission Agreement currently being used by the facility for department review by POC Due Date of 02/20/2026.

Deadline recorded: Feb 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(29)

Regulation authority

CCR

What the official deficiency says

87555(b)(29) - General Food Service Requirements, (b)The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips. This requirement was not met as evidenced by: Based on interviews and LPA observation of records, it was determined that resident R1’s water bottle contained unknown black substance, that indicating it was not properly cleaned or sanitized. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator agrees to provide in-service training to all direct care staff on proper cleaning and sanitizing of resident drinking containers and implement a routine cleaning schedule to ensure all containers remain clean and sanitary. Administrator will submit proof of correction by Plan of Correction(POC )due date 02/10/2026.

Deadline recorded: Feb 10, 2026. 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)In addition to the rights listed in Section 87468.1,... shall have all of the following personal rights: (4) to care, supervision, and...This requirement was not met as evidenced by: Based on interviews conducted and observations made, Licensee did not ensure residents' personal rights and incontinence care needs were met. This is an immediate health and safety risk to residents in care.

Official plan of correction

Licensee to schedule training with approved outside vendor for all care staff regarding personal rights of residents and incontinence care . Licensee to provide scheduled training date to CCL by POC due date of 09/15/2025. Training to include: Staff Names and Signatures. Training to be submitted by POC due date of 09/25/2025.

Deadline recorded: Sep 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times...for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on observations made, Licensee did not comply with the section cited above and did not ensure that bathrooms were in good operating condition. LPAs observed the following to be broken or in disrepair: paper towel dispenser, toilet paper holder, toilet out of order, soap dispenser, and utility sink. This poses a potential health and safety risk to residents in care.

Official plan of correction

During visit on 07/23/2025, LPAs observed that facility has fixed all items that were in disrepair. Deficiency Cleared.

Deadline recorded: Aug 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87470(b)

Regulation authority

CCR

What the official deficiency says

87470 Infection Control Requirements (b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: This requirement was not met as evidenced by: Based on interviews and observations, Licensee did not comply with the section cited above and did not ensure that facility staff were following infection control protocol. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee agrees to submit self-certification that all staff will be trained in PPE by POC due date of 7/24/2025. Proof of training will be complete by POC due date of 8/04/2025

Deadline recorded: Jul 24, 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) A plan for incidental medical and dental care shall be developed...(4)The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: based on interviews and record review, Licensee did not comply with the section cited above and did not ensure that Resident 1’s medication was administered per physician’s orders. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee to submit self certification that training will be conducted for all staff that administer medication by POC due date of 07/12/2025. Training to include the following: Trainer, Date, Topics, Job Role, Staff Names and Signatures. Training to be submitted by POC due date of 07/21/2025.

Deadline recorded: Jul 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(a)(3)(D)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services:(a)...The following provisions shall apply:(3)Equipment and supplies... for personal care and...adequate hygiene practice shall be readily available...:(D) Hygiene items of general use such as soap and toilet paper. This requirement was not met as evidenced by: based on observations amde, Licensee did not comply with the section cited above and did not ensure that facility bathrooms were supplied with general hygiene items such as toilet paper, soap, and paper towels. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee to submit In-service training on replenishing house bathroom supplies. Training to include the following: Trainer, Date, Topics, Job Role, Staff Names and Signatures. Training to be submitted by POC due date of 07/21/2025.

Deadline recorded: Jul 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

87208 Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation...plan & related materials shall be on file in the facility & shall be submitted to the licensing agency with the license application. Any significant changes...which would affect the services to residents shall be submitted...for approval. This requirement was not met as evidenced by: Licensee failed to submit Admissions Agreement for review to ensure changes were not made that required approval by CCL. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee to submit proof of revised Admission Agreements to Centralized Application Bureau (CAB) by POC Due Date of 05/02/2025 for review and approval.

Deadline recorded: May 2, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requirement was not met as evidenced by: based on interviews conducted and document review, Licensee did not comply with the section cited above and ensure that all 5 homes at facility had adequate staffing to meet resident care needs. Licensee has at least 6 residents that require two staff member assistance. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee to submit written plan to ensure staffing is sufficient to meet resident care needs by POC Due Date of 04/25/2025.

