Hazardous items and storageType A
- Official classification
- Type A
- 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 and Admin observation, the licensee did not comply with the section cited above in that drawer containing sharps accessible to residents and kitchen cabinet under sink contained disinfectants and cleaning supplies accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 10/28/2025 Plan of Correction Facility to ensure all sharps and disinfectants are inaccessible to residents. Admin to submit picture of repaired lock on drawer and locking function present on cabinet under sink by plan of correction due date
Staffing, personnel, and trainingType B
- 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, the licensee did not comply with the section cited above in that S1 and S2 did not have a Health Screen and/or 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: 10/28/2025 Plan of Correction Facility to submit proof of Health Screen and TB clearance for S1 and S2 by plan of correction due date.
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(a)(1)
- 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. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. 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 urine puddle present in bath off kitchen, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 10/28/2025 Plan of Correction Facility to submit LIC9098 self-certifying they will keep facility in safe and sanitary conditions at all times, by plan of correction due date.
Licensing and administrationType B
- 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 record review, the licensee did not comply with the section cited above in that S3 did not have current 1st Aid/CPR on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/04/2025 Plan of Correction Facility to submit proof of current 1st Aid/CPR for S3 by plan of correction due date.
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 Admin record review, the licensee did not comply with the section cited above in that S1, S2, S3, and S4 did not have required training on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/04/2025 Plan of Correction Facility to submit training certificates for S1, S2, S3, and S4 by plan of correction due date.