BETSY'S II RCFE

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

1569.625 Staff training; legislative findings; contents (b)(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... This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that one (1) of (5) staff members (S2) did not complete their 2025 annual training which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit proof that staff member S2 has completed their annual training to Community Care Licensing (CCL) by POC due date of 6/3/2026.

Deadline recorded: Jun 3, 2026. 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

87411 Personnel Requirements – General (f) All personnel, including the licensee and administrator, shall be in good 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... This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that staff member S2 did not have a medical assessment or proof of a negative TB test in their personal record which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit proof that staff member S2 has received a medical assessment and proof of a negative TB test to CCL by POC due date of 6/3/2026.

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

Official classification

Type B

Official code

87468(b)(1)(A)

Regulation authority

CCR

What the official deficiency says

87468 Personal Rights (b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1... This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that residents R1 & R2 did not have signed personal rights documents in their records which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit signed personal rights document for residents R1 & R2 to Community Care Licensing (CCL) by POC due date of 5/27/2026.

Deadline recorded: May 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

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... This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that resident R2 did not have a completed and signed pre-placement appraisal in their records which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit a completed and signed pre-placement appraisal for resident R2 to CCL by POC due date of 5/27/2026.

Deadline recorded: May 27, 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... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that a prescribed medication was left unsecured in the storage room in the common area of the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit proof that all staff members have undergone medication management training after 5/6/2026 to Community Care Licensing by POC due date of 5/7/2026.

Deadline recorded: May 7, 2026. A deadline is not proof that correction was completed.

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 observation, the licensee did not comply with the section cited above in that the kitchen cabinets were observed to be very dirty with some caked in dried grease or sauces which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/03/2026 Plan of Correction Licensee or Administrator to provide photographs showing the kitchen cabinets have been cleaned throughly to Community Care Licensing by POC due date of 6/3/2026.

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 observation, the licensee did not comply with the section cited above in that paint and clearing products were observed in the storage room in the common area and in the sink cabinet next to the storage room which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/03/2026 Plan of Correction Licensee or Administrator to submit an LIC 9098 self certification that all toxic items will be kept inaccessable to residents to CCL by POC due date of 6/3/2026.

Official classification

Type B

Official code

87355(e)(3)

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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 that Staff Member S1 was not associated to the facility in the Guardian Background Check System which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/20/2026 Plan of Correction Licensee or Administrator to associate staff member S1 to the facility in the Guardian Background Check System before they work again in the facility and to provide proof of association to the facility or submit an LIC 9098 stating that staff member S1 no longer works at the facility to Community Care Licensing (CCL) by POC due date of 5/20/2026.

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. 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 Room number one (1) was observed with a strong urine odor which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 05/17/2026 Plan of Correction Licensee or Administrator to submit an LIC 9098 self certifying that Room one (1) has been cleaned and no longer smells of urine to CCL by POC 6/17/2026.

Official classification

Type B

Official code

1569.655(a)

Regulation authority

HSC

What the official deficiency says

1569.655 Increase in fee rates for elderly residents; 60 days’ written notice standing amount of reasons for increase;...(a) If a licensee of a residential care facility for the elderly increases the rates,... the licensee shall provide no less than 60 days’ prior written notice. This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that resident R1 was not given the regulated sixty (60) day advanced notice of the rate increase which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee or administrator will submit an LIC 9098 self certifying that they have read and understand Health and Safety Code (HSC) Regulation 1569.655. Licensee will further provide a list of all residents, and notifications provided to those residents who received a rate increase or level of care increase in 2024, 2025 and 2026 to Community Care Licensing by POC due date of 2/18/2026.

Deadline recorded: Feb 18, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87506(b)(8)

Regulation authority

CCR

What the official deficiency says

87506 Resident Records (b)Each resident’s record shall contain at least the following information: (8)Names, address, and telephone numbers of the resident’s representative, as defined in Section 87101(r), to be notified in case of accident, death, or other emergency. This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that 1 of 3 residents records (for R1) did not contain Emergency Contact Information which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit a signed LIC 601 Identification and Emergency Information form for resident R1 to Community Care Licensing (CCL) by POC due date of 1/27/2026.