Deadline recorded: Apr 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(1)

Regulation authority

CCR

What the official deficiency says

87468.2Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1...(1)To have a reasonable level of personal privacy accommodations...personal care & assistance...use of the Internet...this requirement was not met as evidenced by: based on interviews conducted & document review, Licensee did not comply with the section cited above & Residents did not have signed social media consent forms prior to being on social media. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee to conduct training on the facility's social media policy, cell phones, and personal rights of residents. Training to include the following: Date, Topic, Name/Job Role, and Staff Signatures. Training to be submitted by POC Due Date of 04/25/2025.

Deadline recorded: Apr 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal...this requirement was not met as evidenced by: based on observsations made, Licensee did not comply with the section cited above and ensure that all facility exits were unobstructed in the event of emergency. This poses an immediate health and safety risk to residents in care.

Official plan of correction

Licensee to conduct training on keeping all facility exits clear and unobstructed, such as a fire drill, for all shifts (AM, PM, NOC). Training to include the following: Date, Topic, Name/Job Role, and Staff Signatures. Training to be submitted by POC Due Date of 04/25/2025.

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

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted...within seven days of the occurrence of any of the events specified...below. This requirement was not met as evidenced by: Licensee did not comply with section cited above. Per record review, Licensee did not submit incident reports timely. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee to submit Inservice Training on the topics of Incident Reporting and Documentation. Training to include the following: Date, Topic, Name/Job Role, and Signatures. Training to be submitted to CCL by POC due date of 04/24/2025.

Deadline recorded: Apr 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident: Licensee shall ensure...residents are regularly observed for changes... & that appropriate assistance is provided...Licensee shall ensure...changes are documented & brought to the attention of the resident's physician & responsible person, if any. Requirement was not met as evidenced by: based on interviews, records & observations, Licensee did not ensure that facility staff responded appropriately to observations of R1's wound resulting in an unstageable injury. This is an immediate health & safety risk to residents in care.

Official plan of correction

Licensee to schedule training for all care staff regarding observation of a resident. Licensee to provide scheduled training date to CCL by POC due date of 02/21/2025. Training to include: Trainer, Date of Training, Topics, Job Role, Staff Names and Signatures. Proof of Training to be submitted by POC due date of 03/03/2025.

Deadline recorded: Feb 21, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87470(b)(2)

Regulation authority

CCR

What the official deficiency says

87470 Infection Control Requirements (b) (2)All staff...providing direct care to resident who has a communicable disease shall wear appropriate... PPE ...(B)PPE shall be...discarded in the nearest... receptacle with... immediately upon completing a task. This requirement has not been met as evidence by: Based on photos, observation, interviews and record review Licensee did not follow mandated guidance of infection control plan and failed to discard PPE in a tightly-lidded container as required which poses a potential health, safety, and personal rights risk to clients in care.

Official plan of correction

Licensee to submit proof of training of staff on proper PPE donning, doffing and the proper disposal of used PPE following Infection Control Plan. Proof to be submitted to CCL by 2/5/2025.

Deadline recorded: Feb 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(1)

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: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: based on interviews conducted, Licensee did not ensure residents' personal rights. This is an immediate health and safety risk to residents in care.

Official plan of correction

Licensee to schedule training with approved outside vendor for all care staff regarding personal rights of residents. Licensee to provide scheduled training date to CCL by POC due date of 01/04/2024. Training to include: Staff Names and Signatures. Training to be submitted by POC due date of 01/13/2024.

Deadline recorded: Jan 4, 2025. 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)In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents... shall have all of the following personal rights: (4) to care, supervision, and services that meet their individual needs...This requirement was not met as evidenced by: Based on interviews conducted and observations made, Licensee did not ensure residents' personal rights and incontincence care needs were met. This is an immediate health and safety risk to residents in care.

