VILLA CAPRI

Official classification

Type A

Official code

87465(a)(2)

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… (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met as evidenced by: Based on LPA interview and record review, the licensee did not comply with the section cited above in that facility refused to adminsiter R1's physician prescribed medication which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to submit written policy indicating how the facility will meet the requirements of following physicians' medication orders to meet the necessary medical needs of residents.

Deadline recorded: Jul 3, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident, The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: LPA's investigation, R1 was observed to have a change in condition, on 8/18/25, Physician was faxed about R1's changes observed, but there was no follow-up after this date till 8/24/25 at 10:20am, per record reviews. RP was not notified per file reviews, obtained information, and interviews, until 8/27/25 that resident had a change of condition. This is a personal rights risk to resident in care.

Official plan of correction

Licensee to ensure all observed changes in residents are followed-up on when notifying resident's Physician, until the resident changes have been addressed. Ensure responsible parties are notified as required by regulation when changes are observed. Hold an in-service training with your staff regarding this requirement by regulation, " Observation of the Resident " Ensure staff understand the policy of observations of the resident, including documenting what has been done on notifications, what is being done, any changes in monitoring of the resident/care plan updates, and any follow-up needed. Submit proof of training and facility's future compliance by 9/15/25.

Deadline recorded: Sep 15, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities- In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Per review of records, interviews with staff, S1 and S2, and interviews with other related parties, it was identified that staff (S4, S5) inappropriately handled (R1) when trying to provide incontinent care to them, and R1 was refusing care from the staff. (R1) reacted by screaming and kicking at staff when they handled R1 inappropriately. Staff didn't use a different approach and/or stepping away and allowing some time to the resident to be agreeable to the incontinent care needed. This is a risk to residents personal rights.

Official plan of correction

Licensee/Administrator to ensure all caregiving staff in memory care/journey care unit have " Resident Rightd/Personal Rights " training, ensure both staff, S4 & S5 are included. Submit proof of training, include attendees, date/time spent, topics covered, and qualified trainer's name/title. POC due 3/31/25.

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

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465(a)(4) Incidental Medical and Dental Care- The licensee shall assist residents with self-administered medications as needed. This requirement was not as evidenced by: LPAs record reviews, interviews, and observations, Facility policy states that medication refills are to be ordered seven days prior to running out. R1's care plan states that R1's Representative is to be notified a, minimum of two weeks in advance for refills. R1 missed 8 doses of Medication Order #1, and has been provided medication order #2 outside of dosage hours, and given for sleep/insomnia which is not per the Dr's Order. This is a risk to residents rights & health & safety. Civil Penalty assessed at $250 for repeat violation within 12 months, LIC421FC.

Official plan of correction

Licensee/Administrator to ensure all residents receive their medications as prescribed by the Physician. Submit a plan on how the facility will ensure that R1's medications are ordered/filled in a timely manner, and that PRN medications are provided to the resident per dosage instructions on Doctor's Orders, including time frame given, and reason for giving the medication. Hold an in-service training with all medication staff regarding refills/orders in a timely manner, record keeping, and Dr's instruction Orders on PRNs. Submit plan regarding medications as stated above and on plan regarding facility's future compliance. POC due 1/28/25. *Submit proof of training by 2/7/25.

Deadline recorded: Jan 28, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465(a)(4) Incidental Medical and Dental Care-A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self-administered medications as needed. This requirement was not as evidenced by: LPAs record reviews, interviews, and observations, Facility policy states that medication refills are to be ordered seven days prior to running out. R1's care plan states that RP is to be notified when medications need to be filled, minimum of two weeks in advance. R1's last dose of their powdered mix medication was 12/16/24, and today, 12/17, R1 missed the AM dose and will miss the pm dose due to the medication is out, and is just now on order, waiting to be filled, per interviews with staff and other related parties. This is a risk to residents health & safety and personal rights.

Official plan of correction

Licensee/Administrator to ensure all residents receive their medications as prescribed by the Physician. Submit a plan on how the facility will ensure that R1's medications are ordered/filled in a timely manner, ensuring the two week notice is sent out to the RP of R1, and maintaining necessary records to ensure compliance with regulations. Maintain all medication records accurately and keep them up to date. Hold an in-service training with all medication staff regarding refills/orders in a timely manner, and record keeping. Submit plan regarding medications as stated above and discussion of facility's future compliance. POC due 12/18/24. *Submit proof of training by 12/23/24.