Deadline recorded: Jan 27, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

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... This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that 1 of 3 residents files (for resident R2) did not contain an LIC 603 Preplacement Appraisal Information form which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit a signed LIC 603 Preplacement Appraisal Information for Resident R2 to Community Care Licensing by POC due date of 1/27/2026.

Deadline recorded: Jan 27, 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

87465Incidental 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... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that over the counter PRN medication was observed to be unsecured in Room #2 which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

licensee will submit an LIC 9098 Self Certification stating that ALL medications will not be left unsecured by POC due date of 1/14/2026. Additionally, Licensee will re-train ALL staff members in Medication Management. Proof of training to be submitted to Community Care Licensing by no later than 1/28/2026.

Deadline recorded: Jan 14, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(1)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing..(1)There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication... This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that PRN medication was provided to Resident R3 without a licensed medical professional's order or prescription, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will submit an LIC 9098 Self Certification stating that ALL medications will not be left unsecured by POC due date of 1/14/2026. Additionally, Licensee will re-train ALL staff members in Medication Management. Proof of training to be submitted to Community Care Licensing by no later than 1/28/2026.

Deadline recorded: Jan 14, 2026. 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 Storage Space and Access (a)Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances...and other similar items which could pose a danger to residents are in locked storage...This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that unsecured toxins and insulin syringes were observed in a storage room which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will submit an LIC 9098 Proof of Correction self certifying that all toxins and insulin syringes will kept secured at the facility in the future to Community Care Licensing (CCL) by POC due date of 1/14/2026.

Deadline recorded: Jan 14, 2026. 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 Storage Space and Access (a)Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances...and other similar items which could pose a danger to residents are in locked storage...This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that unsecured toxins were observed in a residents bathroom, the laundry room and the storage room which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will submit an LIC 9098 Proof of Correction self certifying that all toxins will kept secured at the facility in the future to Community Care Licensing (CCL) by POC due date of 10/27/2025.

Deadline recorded: Oct 27, 2025. 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... This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that a medication cabinet in common area, next to the storage room was unlocked, which poses a immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will submit LIC9098 to CCL self certifying that all medications will be kept in a safe and locked place. Licensee will further self certify that it has been discussed with all employees that both prescription and PRN medications be secured at all times. This to be done by POC Due Date of 10/27/2025.

Deadline recorded: Oct 27, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(e)(1)(A)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (e)The licensee shall supervise residents as needed...when residents are in proximity to or when there is use of the following items:(1)... heaters,...and other heating devices.(A)Heating devices shall have protective mechanisms...in order to reduce the risk of burns or fire. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that in the common area, next to the storage room, a parabolic dish heater was observed to not have a protective screen which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee removed heater during today's inspection. Deficiency cleared.

Deadline recorded: Oct 27, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a)All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person... This requirement is not met as evidenced by Based on record review, the licensee did not comply with the section cited above in that the facility does not have a currently certified Administrator which poses an immediate health, safety or personal rights risk to persons in care

Official plan of correction

Licensee will provide the documents required to make a currently certified administrator the active Administrator of the facility to Community Care Licensing by the POC due date of 10/27/2025.

Deadline recorded: Oct 27, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(23)

Regulation authority

CCR

What the official deficiency says

87555:General Food Service Requirements(b)The following ...requirements shall apply: (23) All readily perishable foods... capable of supporting...progressive growth of micro-organisms which can cause food infections..shall be stored...at appropriate temperatures. This requirement is not met as evidenced by:Based on observation, the licensee did not comply with the section cited above in that that two (2) condiments that were required to be refrigerated after opening, were left unrefrigerated in a kitchen cabinet. which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will submit an LIC 9098 self certifying that they have trained all staff in food service safety to Community Care Licensing by POC due date of 11/14/2025.

Deadline recorded: Nov 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(25)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements (b)The following food service requirements shall apply: (25)Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in In the cabinet immediately outside of the kitchen area, across from a bathroom, food products and cleaning products were observed to be stored together. which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to store all cleaning products away from food products. Licensee will submit an LIC 9098 self certifying that they have trained all staff in food service safety to Community Care Licensing by POC due date of 11/14/2025.