Official plan of correction

Licensee to schedule training with approved outside vendor for all care staff regarding personal rights of residents. Licensee to provide scheduled training date to CCL by POC due date of 01/04/2024. Training to include: Staff Names and Signatures. Training to be submitted by POC due date of 01/13/2024.

Deadline recorded: Jan 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident: Licensee shall ensure...residents are regularly observed for changes... & that appropriate assistance is provided...Licensee shall ensure...changes are documented & brought to the attention of the resident's physician & responsible person, if any. Requirement was not met as evidenced by: based on interviews, records & observations, Licensee did not ensure that facility staff responded appropriately to observations of R1's wound resulting in an unstageable injury. This is an immediate health & safety risk to residents in care.

Official plan of correction

Licensee to schedule training with approved outside vendor for all care staff regarding observation of a resident and proper documentation. Licensee to provide scheduled training date to CCL by POC due date of 01/04/2024. Training to include: Trainer, Date of Training, Topics, Job Role, Staff Names and Signatures. Training to be submitted by POC due date of 01/13/2024.

Deadline recorded: Jan 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and observations made, Licensee did not comply with the section cited above. Licensee did not ensure that 4 of 8 staff members received their annual 20 hours training as required by Health and Safety Code. This poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 11/17/2024 Plan of Correction Licensee to submit a written plan outlining how they will ensure all staff on site will obtain their annual 20 hour training as required by Health and Safety Code by POC due date of 11/17/2024. Licensee to submit proof of completed annual training for identified staff members by 12/06/2024.

Official classification

Type B

Official code

87465(h)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and observations made, Licensee did not comply with the section cited above. Licensee did not ensure that 4 of 10 resident medications were documented and centrally stored as required. This poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 11/17/2024 Plan of Correction Licensee to conduct a medication audit and conduct an in-service training for all medication technicians reviewing how to centrally store medications. Licensee to provide CCL an update on when audit and in-service training will be scheduled by POC due date of 11/17/2024. In-Service Training to include: Date of Training, Training Topics, Job Role, Staff Names and Signatures. In-service training to be submitted by POC due date of 12/06/2024.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation: (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 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by: Deficient Practice Statement Based on observations made, the Licensee did not comply with the section cited above. 4 of 10 facility sinks were found to be out of Title 22 regulations of 105F to 120F measuring at 147.2F, 128.6F, 125.7F, and 138.2F. This poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 11/17/2024 Plan of Correction Licensee to submit a water temperature log for the next 10 days. Temperature to be checked twice a day for all sinks in each house starting on 11/06/2024. Log to include location of sink and time documented. Log to be submitted to CCL for review and approval by POC due date 11/17/2024.

Official classification

Type A

Official code

1569.17(c)(1)(A)

Regulation authority

HSC

What the official deficiency says

(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and observations made, Licensee did not comply with the section cited above. Licensee did not ensure that Staff Member 1 (S1) had the proper background clearance and/or associations required to provide care at the facility. This poses an immediate health and safety risk to clients in care.

Official plan of correction

POC Due Date: 10/18/2024 Plan of Correction Licensee sent S1 to be fingerprinted. Licensee to ensure that individuals subject to a criminal record review receive proper clearance and are associated to facility per Title 22 regulations. Licensee to submit a detailed step by step plan for how they will ensure fingerprint clearance and association is complete for an employee prior to them working. Plan to be submitted by POC due date of 10/18/2024.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 (f) The following shall be stored inaccessible to residents with dementia: (2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. This requirement is not met as evidenced by: Based on self-reported incident report, the licensee did not comply with the section cited above in that soap in kitchen area was accessible to residents, which poses/posed an imminent health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to submit plan for conducting staff training on how to properly store toxic materials and items that could en danger residents by 08/27/2024 and training to take place no later than 08/30/2024 with a copy of training materials and sign in sheet of participants submitted to CCL by 09/03/2024.

Deadline recorded: Aug 26, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269

Regulation authority

HSC

What the official deficiency says

Enumerated rights; severability(a(6) - ..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 was not met as evidence by** Based on interviews with Administrator and a review of resident R1 medical and facility records, it was found that facility failed to ensure proper supervision resulting in R1 left unsupervised, causing unwitnessed fall and injury in the facility courtyard. This serves as an immediate health & safety risk to residents in care.

