BETSY'S RESIDENTIAL CARE HOME

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care Services 87465 (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: Based on LPA and caregiver observation, the licensee did not comply with the section cited above in that there were pre-poured medications in kitchen drawer, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to self-certify on a LIC9098 they will immediately cease pre-pouring medications by plan of correction due date.

Deadline recorded: Apr 24, 2026. 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

Maintenance and Operation 87303(a) (a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by: Based on LPA, licensee and S1 observation, the licensee did not comply with the section cited above in that water heater closet has rodent droppings present, rodent droppings also observed by LPA, licensee, and caregiver outside in the garage on the same side as the refrigerator; additionally, an insulin syringe was found on the floor in the garage, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to submit plan to have rodent extermintor service completed by plan of correction due date. Rodent exterminator work order and paid invoice showing rodent droppings addressed and contained to be submitted to CCL no later than 5/1/26. Facility also to submit LIC9098 self-certifying they will keep all sharps in appropriate containers by plan of correction due date.

Deadline recorded: Apr 24, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…This requirement is not met by licensee as evidenced by: Based on LPA interview, facility does not currently have at least two [2] staff present on all shifts, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to submit plan to ensure all shifts have at least 2 staff present by plan of correction due date. Facility to submit current LIC500 showing at least 2 staff present on all shifts by no later than 2/18/26.

Deadline recorded: Feb 12, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(6)(C)

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: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (C) The drug name, strength and quantity. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and caregiver observation and record review, the licensee did not comply with the section cited above in that the following errors were observed on the CSML for R1: Vitamin C should be administered 2 times per day but listed on CSML as only one, Aspirin present on current orders but not listed on CSML, Multivitamin with iron listed on current orders but not listed on CSML, Senna listed on current order as 17.2 but listed as 8.6mg on CSML, insulin dose listed as 75 units in the morning and 40 units in the evening. Entry for 75 units in the morning present on CSML but not the 40 units in the evening, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/12/2026 Plan of Correction Facility to submit plan to conduct medication management training of at least 1 hours. Training to be completed by no later than 2/18/26. Training log to be submitted to CCL no later than 2/19/26.

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 and caregiver observation, the licensee did not comply with the section cited above in that there were pre-poured medications in kitchen drawer, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/12/2026 Plan of Correction Facility to self-certify on a LIC9098 they will immediately cease pre-pouring medications by plan of correction due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and caregier observation, the licensee did not comply with the section cited above in that water heater closet has rodent droppings present, rodent dropping also observed by LPA and caregiver outside in the garage on the same side as the refrigerator; additionally, an insulin syringe was found on the floor in the garage, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/25/2026 Plan of Correction Facility to submit rodent exterminator work order and paid invocie showing rodent droppings addressed and contained by plan of correction due date. Facility also to submit LIC9098 self-certfying they will keep all sharps in appropriate containers by plan of correction due date.

Official classification

Type B

Official code

87458(c)(1)(A)

Regulation authority

CCR

What the official deficiency says

(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited above in that R1 did not have TB clearance on file, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/25/2026 Plan of Correction Facility to submit proof of TB clearance for R1 by plan of correction due date.

Official classification

Type B

Official code

87465(c)(3)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine...own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided ...(3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement not met by licensee as evidenced by: based on LPA and caregiver observation PRN outcomesvand entry dates of PRN adminsitration for R2 not documented, which poses a potential health, safety or personal rights risk to residents.

Official plan of correction

Facility to self-certify that they will list outcomes for all PRNs administered for all residents by plan of correction due date.

Deadline recorded: Nov 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(6)

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:(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement not met by licensee as evidenced by: based on LPA and caregiver observation, Calcium Citrate-Vitamin D3 315mg-5mcg not listed on the CSML for R1, which poses a potential health, safety or personal rights risk to residents.

Official plan of correction

Facility to conduct at least 1 hr of medication management training for staff by plan of correction due date.