Deadline recorded: Nov 14, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211Reporting Requirements (a)Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...for the resident within seven days...This report shall include the resident's name, age....(A) Death of any resident... This requirement is not met as evidenced by:Based on observation and record review, the licensee did not comply with the section cited above in that an LIC 624 Unusual Incident report for R4 and an LIC 9186 Client Death Report for R5 was not sent to CCL which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit both the an LIC 624 Unusual Incident report for R4 and an LIC 9186 Client Death Report for R5. Licensee will also submit an LIC 9098 Proof of correction form self certifying that in the future they will submit all forms per CCR 87211 in the required time frame to Community Care Licensing by POC due date of 11/7/2025.

Deadline recorded: Nov 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a)All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in that the facility does not have a currently certified Administrator which poses an immediate health, safety or personal rights risk to persons in care

Official plan of correction

Licensee will provide the documents required to make a currently certified administrator the active Administrator of the facility to Community Care Licensing by the POC due date of 8/25/2025.

Deadline recorded: Aug 25, 2025. 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... This requirement not met by licensee as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that the magnetic key for a medication cabinet in common area, next to the storage room was unsecured next to the cabinet, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will submit LIC9098 to CCL self certifying that all medications wll be kept in a safe and locked place. Licensse will further self certify that it has been discussed with all employees that both prescription and PRN medications be secured at all times. This to be done by POC Due Date of 8/25/2025.

Deadline recorded: Aug 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (a)All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in that the facility does not have a currently certified Administrator which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will provide the documents required to make a currently certified administrator the active Administrator of the facility to Community Care Licensing by the POC due date of 8/6/2025.

Deadline recorded: Aug 6, 2025. 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... This requirement not met by licensee as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that a medication cabinet in common area, next to the storage room was unlocked, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will submit LIC9098 to CCL self certifying that all medications wll be kept in a safe and locked place. Licensse will further self certify that it has been discussed with all employees that both prescription and PRN medications be secured at all times. This do be done by POC Due Date of 6/12/2025.

Deadline recorded: Jun 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

§1569.625 Staff training; legislative findings; contents (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that S1, S2, S3 and S4 did not have required hours of training on file, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit plan to conduct training for S1, S2, S3 and S4 in the required number of hours required by regulation, based on staff members'' start dates, by plan of correction due date. Training reocrds to be submitted no later than 7/3/20255.

Deadline recorded: Jun 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (a) The pre-admission appraisal...shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first...For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement not met by licensee as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that R2, R3 and R5 all did not have current appraisals on file, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit completed current reappraisals for R2, R3 and R5 to Community Care Licensing by POC due date of 7/2/2025.

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

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements – General (C)(1)Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that staff members S2 and S4 did not have current First Aid training certification in their files which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to Submit proof that staff members S2 and S4 have been certified in First Aid to Community Care Licensing by POC due date of 7/2/2025.

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

Official classification

Type B

Official code

87555(b)(23)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. 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 that six (6) various dressings and sauces that were required to be refrigerated after opening, were left unrefrigerated in a kitchen cabinet. which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/02/2025 Plan of Correction Licensee will submit an LIC 9098 self certifying that they have trained all staff in food service safety to Community Care Licensing by POC due date of 7/2/2025.

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... This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that prescription and PRN medications were accessible to residents in rooms 10, 8, 9, and in dining and laundry room, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee will submit LIC9098 to CCL self certifying that all medications wll be kept in a safe and locked place. Licensse will further self certify that it has been discussed with all employees that both prescription and PRN medications be secured at all times.

Deadline recorded: Apr 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

§1569.625 Staff training; legislative findings; contents (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that S1, S2 and S3 did not required hours of training on file, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit plan to conduct training for S1, S2, and S3 in the required number of hours required by regulation, based on staff members'' start dates, by plan of correction due date. Training reocrds to be submitted no later than 5/2/25.

Deadline recorded: Apr 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87618(b)(3)(E)

Regulation authority

CCR

What the official deficiency says

87618 Oxygen Administration ...the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation oxygen tank in storage closet not secured to wall or in cradle, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Admin immediately removed oxygen tank from storage closet and placed in a cradle in resident's room. Deficiency cleared.

Deadline recorded: May 1, 2025. 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

87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health...Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test...This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that S3, S4, and S5 did not have Health Screens on file, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licnesee to submit pictures of or completed Health Screens for S3, S4, and S5, to CCL by plan of correction due date.

