OAKWOOD MEMORY & SENIOR CARE

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, the licensee did not comply with the section cited above in 1 out of 5 staff files reviewed and observed missing some of the required annual training hours which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2026 Plan of Correction Licensee to submit proof that Staff 1 (S1) has completed all of the required annual training hours to CCL by POC due date of 09/11/2026.

Official classification

Type B

Official code

1569.69(a)(2)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. 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 2 out of 5 staff files reviewed and observed missing proof of completion for some of the required annual training hours which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2026 Plan of Correction Licensee to submit proof that Staff 1 (S1) and Staff 3 (S3) have completed all of the required annual medication training hours to CCL by POC due date of 09/11/2026.

Official classification

Type B

Official code

87463(h)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. 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 1 out of 5 resident files reviewed and observed missing a current physician's report within the last 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2026 Plan of Correction Licensee to submit proof of a current physician's report for Resident 2 (R2) to the CCL by POC due date of 09/11/2026.

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 3 out of 5 resident records reviewed and observed missing a current care plan updated and reviewed within the last 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/11/2026 Plan of Correction Licensee to submit updated care plans for Residents 2, 3, and 5 (R2, R3, and R5) to CCL by POC due date of 09/11/2026.

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 comply with the section cited above in ensuring that the required logs are mainitaned and available for inspection by the Departmetn for the required quartlery disaster drills which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/04/2026 Plan of Correction Administrator to submit proof of a current diaster drill being conducted in the facility on every shift to the Department by the POC due date of 09/04/2026.

Official classification

Type B

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on documents obtained and interviews conducted, the Licensee did not ensure that R1 took their medication as directed per their physicians orders which posed a potential health, safety, and/or personal rights risk to residents in care.

Official plan of correction

Licensee to submit proof of a medication administration re-training of all staff giving medications to CCL by POC due date 08/07/2026.

Deadline recorded: Aug 7, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(c)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records:(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not have documentation of required staff training as required. This poses a potential Health Safety or Personal rights risk to residents in care.

Official plan of correction

Licensee reviewed staff training records and had all staff complete their required annual training. POC cleared at time of visit.

Deadline recorded: Jan 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by having a storage closet unlocked wht cleaning solutions, disinfectants and other toxins accessible which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 08/26/2023 Plan of Correction Manager had staff change the batteries for the lock during the visit. Deficiency cleared during visit.

Official classification

Type B

Official code

87303(e)(6)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by having a leaking toilet and sink in the common area restroom not maintained in working order which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/01/2023 Plan of Correction Manager/Administrator agreed to have the toilet and sink repaired and provide CCL with a copy of the invoice no later than the POC date.

Official classification

Type B

Official code

87412(a)

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: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above by not having the Administrators personnel record not at the facility which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/01/2023 Plan of Correction Manager/Administrator agreed to maintaine a copy of the Administrator personnel record at the facility. Manager/Administrator agreed to read the regulation and submit self certification to CCL no later than the POC date.

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by improperly storing food (meat chicken and ground beef) in a dirty freezer which poses health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/01/2023 Plan of Correction Manager/Administrator agreed to dispose of all food (meat, chicken and ground beef) improperly stored in the freezer. Clean the freezer. Manager/Administrator will conduct in-service for the facility cooks and provide CCL with a copy of the in-service attendance sheet, receipt of new meat purchased and photos of the clean freezer and packaged meat chicken and ground beef no later than the POC date.

Official classification

Type B

Official code

87506(a)

Regulation authority

CCR

What the official deficiency says

87506(a) Resident Records. 87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. ***Based on statements made, this requirement not met as evidenced by: On or about 11/26/2022, S1 could not access resident’s records from locked office. This posed a potential risk to the health of the resident.

Official plan of correction

Administration will submit a written plan to CCL that documents how the facility will ensure compliance with 87506 going forward. Plan to be submitted to CCL by POC date in order to clear the deficiency.

Deadline recorded: May 16, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(6)

Regulation authority

CCR

What the official deficiency says

87464(f)(6) Basic Services. (Basic services shall at a minimum include) Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. ****Based upon statements, this requirement not met as evidenced by: Facility refused to return R1 to facility when R1 was medically cleared to return. This posed an immediate risk to R1’s health and welfare.

Official plan of correction

Administration will review 87464 and 87224 and submit a signed and dated declaration to CCL that outlines how facility will comply with the requirement of the regulations going forward. Declaration to be submitted by POC date in order to clear the deficiency.

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

Official classification

Type B

Official code

87224(d)(1)

Regulation authority

CCR

What the official deficiency says

87224(d)(1)(D) Eviction procedures. …In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court….***Based on statements and lack of documents, this requirement not met as evidenced by: Facility refused R1’s return to facility without fully complying with eviction procedures. This posed a potential risk to R1’s personal rights.

Official plan of correction

Administration will review 87464 and 87224 and submit a signed and dated declaration to CCL that outlines how facility will comply with the requirement of the regulations going forward. Declaration to be submitted by POC date in order to clear the deficiency.

Deadline recorded: Apr 14, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Deficient Practice Statement Based on todays inspection LPA observed 2 of 12 resident bedroom sliding door with a chest of drawers by the side of the door, which limits the amount of space available for a resident to exit safely. LPA also observed resident R1s sliding door does not open, LPA attempted with staff S2. Door appears to be jammed which poses an immediate health, safety or personal rights risk to persons in care. A civil penalty for $500.00 was applied during today's inspection for Fire Safety violation- Zero Tolerance.

Official plan of correction

POC Due Date: 08/20/2022 Plan of Correction During visit the door was un-jammed, but does not lock. Facility to send proof resident R1s sliding door is able to open and close properly and resident R2, R3 sliding door area is clear and move dresser near exit door. Facility to send in written plan on how they will stay in compliance, staff training to ensure staff know requirements and fire safety protocols in ensuring all exit doors are not obstructed or unable to open. POC due date for written statement due 8/20/2022 and staff training 8/22/2022 to LPA A Canela

Official classification

Type B

Official code

87303(i)(1)(A)

Regulation authority

CCR

What the official deficiency says

87303(i)(1)(A)(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit. This requirement is not met as evidenced by: Deficient Practice Statement Based on today's visit observation and review with Office Manager S1, the licensee did not comply with the section cited above in all resident bedrooms for 12 out of 12 resident pull cords were not working and when pulled, it did not alert staff as the main monitor was not operational during todays inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/31/2022 Plan of Correction For Maintenance of Operation 87303(i)(1)(A) Facility to send in proof they have contacted a company or service to fix resident room pull cords and send in written plan how facility will stay in compliance. POC due date 8/31/2022 to LPA A Canela