Deadline recorded: Dec 18, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625

Regulation authority

CCR

What the official deficiency says

87625 (b)(1)(2)(3 Managed Incontinence-)In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered. Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. Health & Wellness (H & W) Director Jennifer Haney stated that facility caregivers are to check on the resident every two hours, and change the resident as needed; The resident has a companion with them for part-time hours, and some of the facility caregivers checked a couple times on the resident, to find the companion had already changed R1. Some of the facility caregivers had stopped checking on R1 due to thinking the resident was being provided incontinent care by the resident's private companion. This is a risk to resident's personal rights.

Official plan of correction

Licensee to ensure an inservice is conducted with all staff regarding incontinent care services to residents. Submit plan of future compliance with this regulation, ensuring staff are checking on resident and changing resident timely. Submit proof of training. All POC documentation is due 2/15/24.

Deadline recorded: Feb 15, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

87465(a)(4) Incidental Medical and Dental Care- The licensee shall assist residents with self- administered medications as needed. This requirement was not met as evidenced by: The LPA's review of records, interviews, investigation revealed that the facility didn't refill resident's medication in a timely manner, Medication was ordered 4/3, and resident's responsible party had to go buy the medication on 4/5/23 for the resident. This is a health and safety risk and/or a personal rights risk to residents in care.

Official plan of correction

DEFICIENCY CLEARED TODAY-9/5/23. LICENSEE HELD AN IN-SERVICE TRAINING ON FACILITY'S MEDICATION POLICY & PROCEDURES, ON 7/13/23, REGARDING THE INCIDENT OF R1'S MEDICATION NOT BEING FILLED TIMELY FOR THE RESIDENT AS REQUESTED/REQUIRED. POC CLEARED.

Deadline recorded: Sep 6, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents- In addition to the rights in Section 87468.1, Personal Rights of Residents: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Per LPA's review of records, interviews with staff, and other related parties, resident rang call bell/pendant for assistance on 5/20, with no response till 24 minutes later; & 6/27 resident rang call bell/pendant for assistance and no response till 25 minutes later. This is a risk to resident health & safety and/or personal rights. Civil Penalty assessed in the amount of $250.see LIC421FC.

Official plan of correction

Licensee to ensure all staff are responding to resident call bell/pendants in a timely manner when ringing for assistance. Hold an in-service training with all staff on facility's signal system, Call Bell/Pendant Policy and Procedures. Submit plan of correction , and proof of training by 9/15/23.

Deadline recorded: Sep 15, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(4) Additional Personal Rights of Residents- In addition to the rights in Section 87468.1, Personal Rights of Residents:To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Per investigation, Resident waited an hour for assistance after requesting a med-tech, R1 had requested S3/staff to call for a med-tech for them. S3 never called for a med-tech. R1 called on their own for a med-tech to assist them after waiting an hour. This is a risk to residents personal rights and/or a risk to resident's health & safety.

Official plan of correction

Licensee/Administrator to have an in-service with all staff regarding " residents personal rights " and that staff are to not violate these rights at any time. Proof of training to include, Trainer, Topics, Date/Time Spent and Attendees. Submit plan of correction, and proof of training by 8/18/23. POC due 8/18/23.

Deadline recorded: Aug 18, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

Maintenance and Operation 87303€(2) 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 and not more than 120 degree F . This requirement was not met as evidenced by: LPA toured with the Administrator and Maintenace Director, hot water was checked on both florrs and in meory care, 122.F, 121.5F, and 123.4F , this is not within regulation.This is an immediate health and safety risk to residents in care

Official plan of correction

Licensee/Administrator to ensure the facilty's hot water heater/boiler(s) are turned down and monitor the hot water to be within regulation requirement, no lower than 105F and no higher than 120F. Submit a week, 5 day log, of the hot water checks by 6/15/23. Submit plan of correction by 6/9/2023.