Deadline recorded: Nov 13, 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(a) Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator. This requirement not met as evidenced by: Based on LPA and and licensee interview and record review, the licensee did not comply with the section cited above in that Administrator does not have an actively current Administrator certificate or Administrator, which poses an immediate health, safety or personal rights risk to residents

Official plan of correction

Licensee to submit to CCL Adminsitrator paperwork for Administrator candidate once candidate is selected. Paperwork to include: LIC215, LIC500, LIC308, LIC501, detailed employment/education history, and copy of Admin certificate

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

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... This requirement is not met as evidenced by: Based on LPA and caregiver observations, the licensee did not comply with the section cited above in that S2 and S3 did not have the required number of training hours completed, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to submit current and completed training certificates in the requried number of hours by plan of correction due date.

Deadline recorded: Jul 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405(a) Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator. This requirement not met as evidenced by: Administrator does not have an actively current Administrator certificate. This poses an immediate health, safety or personal rights risk to residents

Official plan of correction

Administrator to submit copy of current Administrator certificate.

Deadline recorded: Jul 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(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: Deficient Practice Statement Based on LPAs observation and record review, the licensee did not comply with the section cited above in that three (3) of five (5) staff (S1, S2, S3) did not have First Aid which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/17/2025 Plan of Correction Facility to submit plan to have staff complete First Aid. Facility to submit proof of First Aid certificates for S1,S2,S3 by no later then 3/7/2025.

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 LPAs and licensee observations, the licensee did not comply with the section cited above in that Hallway floor outside of hall bathroom has water damages causing expansion of laminate flooring resulting in uneven walking surface. Floor bows inward under weight, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/07/2025 Plan of Correction Facility to submit video of repaired flooring bearing weight without bowing by Plan of Correction due date.

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 LPAs and licensee observations, the licensee did not comply with the section cited above in that resident room 2 had commode full of waste and urine, with very strong odor filling the room. LPAs observed resident room 4 to have strong odor from urine as well which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/21/2025 Plan of Correction Facility to submit LIC9098 self certifying that all waste and urine will be discarded promptly and properly. Additionally licensee will self certify that facility will remain free of incontince odors by Plan of Correction due date.

Official classification

Type A

Official code

87625(b)(2)

Regulation authority

CCR

What the official deficiency says

87625(b)(2) Managed Incontinence (b) In addition to Section 87611...the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night This requirement is not met as evidenced by: Based on evidence obtained during investigation, the licensee did not comply with the section cited above in that licensee did not ensure incontinence needs were met per hospice care plan, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to update care plan for resident per hospice care plan and send LIC500 showing sufficient staff to meet care and incontinence needs.

Deadline recorded: Aug 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87458(a)

Regulation authority

CCR

What the official deficiency says

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year... This requirement was not met by licensee as evidenced by: Based on LPA observation the Physician's Report for new resident R1 was not signed by a physician. Per LPA interview with licensee, the unsigned Physician's report is the only one retained by facility for R1, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to submit pictures of Physician's report for R1 that is signed by their physician by plan of correction due date.

Deadline recorded: May 30, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87208(a)

Regulation authority

CCR

What the official deficiency says

87208 Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation. This requirement was not met by licensee as evidenced by: Per agreement during office meeting with licensee on 3/29/2024, licensee was to review and submit facility's Plan of Operation. Licensee has not submitted Plan of Operation to CCL, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to submit to CCL the facility's Plan of Operation by plan of correction due date.

Deadline recorded: May 30, 2024. 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 (h) The following requirements shall apply to medications...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 med cart in living room was unlocked which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to submit to CCL a plan to train staff to properly store medications. Plan due by plan of correction due date. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 5/31/2024. Training log to include: name of trainer, name of course, staff attendees and hours completed. A civil penalty in the amount of $250 is being assessed for repeat violation within 12 months.

Deadline recorded: May 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

87705 (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication... cleaning supplies and disinfectants. This requirement was not met by licensee as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that the hallway closet containing toxins was unlocked and accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Facility to submit plan on how they will store toxins to be in compliance by plan of correction due date. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 5/31/2024. Training log to include: name of trainer, name of course, staff attendees and hours completed. A civil penalty in the amount of $250 is being assessed for repeat violation within 12 months.