Deadline recorded: May 1, 2025. 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...This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPAs observed intake vent in front hallway covered in dust/dirt and a grease like substance, which poses an immeidate health, safety or personal rights risk to persons in care.

Official plan of correction

Photos of cleaned vent to be submitted no later than 5/2/25.

Deadline recorded: May 1, 2025. 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

87303 Maintenance and Operation (e)Water supplies and plumbing fixtures shall be maintained... (2)Faucets used by residents...shall deliver hot water...of not less than 105 degree F and not more than 120 degree F. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that which poses an immeidate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to submit plan to record water temperature for 2 weeks showing water tempertaure within regulation by plan of correction due date. Two week water log to be submitted no later than 5/9/25. Log to be submitted with picture of thermotoer in running water with temperature visible.

Deadline recorded: Apr 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(f)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (f)All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPAs observed unsealed/ tied trash bags full of soiled incontinence briefs in laundry room with eggs, which poses an potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee immediately discarded trash bags. Deficiency cleared.

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

Official classification

Type B

Official code

87555(b)(23)

Regulation authority

CCR

What the official deficiency says

87555 General Food Service Requirements(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation large container of eggs left on a shelf unrefrigerated in laundry room, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee immediately removed eggs and put them inside the house in refrigerator. Deficiency cleared.

Deadline recorded: Apr 25, 2025. 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 Storage Space and Access (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 not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that door to laundry room from facility unlocked; LPAs observed unsecured cleaning products in metal cabinet found unlocked in laundry room, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit LIC9098 self-certifying laundry room door will remain locked and/or keep all cleaning supplies and toxins inaccessible to residents.

Deadline recorded: Apr 25, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

87463 Reappraisals (a) The pre-admission appraisal...shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first...For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that R1, R2, R3, R4, and R5 all did not have current appraisals on file, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit completed current reappraisals for R1, R2, R3, R4, and R5 by 5/2/25

Deadline recorded: May 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency ...(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 requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that licensee did not submit to CCL an Incident Report for R3 or R4 after they experienced incidents that required one be submitted, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit LIC9098 self-certifying they will submit incident reports to CCL for all residents when required by regulation by plan of correction due date.

Deadline recorded: May 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

87625 Managed Incontinence (b)...the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPAs observed an extremely strong urine odor in room five (5) and odor in room two [2B], which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit LIC9098 self-certifying they will keep residents and the facility free from incontinence odors by plan of correction due date.

Deadline recorded: May 1, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(4)

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: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that R3's prescription medication had it's label partially removed, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Licensee to submit LIC908 self certifying that they will not alter prescription medication labels by plan of correction due date.

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

Official classification

Type A

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

1569.625(b)(2)...training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training...four hours of which shall be specific to postural supports, restricted health conditions, and hospice care.. This requirement was not met by licensee as evidenced by: failure to satifsy plan of correction for this regulation deficeincy issued on 10/30/2024, which poses an immediate health, safety, and/or personal rights risk to resident in care.

Official plan of correction

Facility to submit proof of staff enrollment for all staff on CCO website to CCL by plan of correction due date. Licensee to submit completed annual staff training totalling 20 hours no later than 11/27/24. civil penalty assessed

Deadline recorded: Nov 14, 2024. 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

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be... (2) Faucets used by residents ...shall deliver hot water. Hot water temperature controls shall be maintained ... 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 by licensee as evidenced by: water temperature over 120 degrees F in two [2] out of five [5] sinks measured, which poses an immediate health, safety, and/or personal rights risk to resident in care.

Official plan of correction

Facility to submit plan to regulate water tempertaure such that it remains within the regualtion requirements and submit phopgraphic proof of complaince with regualtion. Licensee agrees to submit photographs of water temperature readings with therometer itself and its reading present in picture. Picture to include number of room and/or location of where water temperature is being measured. Licensee agrees to take at least two readings per day, in rooms identified in 11/13/24 report, beginning on 11/14/24. Licensee will come to CCL Santa Rosa regional office to show all water temperature reading pictures on 11/26/24. civil penalty assessed.

Deadline recorded: Nov 14, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

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 records reviewed, the Licensee did not comply with the section cited above. 1 of 4 staff members were missing proof of their health screening report and proof of negative TB. This poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 06/20/2024 Plan of Correction Licensee to submit health screening report and proof of negative TB test by POC due date of 06/20/2024.