Deadline recorded: Jun 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(9)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements 87555(b)(9) The following food service requirements shall apply: Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement was not met as evidenced by: LPA observed that two large boxes of lentil beans they were opened and were not covered and stored appropriately, a large box of rice was open and was not covered and stored appropriately;These items were not covered appropriately to protect the safety and acceptability necessary to prevent contamination; This is an immediate health and safety risk to residents in care

Official plan of correction

License/Administrator to hold an in-service training with all kitchen staff regarding facility’s storage of food, food preparation, and food services to protect the safety and acceptability necessary to prevent contamination. Submit plan of correction in how the facility will correct the deficiency and maintain future compliance with this regulation. Proof of training to include trainer, topics, date, time . spent, attendees, and employee signatures; Submit proof of training by 6/15/23.. Submit plan of correction by 6/9/23

Deadline recorded: Jun 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309(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 wasn't met as evidenced by: LPA observed that the beauty salon in assisted living was unlocked with no staff inside, this left poisons/chemicals, toxins, and other items in the salon accessible to residents in care. This is an immediate health and safety risk to residents in care

Official plan of correction

Licensee/Administrator to ensure all toxins/cleaners/chemicals and any other items that may pose a risk to residents, are locked up and inaccessible at all times. Hold an in-service with all staff regarding storage of above items. Submit proof of training by 6/15/23. Submit plan of correction by 6/9/23.

Deadline recorded: Jun 9, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by: LPA reviewed five(5) resident records. Resident three(R3) lacked an updated medical assessment as required by regulation. This is a potential health and safety risk to resident(s) in care.

Official plan of correction

Licensee/Administrator to ensure that all residents in memory care have required updated medical assessments, per regulations. Facility to obtain an updated medical assessment on R3; Please submit a copy of resident's medical assessment by POC due date of 6/30/23.

Deadline recorded: Jun 30, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(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: (4) The licensee shall assist residents with self-administered medications as needed. LPA reviewed two incident reports of staff not providing correct medication dosage and/or correct medication for the resident which resulted in two incidents of medication errors. This is a health and safety risk and/or personal rights violation to the residents in care.

Official plan of correction

POC CLEARED BY ADMINISTRATOR PROVIDING INSERVICE ON MEDICATION ASSITANCE TO STAFF THAT GAVE MEDICATION IN ERROR PER REPORTED INCIDENTS (2). Licensee to ensure that all residents are provided medication assistance by qualified staff and that medications are being provided per Physician's Orders. Administrator provided copies of training(s).

Deadline recorded: Oct 15, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

87303(e)(2)Maintenance and Operation: Water supplies and plumbing fixtures shall be maintained as follows: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 degree C) and not more than 120 degree F (49 degree C). This requirement was not met as evidenced by review of records, interviews with staff and other related parties. The hot water has had some incidents of running cold for 15 mins or so before getting warm and running hot intermittently. Currently a unit is affected by this, and Professional Plumber identified a part needing to be replaced. Currently, it is on order and will be installed as soon as received. Hot water may continue to run hot intermittently till repaired. Licensee has reported all hot water incidents. his is a risk to health and safety and/or a personal rights violation to residents in care.

Official plan of correction

POC CLEARED 10/14/2022-BY ADMINISTRATOR ADDRESSING THE HOT WATER ISSUE AS NEEDED AND REQUIRED. Currently, the hot water is running within regulation, and a part has been ordered to replace the " temperature Valve " per last Plumbing inspection service. This will be installed as soon as received. Licensee to continue to ensure there is a plan in place for hot water issues, as needed, for residents affected and/or provide information of other units that may be available to the resident with no hot water concerns. Ensure communication is made/notification to residents and responsible parties, of hot water issues, including any updates. Licensee to continue to ensure hot water to residents in the facility.

Deadline recorded: Oct 17, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87555(b)(9)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/09/2022 Plan of Correction The Licensee to submit plan on kitchen's food storage, including ensuring lableing of all stored food items and on fresh made food items, including information/training to all kitchen staff on what are the discard dates of all food items and maintenance plan to ensure food items are appropriately stored, and food items discared when required, ensuring all is done in a timely manner to help ensure health and safety of all residents in care-submit plan by 3/9/22. Submit proof of training by 3/18/22.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/09/2022 Plan of Correction Licensee to ensure all medications in the facility, residents and/or of staff, are locked up and secured at all times. Submit inservice-training of staff to review storage of all medications in the building, including staff's personal medications, are secured to help ensure the health and safety of all resients in care. Submit plan of completing the correction by 3/9/22. Follow up with proof of training, including all staff that attended-by 3/18/22.