Official plan of correction

Facility failed to ensure that proper care and supervision were provided to resident R1. Administrator agrees to submit updated plan of action on how staff are to provide adequate supervision for all residents during evening hours. Written statement to be submitted to CCLD by POC date 4/28/2024. Civil Penalty issued for a total of $250 for repeat violation.

Deadline recorded: Apr 27, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified.. This requirement was not met as evidence by:** Based upon review of facility and CCLD records, it was found that the facility failed to properly complete and report an Unusual Incident Report LIC624 regarding resident R1 sustaining unwitnessed fall located in facility courtyard. This serves as a potential healthy and safety risk to residents in care.

Official plan of correction

Administrator failed to follow proper reporting requirements for incidents. Administrator agrees to conduct an in-service training for all staff on reporting protocols and incident report review to clear deficiency. Signed training to be submitted to CCLD by POC date 5/3/2024.

Deadline recorded: May 3, 2024. 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 (a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This was not met as evidence by: Based on photo evidence and interviews with multiple staff, LPA found that caregiving staff have been witnessed to be asleep during their shifts which serves as a potential health & safety risk to residents in care.

Official plan of correction

Facility agrees to submit plan of action on how to ensure staffing is sufficient and providing adequate supervision for residents in care. Plan of action to be submitted to CCLD by POC date 1/31/2024.

Deadline recorded: Jan 31, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(b)

Regulation authority

CCR

What the official deficiency says

Safeguards for Resident Cash, Personal Property and Valuables: Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables.. This was not met as evidence by: Based on interviews with multiple staff, LPA received consistent information regarding resident clothing being shared amongst each other due to inaccessible clothing (soiled or requiring replacement). This serves as a potential personal rights risk to residents in care.

Official plan of correction

Facility agrees to submit plan of action on how to ensure resident personal clothing items are sufficient and maintained. Plan of action to be submitted to CCLD by POC date 1/31/2024. In addition, facility is to ensure all laundry machines pending repair or replacement have been resolved. Proof of Corrections Form LIC9098 confirming laundry machines for each cottage are functioning by POC due date 2/21/2024.

Deadline recorded: Feb 29, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269

Regulation authority

HSC

What the official deficiency says

Enumerated rights; severability-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 was not met as evidence by: Based on observation, records review & interviews, the licensee did not comply with the section cited above involving resident R1's needs not being met resulting in development of pressure sore while under facility care which poses an immediate health & safety risk to persons in care.

Official plan of correction

Facility failed to ensure staff were sufficient and competent to provide necessary services to meet resident needs. Administrator is to implement a vendorized training for all staff that provide resident care on continuous bedridden care, continence care and other topics pertaining to meeting resident physical care requirements. Training date is to be submitted to CCLD by POC date 1/25/2024. Completed training log signed by all staff is to be submitted to CCLD by POC date 2/8/2024. This is an amendment of the original report to indicate civil penalty language and amount correction** Civil penalty of $250 issued for repeat violation within a 12 month period for regulation 1569.625(b)(2).

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

Official classification

Type A

Official code

1569.269

Regulation authority

HSC

What the official deficiency says

Enumerated rights; severability-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 was not met as evidence by:** Based on LPA interviews with Acting Administrator, staff, review of records and observations, it was found that resident R1 sustained an unexplained injury on 12/31/2023 due to several residents not properly supervised. This is an immediate health & safety risk to residents in care.

Official plan of correction

Facility agrees to provide written plan on how they will remain in compliance with the regulations and H & S Codes and meeting staffing expectations. Plan to be submitted to CCLD with LIC9098 Plan of Corrections by POC date 1/10/2024.

Deadline recorded: Jan 10, 2024. 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

The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidence by:** Based on review of Omnicare Pharmacy medication audit conducted 12/20/2023 and interview with Omnicare Nurse (N1) it was found that staff (S2) was observed inappropriately administering medications directly into residents' mouths/tongue when staff are to only provide assistance with self-administering. This serves as an immediate health & safety risk to residents in care.