Deadline recorded: May 17, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

87465 (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: Based on: LPA observation, the licensee did not comply with the section cited above as unlocked drawer in kitchen contained pre-poured medication. Due to Licensee’s failure to respond to and work with CCL's TSP to correct identified concerns, deficiencies are being re-cited.

Official plan of correction

Facility to train staff to properly store medications. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 6/6/2024. Training log to include: name of trainer, name of course, staff attendees, and hours completed.

Deadline recorded: Jun 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(f)(2)

Regulation authority

CCR

What the official deficiency says

87303(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens. This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that syringe for insulin was found accessible, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.

Official plan of correction

Facility to train staff to properly store syringes. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 6/6/2024. Training log to include: name of trainer, name of course, staff attendees and hours completed.

Deadline recorded: Jun 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

87412 (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening...This requirement is not met as evidenced by: Based on LPA record review, the licensee did not comply with the section cited above in that staff (S1) did not have health screen, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.

Official plan of correction

Facility to submit to CCL health screen with clear TB for S1 and S3 by plan of correction due date.

Deadline recorded: Jun 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

HSC 1569.625 (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually... This requirement is not met as evidenced by: Based on LPA record review, the licensee did not comply with the section cited above in that training records for staff not available, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.

Official plan of correction

Facility to submit proof of training to CCL for S1, S2, and S3 by plan of correction due date. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 6/6/2024. Training log to include: name of trainer, name of course, staff attendees and hours completed.

Deadline recorded: Jun 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(9)

Regulation authority

CCR

What the official deficiency says

87555(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: Based on LPA observation, the licensee did not comply with the section cited above in that opened food items in refrigerator were not covered or labeled, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.

Official plan of correction

Facility to conduct staff training on how to properly store opened food items. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 6/6/2024. Training log to include: name of trainer, name of course, staff attendees and hours completed.

Deadline recorded: Jun 6, 2024. 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(b) The following food service requirements shall apply: (23) All readily perishable foods...capable of supporting... growth of micro-organisms...shall be stored in covered containers at appropriate temperatures. 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 bowl of cooked pasta left out overnight, which posed a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.

Official plan of correction

Facility to conduct staff training on how to properly store cooked food items. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 6/6/2024. Training log to include: name of trainer, name of course, staff attendees and hours completed.

Deadline recorded: Jun 6, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705 (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that kitchen drawer containing sharp knives not locked, which poses/posed a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.

Official plan of correction

Facility to conduct staff training on how to properly store sharp knives and items that could danger residents by plan of correction due date. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 6/6/2024. Training log to include: name of trainer, name of course, staff attendees and hours completed.

Deadline recorded: Jun 6, 2024. 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

(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 responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Licnsee observation the licensee did not comply with the section cited above because: med cart in living room to be unlocked, all medication accessible to residents, unlocked drawer in kitchen contained: prescription Tramodal, unwrapped syringe, and pre-poured medication in dishes, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/09/2024 Plan of Correction Facility to submit to CCL a plan to train staff to properly store medications. Plan due by plan of correction dated of 2/9/2024. Training to be completed and log provided to CCL by no later than 2/16/2024

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 and Licensee observation, the licensee did not comply with the section cited above as LPA and Licensee observed unlocked drawer in kitchen to contain pre-poured medication in dishes. LPA and Licensee observed pillboxes in living room stacked on chair by the computer which contained medications, to be accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/09/2024 Plan of Correction Facility to submit to CCL a plan to train staff to properly store medications. Plan due by plan of correction dated of 2/9/2024. Training to be completed and log provided to CCL by no later than 2/16/2024

Official classification

Type A

Official code

87606(b)

Regulation authority

CCR

What the official deficiency says

(b) A facility shall notify the local fire jurisdiction within 48 hours of accepting or retaining any bedridden person, as specified in Health and Safety Code Section 1569.72(f). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA interview with Licensee, the licensee did not comply with the section cited above in that facility has one resident (R1) that is bedridden but facility does not have bedridden fire clearance and could not produce proof of notification to fire deptartment, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/09/2024 Plan of Correction Facility to produce proof of notification of bedridden status to Santa Rosa Fire Department by POC due date.

