Background checksType A
- Official classification
- Type A
- 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 LPA and Licensee observation, the licensee did not comply with the section cited above in S3,S4,S5 are not associated to facility Guardian Roster which poses an immediate health, safety or personal rights risk to persons in care
Official plan of correction
POC Due Date: 08/05/2026 Plan of Correction Licensee to associate all staff to Guardian Roster and submit to CCL facility Guardian roster print out showing all staff as being associated to the facility by Plan of Correction due date 8/05/2026.
Medication handling and storageType A
- Official classification
- Type A
- Official code
- 87465(h)(2)
- Regulation authority
- CCR
What the official deficiency says
(h) The following requirements shall apply to medications which are centrally stored: (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: Deficient Practice Statement Based on LPA and Licensee observation the licensee did not comply with the section cited above in LPA observed drawer in bathroom accessible to residents to have an unsecured drawer with medications including vitamins,ibuprofen, and nasal spray. In addition, LPA observed unsecured medication in unlocked kitchen cabinet which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/05/2026 Plan of Correction Licensee to submit LIC9098 with proof of picture that all medication has been locked and stored properly by plan of correction due date 8/04/2026.
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 LPA and licensee obervation the licensee did not comply with the section cited above in that Personnel Records were not present at facility available for LPA to review including LIC503 Health Screening and LIC501 Personnel Record for all staff which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/11/2026 Plan of Correction Licensee to submit LIC503 and LIC501 for all staff to CCLD by plan of correction due date 8/11/2026.
Staffing, personnel, and trainingType B
- 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 LPA and Licensee review and observation the licensee did not comply with the section cited above in Staff S1,S2 and S3 lacked required 20 hours annual training which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/11/2026 Plan of Correction Licensee to submit proof that staff have been signed up or in process of required 20 hour required training to CCL by plan of correction due date 8/11/2026
Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87506(a)
- Regulation authority
- CCR
What the official deficiency says
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Licensee observation and record review the licensee did not comply with the section cited above in R1,R2, were missing Needs and Service Plans, Reappraisal. R5 was missing all required paperwork which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/11/2026 Plan of Correction Licensee to submit all required missing paperwork for R1,R2 and R5 to CCL by Plan of Correction due date 8/11/2026
Admission, assessment, and evictionType B
- Official classification
- Type B
- Official code
- 87458(c)(1)
- Regulation authority
- CCR
What the official deficiency says
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Licensee observation and record review , the licensee did not comply with the section cited above in R1, R2,R3 and R5 were missing Medical Assessment and TB Clearance which posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/11/2026 Plan of Correction Licensee to submit Heath Screening and Tb results to CCL by Plan of Correction Due date 8/11/2026.