Official classification

Type A

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 records reviewed, the Licensee did not comply with the section cited above. 3 of 4 staff members were missing proof of their annual 2023 training. This poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 06/20/2024 Plan of Correction Licensee to submit written plan outlining how they will ensure annual training is completed timely by POC due date of 06/20/2024. Licensee to submit proof of online training for all staff by POC due date of 06/30/2024.

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 observations made, the Licensee did not comply with the section cited above. LPA observed the following toxins, hazards, and medications to be accessible: unlocked knife drawer, Disinfectant cleaner, bed bug repellent, blood sugar monitors and sharps, 3 bottles of cough syrup, 1 bottle of Pepto Bismol and 1 bottle of Tums. This poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 06/20/2024 Plan of Correction Licensee to submit self certification that training for Regulation 87705(f)(2) will be conducted for all staff by POC due date of 06/20/2024. Training to review items that are inaccessible to residents in care. Licensee to conduct Inservice Training that includes the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 06/30/2024.

Official classification

Type B

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 observations made, the Licensee did not comply with the section cited above. 2 of 2 staff members were found to be background cleared but not associated to the facility as required. This poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 06/30/2024 Plan of Correction Licensee to ensure that all staff members are associated to the facility per regulation. Licensee to submit proof of Guardian Roster with associated staff members by POC due date of 06/30/2024.

Official classification

Type B

Official code

87465(h)(4)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations made, the Licensee did not comply with the section cited above. 4 of 9 resident medications reviewed were not centrally stored as required. LPA observed that some medications were not logged or incorrectly documented. This poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 06/30/2024 Plan of Correction Licensee to conduct in-service training for all staff to review how to document centrally store medications. Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 06/30/2024.

Official classification

Type B

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 observations made, the Licensee did not comply with the section cited above. LPA observed pre-poured medications located in a locked cabinet. This poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 06/30/2024 Plan of Correction Licensee to conduct in-service training for all staff reviewing that pre-poured medications are not allowed. Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 06/30/2024.

Official classification

Type B

Official code

87456(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on observations made, the Licensee did not comply with the section cited above. 1 of 9 residents did not have a completed Pre-Appraisal as required. This poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 06/30/2024 Plan of Correction Licensee to complete pre-appraisal for resident and submit a copy to Community Care Licensing (CCL) by POC due date of 06/30/2024.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) 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 is not met as evidenced by: Deficient Practice Statement Based on observations made, the Licensee did not comply with the section cited above. 2 of 9 residents did not have an updated Physician's Report as required. These two residents had a dementia diagnosis. This poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 06/30/2024 Plan of Correction Licensee to schedule appointments for both residents so they can have a new assessment completed. Licensee to provide an update on their statuses by POC due date of 06/30/2024. Copies of updated physician reports to be submitted Community Care Licensing (CCL) once received.

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 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 is not met as evidenced by: Deficient Practice Statement Based on observations made, the Licensee did not comply with the section cited above. 7 of 13 facility sinks were found to be out of Title 22 regulations of 105F to 120F measuring between 120.5F and 126.8F. This poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 06/30/2024 Plan of Correction Licensee to submit a water temperature log for the next 10 days. Temperature to be checked twice a day for all sinks starting on 06/20/2024. Log to include location of sink and time documented. Log to be submitted to CCL for review and approval by POC due date 06/30/2024.

Official classification

Type B

Official code

87467(a)

Regulation authority

CCR

What the official deficiency says

87467 Resident Participation in Decisionmaking (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. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the Licensee did not comply with the section cited above. 9 of 9 resident files did not have a needs and services plan. This poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 06/30/2024 Plan of Correction Licensee to complete all needs and services plans and submit copies to CCL by POC due date of 06/30/2024.

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 record review, the licensee did not comply with the section cited above in two out of two staff not having documented annual training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/30/2023 Plan of Correction Licensee agrees to update the training logs to reflect all required trainings and provide the required annual training to their existing staff and submit proof of training to CCL no later than POC due date, 6/30/2023.

Official classification

Type B

Official code

1569.69(a)

Regulation authority

HSC

What the official deficiency says

(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: This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in two out of two staff not having documented annual training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/30/2023 Plan of Correction Licensee agrees to submit proof of medication training to CCL no later than POC due date, 6/30/2023.