MIRABEL LODGE

Official classification

Type A

Official code

87465(a)(1)

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. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement not met by licensee as evidenced by: Based on LPA record review and interview, the licensee did not comply with the section cited above in that staff did not provide the care that was required for R1, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

***Amended...LPA returned to remove civil penalties in the amount of $1000. Facility to arrange for personal rights training and what medical professionals are best suited to assess residents needs with local ombudsman by plan of correction due date. Training to take place no later than 5/8/26, licensee to attaned training as well as all care staff and Administrative Assistant. Additonally, facility to submit to CCL a written defined policy outlining the facility protocols for those incidents where residents need medical attention as noted by after visit summaries, Emergency Medical Services personnel or reports, doctors or any medical professional reports or suggestions, and staff observation. Written policy to include chain of command for reporting and identification of staff repsonsible for each action idenified in chain of command. Written policy due by plan of correction due date. Lastly, facility to submit proof of staff training on Observation of a Resident, regulation 87466 and the chain of command policy. Training to be completed no later than 5/1/26.

Deadline recorded: Apr 24, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care(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: Based on LPA observation the licensee did not comply with the section cited above in that keys to medication room and prescription Thick-It left unattended and accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to self-certify on a LIC9098 that they will ensure all medications and keys to medication remain inaccessible to all those not authorized to administer medications.

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

Official classification

Type B

Official code

1569.69

Regulation authority

HSC

What the official deficiency says

§1569.69 Employees assisting residents with self-administration of medication; training requirements (a)(1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. This requirement not met by licensee as evidenced by: Based on LPA record review, current documentation of medication training or medication shadow training not present for S3, which poses an potential health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to submit proof of completed required medication training including shadow training for S3 by plan of correction due date.

Deadline recorded: Jan 3, 2026. 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...for the provision of adequate services. This requirement not met by licensee as evidenced by: Based on LPA record review and interview, the licensee did not comply with the section cited above in that facility could not show that R1 received timely medical attention, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to conduct in-service training on personal rights and providing timely medical care. Facility to submit plan to conduct training by plan of correction due date. Training to be completed no later than 1/5/25. Training logs submitted to show trainer, attendees, date, subject matter and duration.

Deadline recorded: Dec 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(d)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration provided all of the following requirements are met...This requirement not met by licensee as evidenced by: Based on LPA record review and interview, the licensee did not comply with the section cited above in that facility does not use PRN MARs for documenting the administration of PRN medication, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to conduct an one hour duration of in- service training for all staff on medication management by plan of correction due date. Training logs submitted to show trainer, attendees, date, subject matter and duration.

Deadline recorded: Dec 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(A)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish... (1)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 in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This requirement not met by licensee as evidenced by: Based on LPA record review and interview, the licensee did not comply with the section cited above in that facility could not show that facility did not notify R1's PCP via a method of communication shown to be received which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Faciliy to self-certify on a LIC9098 that they will maintain compiance with all reporting requierments as outlined in regualtion 87211

Deadline recorded: Dec 31, 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...for the provision of adequate services. This requirement not met by licensee as evidenced by: Based on LPA record review and interview, the licensee did not comply with the section cited above in that R3 did not receive timely medical care, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to conduct in-service training on personal rights and providing timely medical care. Facility to submit plan to conduct training by plan of correction due date. Training to be completed no later than 1/5/26. Training logs submitted to show trainer, attendees, date, subject matter and duration.

Deadline recorded: Dec 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.269(a)(1)

Regulation authority

HSC

What the official deficiency says

Type A - §1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other people. This requirement has not been met as evidence by: Based on LPA’s observations and interviews with staff, the facility staff assisted residents in care using inappropriate comments and not notifying the residents of their intentions when performing transfers, which poses an immediate risk to the health and safety of clients in care.

Official plan of correction

The facility will conduct all staff training regarding personal rights. Training subject, date of training and signed attendance forms to be submitted to CCL by POC due date.

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

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

Type A - 87465 (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication...the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on records review and interviews with staff, there is a written order from a physician dated 12/20/24 indicating the need for gait belt shall be utilized daily to assist R1 with transfers, but staff (S1 & S2) interviews revealed that they do not use gait belts with none of residents in care, which poses an immediate risk to the health and safety of clients in care

Official plan of correction

The facility will conduct all staff training regarding use of assistive devices & postural support management. Training subject, date of training and signed attendance forms to be submitted to CCL by POC due date. **Civil Penalty assessed in total amount of $250.00 for repeated violation within 12 months.

Deadline recorded: Aug 2, 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

(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. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate 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 is not met as evidenced by: Deficient Practice Statement Based on LPAs/staff observation, interview and record review, the licensee did not comply with the section cited above in all fire extinguishers were expired as February 2024 and two out of nine residents are bedridden which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/14/2025 Plan of Correction Administrative Assistant immedicately contacted Fire Department to follow up on the reason why the fire extinguishers were not charged. Also, the facility faxed over physician's report for two residents (R1 and R2) to get updated ambulatory status corrected on LIC602s. The facility will submit self-certification as proof that both items were corrected to CCL by POC due date.