Official plan of correction

Licensee failed to ensure staff are completing medication protocol in compliance with Title 22 regulations. Licensee agrees to develop a plan of action to ensure facility is in compliance moving forward. Written plan of action is to be submitted to CCLD by POC date 12/21/2023. In addition, Licensee is to conduct medication administration training for all medtech staff. Completed and signed training to be submitted to CCLD by POC date 1/4/2023.

Deadline recorded: Dec 21, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(i)

Regulation authority

CCR

What the official deficiency says

Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: This was not met as evidence by:** Based on Omnicare Pharmacy audit it was found that the facility staff have not properly processed or disposed of several expired medication. This serves as potential health & safety risk.

Official plan of correction

License failed to ensure resident medication is properly maintained. Licensee agrees to develop a plan of action to ensure facility is in compliance moving forward. Written plan of action is to be submitted to CCLD by POC date 12/21/2023. In addition, Licensee is to submit a LIC9099 Proof of Corrections Form self-certifying that all expired or discontinued medications are disposed of in a proper manner. LIC9099 to be submitted to CCLD by POC date 1/4/2023.

Deadline recorded: Dec 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)

Regulation authority

CCR

What the official deficiency says

87464(f) - Basic services shall at a minimum include care and supervision as described in Health and Safety Code section 1569.2(c). These requirements were not met as evidenced by:** Based on interview with home health agency (H1) it was found that H1 had observed resident R2 left in soiled continence care on multiple occasions. In addition, based on photo evidence, resident R1 was observed to be left in soiled clothing on multiple occasions. This serves as an immediate health & safety and personal rights risk to residents in care.

Official plan of correction

Licensee failed to ensure residents were provided proper basic services. Licensee agrees to develop a plan of action to ensure facility is in compliance moving forward. Written plan of action is to be submitted to CCLD by POC date 12/21/2023.

Deadline recorded: Dec 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87393(a)

Regulation authority

CCR

What the official deficiency says

87303(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 was not met as evidence by:** Based on tour of the facility, LPA observation and photo evidence it was found that the facility was not in safe or sanitary condition. Urine was observed uncleaned on resident bedroom floors, bathrooms as well as photo evidence indicating feces in common areas. This serves as a potential health & safety risk to residents in care.

Official plan of correction

Licensee failed to ensure facility was in a clean, safe and sanitary condition. Licensee agrees to develop a plan of action to ensure facility is in compliance moving forward. Written plan of action is to be submitted to CCLD by POC date 12/21/2023.

Deadline recorded: Jan 4, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(5)

Regulation authority

CCR

What the official deficiency says

87465(a)(5): Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement is not met as evidenced by: Based on record review and interview with Administrator the facility failed to ensure R1's medication was given as prescribed by doctor which poses an immediate health and safety risk to resident in care.

Official plan of correction

Administrator agrees to submit proof of additional training for medication passes with ALL staff and to ensure future compliance and submit an LIC 9098-Self Certification. Administrator shall provide a plan to train all staff by June 5, 2023. In addition, Administrator shall provide a sign-in sheet with proof of training by June 13, 2023.

Deadline recorded: Jun 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements:(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following:(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident... This requirement is not met as evidenced by: Based on Record Review, the Licensee did not comply with the section cited above, and did not submit reports to CCL as required. This poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee to provide training to all Staff reviewing the Regulation: 87211 Reporting Requirements and how to properly fill out the LIC 624 form. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures by POC due date of 11/29/2022.

Deadline recorded: Nov 29, 2022. 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

Peronnel Requierments-General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This was not met by:** Based on a observations, staff interviews and record review LPA found that staff (S3) had provided supervision for residents alone without approrpriate caregiver traning and against S3's required duties. Potential risk to residents in care.

Official plan of correction

Facility is to submit plan for ensuring staff scheduling is sufficient for shift changes and lunch breaks. A copy of an updated caregiver schedule is to be submitted to CCL by POC date 11/15/22. In addition, facility is to submit a plan determining staff cross training for caregiver capabilities in needs for scheduling emergencies. Plan to be submitted to CCL by POC due date 11/15/22.

