FIVE PALMS CARE HOME

Official classification

Type A

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's/Licensee observation, record review and interview with Licensee, the licensee did not comply with the section cited above by not making provisions to ensure construction area was free of hazards which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2026 Plan of Correction Licensee agreed to submit written plan to CCL and proof that resident's responsible parties were notified by POC due date 4/3/26.

Official classification

Type A

Official code

87303(e)(3)

Regulation authority

CCR

What the official deficiency says

(3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA/Licensee observed water temperature in resident's bathroom measured at 158.5, 158.5, 160.7 degrees F in the main building which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2026 Plan of Correction Licensee/Administrator to ensure hot water is maintain between 105F and no higher than 120F. Licensee turned down the hot water heater and will monitor for a period of one week ensuring hot water is within regulation. Licensee agreed to submit self-certification form ensuring that water measures will be kept within regulation to clear the deficiency by POC due date 4/3/26.

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's/Licensee observation, records review and interviews with Administrator, the facility failed to leave medication in original container pre-pouring into more than 24 hour container which poses an immediate health and safety risk to resident in care.

Official plan of correction

POC Due Date: 04/03/2026 Plan of Correction Licensee/Administrator agrees to stop pre-pouring medication greater than a 24 hr period. Submit self certification (LIC9098) of above to CCL by POC 4/3/2026.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

(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. 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 having construction crew members present in the hallway near lateral exit making loud noise and having unlocked materials including sharps replacing the hallway flooring, while there were seven residents in the adjacent living room playing bingo, there were no posters alerting residents about construction zone, Licensee did not notify the Department and resident's responsible parties which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction Licensee agrees to submit a written plan to CCL and proof that resident's responsible parties were notified by POC due date 4/17/26.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. 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 seven out of ten residents (R1, R2, R3, R4, R5, R6 & R7) care plans were not updated 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: 04/17/2026 Plan of Correction Licensee agrees to arrange a meeting with parties outlined in regulation 87463(a) and update appraisals for noted residents. Licensee will submit self certification (LIC9098) that all appraisals have been updated per regulation 87463 by POC due date, 4/17/26 to clear the citation.

Official classification

Type B

Official code

87508(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information: 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 a current register of resident's form on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/17/2026 Plan of Correction Facility to submit a current Register of Residents to CCL by POC date in order to clear the deficiency and agrees to keep it current going forward in compliance with regulation 87508(a)

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

Type B - 87457 Pre-Admission Appraisal 87457 Pre-Admission Appraisal: (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria… This requirement is not met as evidenced by: Based on records reviewed, Licensee did not complete an evaluation of resident’s condition prior to admission and keep it in the file which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will submit a plan of how they will ensure resident’s pre-admission appraisals are completed prior to resident’s admission including their individual service needs. Plan of future compliance to be submitted to CCL by POC due date.

Deadline recorded: Nov 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

Type B: 87211(a)(2) 87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports..: (2) Occurrences, such as...major accidents which threaten the welfare, safety or health of residents..., shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This rerquirement was not met as evidence by: Based on LPA’s record review and interview, the facility failed to submit an incident report when R1 went AWOL on 8/31/25 which possessed a potential health and safety risk to residents in care.

Official plan of correction

Licensee agrees to review regulations pertaining to reporting requirements. Licensee agrees to submit a plan to ensure incident reports are submitted to CCL and responsible party within 7 days, submit plan to CCL by POC. **Civil Penalty assessed in total amount of $250.00 for repeated violation within 12 months.

Deadline recorded: Nov 26, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports..: (2) Occurrences, such as...major accidents which threaten the welfare, safety or health of residents..., shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This rerquirement was not met as evidence by: Based on LPA's observations, records review and interview with Administrator, the facility did not notify CCL within 24 hours of occurreence of R1's death which poses a potential risk to the health & safety of the residents.

Official plan of correction

Licensee to provide training to all Staff reviewing the Regulation: 87211 Reporting Requirements. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures. Training to be submitted to CCL for review and approval by POC due date.

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

Official classification

Type B

Official code

87506(d)(e)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, & copy upon demand during normal business hours…(e) Original records...shall be retained for a min of 3 years following termination of service to the resident. This requirement was not met as evidence by: Based on LPA's record review and interview with Licensee, the facility did not have available R1's records when requested by CCL, which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee agreed to review regulation 87506 regarding resident records and will retain at the facility resident's records to be available to the licensing agency for review as stated per regulation. Licensee will submit documents requested by POC due date.

