GREEN ACRES MANOR

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 and Admin observation, the licensee did not comply with the section cited above in that Area designated as RV parking/garage on current facility sketch is also being utilized as a live-in staff room in which two (2) staff members sleep and reside, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/30/2026 Plan of Correction Facility to submit updated sketch and LIC 200 to CCL by plan of correction due date. LPA discussed with applicant licensee that no staff shall reside in garage or sleep in garage until fire clearance is granted. Once LIC200 and updated sketch are received CCL will send STD850 to fire department for fire clearance inspeciton.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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 LPA and Admin observation, the licensee did not comply with the section cited above in that water temperatures in sinks accessible to residents in care measured at 118.3 degrees F in room #11, 110.5 degrees F in room #10, 115.5 degrees F in room #8, 107.3 degrees F in long hall bathroom, 124.2 degrees F in bath next to room #2, and 124.7 in main shower room sink but 104.1 degrees F in main shower room shower head, 147.7 degrees F in room #3 and 149.5 degrees F in room #5. Water temperatures are therefore both over and under the allowable range of 105 to 120 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/30/2026 Plan of Correction Facility to submit plan to submit 3 day water temperature log showing rooms #3, #5, bath next to room #2 and main shower room sink and shower head are within 105-120 degrees F. 3 day water temperature log due no later than 7/13/26.

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 LPA and Admin observation, the licensee did not comply with the section cited above in that Fan switch in main shower room malfunctioning as it will not stay in the on position, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/13/2026 Plan of Correction Facility to submit to CCL video showing fan switch operational by plan of correction due date.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin record review, the licensee did not comply with the section cited above in that S1 and S2 did not have TB clearance on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/13/2026 Plan of Correction Facility to submit proof of TB clearance for S1 and S2 by plan of correction due date.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin observation, the licensee did not comply with the section cited above in that facility did not have at least a 2 day supply of perishable and 7 day supply of non-perishable food sufficient for 12 residents, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/13/2026 Plan of Correction Facility to submit 7 day menu for 12 residents, 3 meals for each day. Facility to submit receipts for food that will be used to make/cook menu items identified in 7 day menu by plan of correction due date.

Official classification

Type B

Official code

87463(h)(1)

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. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin record review, the licensee did not comply with the section cited above in that R1, R2, and R3 did not have current physician reports on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/13/2026 Plan of Correction Facility to submit current physician reports for R1, R2, and R3 by plan of correction due date.

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...shall deliver hot water...of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). Based on LPA observation, the licensee did not comply with the section cited above in that water temperatures in sinks accessible to residents in care measured at 103.1 degrees F in room #9/#10, 125.6 degrees F in room #2 but measured at 98.5 degrees F in shower faucet in long hall bathroom next to kitchen, and 103.4 in smaller long hall bathroom, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to submit 3 day water temperature log for sinks in facility showing temperature within 105-120 degrees F by plan of correction due date. Log to be accompanied by pictures of thermometer in running water with temperature reading visible in picture.

Deadline recorded: Mar 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(20)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b) The following food service requirements shall apply: (20) The ventilating systems in food preparation areas shall be maintained in working order and shall be operated when food is being prepared. Food preparation equipment shall be placed to provide aisles of sufficient width to permit easy movement of personnel, mobile equipment and supplies. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin observation, the licensee did not comply with the section cited above in that kitchen does not have operational ventilation, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction Facility to install ventilation system in kitchen above range/stove by plan of correction due date. Facility to submit to CCL pictures of system by plan of correction 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 LPA and Admin observation, the licensee did not comply with the section cited above in that kitchen range/stove has a broken oven door and burners which are not operating properly. Also, carpet at entrance to the long hall is heavily soiled and has a wearing hole that presents as a tripping hazard, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction Facility to repair or replace range/oven such that the burners and door are fully functional by plan of correction due date. Facility to repair or replace carpet such that it is sanitary and no longer presents as a tripping hazard by plan of correction due date.

Official classification

Type B

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 LPA observation, the licensee did not comply with the section cited above in that water temperatures in sinks accessible to residents in care measured at 128.4 degrees F in room #12 and 124.7 degrees F in room #15 but measured at 94.3 degrees F in jack and jill style bath in room #9/#10 and 87.8 degrees F in main bathroom next to kitchen, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction Facility to submit 2 week water temperature log for each sink in facility showing temperature within 105-120 degrees F by plan of ocrrection due date. Log to be accompanied by pictures of thermomter in running water with temperature reading visible in picture as well - or- facility can install a water temperature regulator and provide CCL with copy of work order and paid invoice.