Official classification

Type A

Official code

87303(i)(1)

Regulation authority

CCR

What the official deficiency says

(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: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs/staff observation and interview, the licensee did not comply with the section cited above in one out of three call alert staff did not repond timely to call monitors due to system was off which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/14/2025 Plan of Correction Administrative Assistant turned on the alert system and staff was able to get alerts about residents needing help while in their room. The facility will submit a written plan about how they will ensure the system is maintained on to alert staff by POC due date.

Official classification

Type A

Official code

87355(e)

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: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs/staff observation, interview and record review, the licensee did not comply with the section cited above in 2 out of 27 staff were cleared, but they were not associated to facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/14/2025 Plan of Correction Administrative Assistant immediately associated staff to their roster through Guardian. THe facility will submit LIC9098 self-certification form certifying that they will monito their facility roster regularly to prevent staff not been associated to the facility timely.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's/staff observation, interview and record review, the licensee did not comply with the section cited above in two out of five residents were not given their medications as prescribed which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/14/2025 Plan of Correction Administrative Assistant agrees to review medication of all residents to ensure that medication are given to residents as prescribed by their doctor and will submit a self-certification form acknowledging the review of medications to CCL by POC due date,

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(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 requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs/staff observation and interview, the licensee did not comply with the section cited above in bathroom toilet in room 7 found cracked and staff placed out of order sign, sticky floor observed throughout facility and trash can with no lid was observed in bathroom room 20, Bathroom in room 12 observed with feces on floor in shared bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/27/2025 Plan of Correction Administrative Assistant agreed to submit pictures as proof of repairs/clean areas of concern to CCL by POC due date.

Official classification

Type B

Official code

87307(a)(3)(D)

Regulation authority

CCR

What the official deficiency says

(D) Hygiene items of general use such as soap and toilet paper. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs/staff observation and interview, the licensee did not comply with the section cited above in No toilet paper or paper towels found in residents room which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/27/2025 Plan of Correction The facility will submit a written plan regarding how they will resolve this recurrent issue about toilet paper and paper towels to CCL by POC due date.

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's/staff observation and interview, the licensee did not comply with the section cited above by having unpacked dry goods with no expiration dates noted which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/27/2025 Plan of Correction ADministrativa Assistant contacted their food supply vendor to inquire about the reasons of the missing information on food packaged delivered. The facility agreed to write down expiration dates on food packages and will submit pictures of dates written on goods that did not have expiration dates on them to CCL by POC due date.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

Type A- 87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. Based on interviews with staff and records review Licensee did not ensure proper management of medication by staff did not give R1’s their dosage of Seroquel 150mg as prescribed by their physician’s, which poses an immediate risk to the health & safety of residents in care.

Official plan of correction

Licensee agrees to retrain staff on medication management from an outside vendor & will write a plan to ensure resident medications will be dispensed to residents in care as prescribed by their physician daily. Licensee to submit the updated plan to CCL by POC due date to clear the citation. **Immediate Civil Penalty assessed in the amount of $250.

Deadline recorded: Aug 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87203

Regulation authority

CCR

What the official deficiency says

Type A 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 has not been met as evidence by: Based on records obtained and interviews conducted with licensee, the licensee did not comply by not ensuring the ability of residents to exit, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility will ensure all exits are always free from obstructions. Licensee will send in written statement to CCL that they understand and will be complying to regulation 87203. POC due date. **Immediate Civil Penalty assessed in the amount of $500.

Deadline recorded: May 24, 2024. 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

(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. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate 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 is not met as evidenced by: Deficient Practice Statement Based on LPA's/Licensee observation and interview, the licensee did not comply with the section cited above in communal area and in one resident bedroom, there was a wheel chair stored in front of sliding glass door, obstructing the exit.which poses an immediate health, safety or personal rights risk to persons in care. As a result of the fire clearance violation, an immediate civil penalty in the amount of $500 is issued today.

Official plan of correction

POC Due Date: 04/19/2024 Plan of Correction LIcensee removed the wheelchairs immediately. Licensee will submit a written plan how they will ensure that nothing blocks the exits in the future to clear the citation by POC due date.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs/Licensee observation and interviews the licensee did not comply with the section above two rusty shower chairs, holes in resident bedroom screen, two faucets broken in resident bedrooms, urine smell in resident room, ceiling fans observed covered with thick layer of dust, cement ramp not flush with cement walkway where residents walk, sticky floors in dining area, trash cans without lids/covers, lights not working, and broken electrical plate in resident room, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2024 Plan of Correction Licensee will submit a schedule plan of needed repairs that will be corrected in a timely manner by POC due date to clear the citation. LPA will return to ensure that repairs had been 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 LPAs/Licensee measured hot water in one resident bedroom tested was 131.6 F degrees which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2024 Plan of Correction Licensee will turn down the water heater and will implement a log to document water temperature is measured within regulation and will submit log sample to CCL by POC due date to clear the citation.