Deadline recorded: Nov 3, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(b)(10)

Regulation authority

CCR

What the official deficiency says

87506(b)(10) Resident Records: (b) Each resident’s record shall contain at least the following information: (10): Reports of the medical assessment specified in Section 87458, Medical Assessment, and of any special problems or precautions. This requirement was not met as evidenced by: Based off of observation of facility records and interviews with staff members. LPA learned and identified that R1 did have a change of condition, and was not documented on a LIC 602/Physicians Report nor retained in resident records. This is a potential health, safety and personal rights risk to the residents in care.

Official plan of correction

Licensee shall retrain all staff on admissions, reappraisals and record keeping. Licensee shall provide a self-certification and the understanding of this regulation. In addition, Licensee shall provide a written statement on how future compliance will be met. Administrator requested to have an extension of the Plan of Correction (POC). POC extension granted for October 31, 2022.

Deadline recorded: Oct 31, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.312(d)

Regulation authority

HSC

What the official deficiency says

1569.312(d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by: Based on interviews conducted, the Licensee did not comply with the section cited above and did not ensure that staff knew the general whereabouts of R1. It was reported that R1 left the facility unassisted and without staff knowledge. A search was conducted and R1 was found unharmed. This poses an immediate risk to the health and safety of residents in care.

Official plan of correction

Licensee contacted Repair Company to make needed repairs at the secure entry of facility. Refresher training is scheduled for all staff and inservice training sign-in sheet will be sent to CCL by POC date of 7/15/2022.

Deadline recorded: Jul 7, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87707(a)(2)

Regulation authority

CCR

What the official deficiency says

Direct care staff shall complete at least eight hours of in-service training on the subject of serving residents with dementia...and in each succeeding 12-month period. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not have at least 8 hours of documented in-service training for staff. This poses a potential Health, Safety or personal rights risk to residents.

Official plan of correction

Licensee to ensure staff assisting resident with dementia receive on-going annual training specifically addressing care needs of residents with dementia. Licensee to review regulation requirements and submit plan to CCL to ensure staff receive required training per regulation.

Deadline recorded: Jul 29, 2022. 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(a)(2) Personal Rights of Residents in All Facilities Residents in all residential care facilities for the elderly shall have all of the following personal rights:To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.**This requirement is not met as evidenced by: Based on record review and interviews facility failed to ensure resident was accorded a safe environment being hit by R1 back to back.

Official plan of correction

Facility will submit a written plan to prevent R1 aggression with R2 and other residents and submit training for staff for this plan. Facility will update Care Plan for R1.

Deadline recorded: Oct 19, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(d)

Regulation authority

CCR

What the official deficiency says

87211(a)(1)(d) Reporting Requirements. The licensee shall send a written report, within seven days, to the licensing agency and the person responsible for the resident when any incident occurs which threatens the welfare, safety or health of any resident. **This requirement is not met as evidence by: Based on record review and staff interview facility failed to report incident that threatened the safety or health of resident. This poses a potential health or safety risk to residents in care.

Official plan of correction

Facility will submit incident that occurred on 9/17/21 to CCL by 10/18/21.

Deadline recorded: Oct 18, 2021. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.312(d)

Regulation authority

HSC

What the official deficiency says

1569.312(d) Being aware of the resident's general whereabouts, although the resident may travel independently in the community. Based on review of incident report and interview with Administrator, this requirement has not been met as evidence by: It was reported R1 went into another residents room, climbed over the air conditioning unit that was against the window, cut the screen with a key that was in his possession and climbed over the widow and got out. R1's physician report states R1 may not leave facility unassisted . This is a potential risk to the health and safety of residents in care.

Official plan of correction

CItation cleared during inspection. Conducted staff training and checked all windows. Will initiate 15 minute checks on all new resident admissions, instead of every 30 minute.

Deadline recorded: Sep 23, 2021. A deadline is not proof that correction was completed.