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, the licensee did not comply with the section cited above in that laundry room in long hall has cabinet that stores cleaning solutions and toxins; however, cabinet framing is heavily worn down such that the locking feature does not always securely lock, leaving toxins accessible to residents, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/31/2025 Plan of Correction Facility to repair or replace cabinet in laundry room such that the locking feature consistently locks. Facility to provide picture of repaired/replaced cabinet by plan of correction due date.

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. This requirement was not met by licensee as evidenced by: Based on LPA observation ants present in resident room in facility, which poses a potential health, safety, and personal rights risk to residents in care.

Official plan of correction

Facility to submit service work order from pest control company along with paid invoice by plan of correction due date.

Deadline recorded: Aug 23, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that S4 did not have proof of TB clearance on Health Screen or in file. which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/03/2024 Plan of Correction Facility to submit to CCL picture of completed TB test and clearance for S4 by plan of correction due date.

Official classification

Type B

Official code

87307(a)(3)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed for each resident, except that married couples may be provided with one appropriate sized bed. Each bed shall be equipped with good springs, a clean and comfortable mattress, available pillow(s) and lightweight warm bedding. Fillings and covers for mattresses and pillows shall be flame retardant. Rubber sheeting shall be provided when necessary. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above in that R1 in room #10 did not have bed present. R1's pre-appraisal, care plan, and physician's report did not note a preference or an approval for not having a bed which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/27/2024 Plan of Correction Facility to submit to CCL either a care plan update or a note from the family or responsible party for R1 indicating their desire and approval for R1 to not have a bed in their room, by plan of correction due date.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Admin observation and record review, the licensee did not comply with the section cited above inthat S1, S2, and S3 do not have current 1st Aid/CPR certifications on file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/05/2024 Plan of Correction Facility to submit to CCL pictures of current 1st Aid/CPR cards or certificates for S1, S2, and S3 by plan of correction due date.

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 Admin observation, the licensee did not comply with the section cited above in that S2, S3, and S5 did not have current annual training on file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/11/2024 Plan of Correction Facility to submit screenshots of completed training on vendor website for S2, S3, and S5 by plan of correction due date. (Admin to inquire with vendor as to how to print a training log for each respective employee showing total number of hours completed with completion 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 LPA, caregiver, and Admin observation, the licensee did not comply with the section cited above in that pantry had tomatoes stored in bin that had black spots, white film, and bluish greenish fuzzy film surrounded by white substance, storage bin containing canned goods had sticky brown film and brown substance with orange film and spots on some cans, open ziploc of lentils, lentils spilling out into bin, macaroni and cheese box with best when used by date of 3/20/2023 which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/27/2024 Plan of Correction Facility discarded tomatoes and macaroni and cheese box. Facility to submit pictures of food storage bin that is clean and free from films and sticky substances by plan of correction due date.

Official classification

Type B

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA, caregiver, and Admin observation, the licensee did not comply with the section cited above in that kitchen had block of knives open and accessible when half door to kitchen is left open. LPA observed on three occasions during inspection that half door to kitchen was left unlocked, making knives accessible to residents in care which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/27/2024 Plan of Correction Facility to submit LIC9098 self-certifying knives have been moved and are now stored in a locking cabinet or drawer by plan of correction due date.

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 in 2 out of 2 laundry rooms were left unlocked and toxins were 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: 06/23/2023 Plan of Correction Licensee shall submit a Plan of Correction which includes a Self-Certification LIC 9098 understanding the regulations. In addition, Licensee shall conduct staff training and provide a statement to licensing on how this regulation will be followed in the future.

Official classification

Type A

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation/file review, the licensee did not comply with the section cited above in 3 out of 4 staff members not having an Active First Aid/CPR Card. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/23/2023 Plan of Correction Licensee shall submit a Plan of Correction which includes a Self-Certification LIC 9098 understanding the regulations. In addition, Licensee shall show proof of staff members scheduled for First Aid/CPR training and providing a statement on how this regulation will be followed.

Official classification

Type A

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation/record review, the licensee did not comply with the section cited above in 2 out of 7 residents did not have the medication on record which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/23/2023 Plan of Correction Licensee shall submit a Plan of Correction which will include an LIC 9098-Self Certification and to ensure that ALL resident medications are reviewed and the doctors notified if there are any medications missing, discontinuations needed or any updates to the Medication Administration of the residents in care. In addition, Licensee shall provide a written statement on how this regulation will be followed in the future.