Official classification

Type A

Official code

87303(i)(1)

Regulation authority

CCR

What the official deficiency says

(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: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs/Licensee observed auditory emergency signal system not working or lacking in 4 out of the 12 client bedrooms inspected, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2024 Plan of Correction Liecensee will develop a policy regarding how the facility will ensure all required emergency pendant/call bell alarm system are working properly and staff are following facility's policy/procedures/staffing to ensure a timely response in answering resident's emergency alarms to ensure that resident's needs, health & safety are being addressed appropriately and within regulations to CCL by POC due date to clear the citation.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's/Licensee observation, records review and interview with Licensee, the licensee did not comply with the section cited above in spot check of medications were conducted and 4 out 5 residents (R1, R2, R3 & R4) medications were not given to residents according to their physician's order, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2024 Plan of Correction Licensee will submit written plan which addresses how facility will ensure compliance with 87465(c)(2) going forward. To be submitted to CCL by POC date in order to clear the deficiency.

Official classification

Type A

Official code

87705(f)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs/Licensee observed storage cabinets containing potentially toxic chemicals unlocked in two communal restrooms. Aerosol hair products in drawer were observed in communal area and readily accessible to residents. Additionally, the laundry room door was observed unlocked and unattended with cleaning and laundry chemicals readily accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/19/2024 Plan of Correction Facility to send in written statement on how they will stay in compliance to CCL by POC due date to clear the citation.

Official classification

Type B

Official code

87219(a)

Regulation authority

CCR

What the official deficiency says

(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs/Licensee had a discussion regarding activities were not occurring during scheduled times. The licensee did not comply with the section cited above by not having any activities during LPA's visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2024 Plan of Correction The licensee agrees to write a plan to designate a back up staff that could conduct activities as specified on the regulation for residents when designated staff is busy. Plan with designated staff responsible for activities will be submitted to CCL by POC due date to clear the deficiency.

Official classification

Type B

Official code

87555(a)

Regulation authority

CCR

What the official deficiency says

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs/Licensee observed expired canned goods, unpacked dry good not with expiration dates noted, and uncovered prepared foods in the walk-in refrigerator. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2024 Plan of Correction Licensee will develop and implement a system in how they will ensure to properly store food to ensure quality of food and safety of residents. Licensee will submit written policy as proof of correction to CCL by POC due date.

Official classification

Type B

Official code

87467(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in 4 out of five residents (R1, R2, R3 and R4) needs their care plan to be updated, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2024 Plan of Correction Licensee to update and complete resident's Needs & Services Plan, with appropriate signatures of Licensee and Resident or resident's responsible party. Facility to submit LIC9098 form ensuring compliance with regulation to CCL by POC due date.

Official classification

Type B

Official code

87705(c)(3)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 5 staff (S1, S2 & S3) do not have annual required training hours completed, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2024 Plan of Correction Licensee to conduct staff required training. Licensee agrees to submit written self-certification LIC9098 by POC due date ensuring that staff have completed required training hours to clear the citation.

Official classification

Type B

Official code

87705(j)

Regulation authority

CCR

What the official deficiency says

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's/Licensee observation and interview, the licensee did not comply with the section cited above in auditory alarms on several resident bedroom sliding glass door exits were not activated, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2024 Plan of Correction Facility to send in written statement they understand regulation and how they will ensure they stay in compliance to CCL by POC due date to clear the citation.

Official classification

Type B

Official code

87555(b)(6)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements:(6) In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above by not having dated menus on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/25/2024 Plan of Correction Licensee to ensure facility keeps track of meals that are served when they alter from what was planned. Licensee to submit self-certification form (LIC9098) notifying the Department that they are back in compliance with regulation by POC due date.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement has not been met as evidence by: Based on interviews with staff and records review Licensee did not ensure proper management of medication by medication technician staff (S1) who are responsible for medication management of all residents in care which poses an immediate risk to the health & safety of residents in care.

Official plan of correction

Licensee agrees to conduct a medication audit, retrain staff on medication management from an outside vendor & will write a plan to ensure resident medications are logged into the Centrally Stored Medication Records daily. Licensee to submit the updated plan to CCL by POC due date to clear the citation.

Deadline recorded: Jan 10, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above, LPA/lead staff observed missing face cover plate in room# 7, bathroom in room #6 has an out of order sign, there are two drawers missing in shared bathroom for room# 4 and 5 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2023 Plan of Correction Licensee/Administrator agrees to fix maintenance issues and will provide receipts of service to CCL by POC due date to clear deficiency.

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 comply with the section cited above in four out of six resident's bathrooms 123.8, 118.6, 121.6, 122.4, 108.1, and 127.9 degrees which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/24/2023 Plan of Correction Licensee/Administrator agrees to turn hot water heater lower, and send a written statement that hot water temperature will be checked once/month, temperature log will be taken daily for one week, and send LIC9098 to CCL by POC due date to clear defiency.

Official classification

Type B

Official code

87507(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA/Lead staff observation, interview and record review, the licensee did not comply with the section cited above in 29 out of 29 admission agreements were not updated after change of ownership indicating the changes including to the use of surveillance cameras in the common areas which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/07/2023 Plan of Correction Licensee/Administrator agrees to create an addendum indicating the change of ownership and use of surveillance cameras in the common areas. The addendum will be signed by residents or their responsible parties by POC due date to clear deficiency.