Deadline recorded: Oct 31, 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/Licensee observation, interview and record review, the licensee did not comply with the section cited above in one out of eight residents is bedridden which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/18/2025 Plan of Correction Licensee agrees to obtain physician's report for resident (R4) to get updated ambulatory status corrected on LIC602. The facility will submit self-certification as proof that item was corrected to CCL by POC due date.

Official classification

Type A

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (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's/Licensee observation and interview, the licensee did not comply with the section cited above in having adequate supply of perishables available for at least two days for a minimum of 15 residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/18/2025 Plan of Correction Licensee agrees to submit proof of purchase of food by 4/18/25 to CCL to ensure adequate food supply is onsite of the facility. Self certification to be submitted to CCL by POC date of 04/18/2025.

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 in LPAs and administrator found LPAs observed refrigerators and behind stove to be soiled and unclean also food not properly stored open in the refrigerator and freezer, food was not covered with signs of freezer burn, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/01/2024 Plan of Correction Licensee agrees to keep all food stored properly and staff cook to complete safe food and handling practices also to ensure all areas remain clean in kitchen and throughout the facility. Licensee to submit LIC9098 certifying that the plan of correction for training and food storage policy..

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. 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 LPAs and administrator observed 1 exit to be obstructed in C1 room, medical equipment and wheelchair found in front of emergency exit, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/01/2024 Plan of Correction Licensee agrees to keep all passageways free from obstruction. Staff moved the medical equipment and wheelchairaway from exit door allowing passage. Licensee to submit LIC9098 certifying that the passageway will be kept free from obstructions.

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 that LPAs and administrator observed paint and insect killer outside and accessible to clients, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/01/2024 Plan of Correction Licensee agrees to keep all toxins and harmfuk chemicals will be locked up and inaccesible to clients. Staff locked up all chemicals passage. . Licensee to submit LIC9098 certifying that all toxins, chemicals, and poisons will be locked up and/or inaccessible to clients.

Official classification

Type B

Official code

1569.69

Regulation authority

HSC

What the official deficiency says

This requirement is not met as evidenced by: (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: (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. Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that 4 of 5 staff records did not contain documentation of completed training records as required. Annual training for dementia, hospice, and medication annual training have not been completed, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/07/2024 Plan of Correction Licensee agrees to ensure all training has been completed and will ensure all required training will be completed anually as required by regualtion. Licensee will provide proof of completion by POC and to submit LIC9098 certifying that all training is completed and will completed on time moving forward.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) alcohol…cleaning supplies and disinfectants. This requirement was not met, as evidenced by: Based on observations made by LPA/Administrator, the facility staff did not ensure that two bottles of alcohol antiseptic 80% topical solution hand sanitizer were on the shelf of unlocked closet located in the hallway accessible to residents in care, which poses an immediate risk to the health and safety of residents in care.

Official plan of correction

Facility to send in written plan they understand regulation and how it will be followed. The facility will remove items that should not be accessible by POC due date.

Deadline recorded: Nov 17, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement has not been met as evidence by: Based on LPA's/staff observation that exit door located in resident's room#8 was blocked with a recliner. Staff immediately removed recliner obstructing the exit from the passageway, which poses an immediate risk to the health and safety of residents in care.

Official plan of correction

Licensee agrees to keep all passageways free from obstruction. Staff moved the recliner away from exit door allowing passage. Licensee to submit LIC9098 certifying that the passageway will be kept free from obstructions.

Deadline recorded: Oct 28, 2023. 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

87303 Maintenance and Operation (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. Based on LPA's/staff observations and interviews with Licensee the heater in the back of the building is not working properly, which is an immediate risk to the health and safety of residents in care.

Official plan of correction

Licensee agrees to provide proof of service that heater in the back is working properly by POC due date.

Deadline recorded: Oct 28, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

00000

Regulation authority

CCR

What the official deficiency says

***AMENDED DOCUMENT - no deficiencies were cited. 80061 Reporting Requirements (a)Each licensee shall furnish to the licensing agency reports as required by the Dprt...a report shall be made to the licensing agency within the agency's next working day during its normal business hours....(1)(A) Death of any client from any cause. This requirement has not been met as evidence by: ***AMENDED DOCUMENT - no deficiencies were cited. Based on LPA’s records review and interviews conducted with staff, facility did not ensure that CCL was notified of death of R1 on 7/31/22. Facility submitted a death report for R1 on 8/3/22 which poses a potential health & safety risk to residents in care.

Official plan of correction

***AMENDED DOCUMENT - no deficiencies were cited Facility to submit written statement acknowledging that they have read and understand " Reporting Requirements " by POC due date

Deadline recorded: Aug 26, 2022. A deadline is not proof that correction was completed.