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 LPA and Licensee observation, the licensee did not comply with the section cited above in that a 64 ounce jug of bleach was accessible in the hallway shower which conained approximately 4 ounces remaining in the jug. Unlocked hallway closet had toxins accessible including acetone and disinfectants, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/09/2024 Plan of Correction Facility to submit plan on how they will store toxins to be in compliance with regualtion 87705(f)(2) by POC due date. Facility to complete staff training on proper storage of toxins and subnit to CCL training log no later than 2/16/2024. Facility to submit picture of locking closet doorknob.

Official classification

Type B

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 LPA and Licensee observation, the licensee did not comply with the section cited above in that a plastic container on side of house was filled with brown liquid and old tools covered in orange and brown spots, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/08/2024 Plan of Correction Facility cleared and cleaned bin during LPA inspection. Deficiency cleared.

Official classification

Type B

Official code

87303(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Licensee observation, the licensee did not comply with the section cited above in that syringe for insulin was found accessible in unlocked kitchen drawer. Syringe was unwrapped from packaging and possibly used, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/16/2024 Plan of Correction Facility to submit to CCL a plan to train staff to properly store syringes. Plan due by plan of correction date of 2/16/2024. Training to be completed and log provided to CCL by no later than 2/16/2024

Official classification

Type B

Official code

87303(f)(3)

Regulation authority

CCR

What the official deficiency says

(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Licensee observation, the licensee did not comply with the section cited above in that trash bins in residents rooms are not covered. Trash bin in resident room (R2) contained soiled brief for at least 2 days, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/16/2024 Plan of Correction Facility to submit to CCL pictures of trash bins fitted with appropriate lids by POC due date.

Official classification

Type B

Official code

87307(d)(2)

Regulation authority

CCR

What the official deficiency says

(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Licensee observation, the licensee did not comply with the section cited above in that the drywall/sheet rock is missing from around shower spigot and pipe(s) exposed in resident's shower (R3) in room #1 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/16/2024 Plan of Correction Facility to submit to CCL pictures of repaired shower spigot so that pipes are not exposed and the shower spigot works properly. Facility to submit pictures by POC due date.

Official classification

Type B

Official code

87412(a)(11)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited above in [1] out of [2t] staff (S1) did not have health screen, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/16/2024 Plan of Correction Facility to submit to CCL health screen with clear TB for S1 by POC due date,

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited above in [2] out of [2 ]staff (S1 and S2) which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/29/2024 Plan of Correction Facility to submit proof of training to CCL for S1 and S2 by POC due date. Training log must include name of course, hours completed, date completed, and trainer's name.

Official classification

Type B

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 LPA and Licensee observation, the licensee did not comply with the section cited above in that opened food items in refrigerator were not covered or labeled including a cake, half of a tomato, bowl of red substance, and a cup of brown liquid, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/16/2024 Plan of Correction Facility to conduct staff training on how to properly store opened food items. Facility to submit trainng log and materials used to administer training by POC due date.

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 onLPA and Licensee observation, the licensee did not comply with the section cited above in that a bowl of cooked pasta left out overnight and during the day previous at room temperature, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/16/2024 Plan of Correction Facility to conduct staff training on how to properly store cooked food items. Facility to submit trainng log and materials used to administer training by POC due date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation and Licensee record review, the licensee did not comply with the section cited above in that facility has not conducted quarterly disaster drill since 2020, as documented in disaster drill paperwork. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/16/2024 Plan of Correction Facility to conduct a drill for each shift and submit drill log to CCL by POC due date.

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 LPA record review, the licensee did not comply with the section cited above in [1] out of [3] residents. Resident R1 has a physician report dated 2022 but nothing current which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/01/2024 Plan of Correction Facility to submit to CCL a current LIC602 for R1 by POC due date.

Official classification

Type B

Official code

87705(c)(6)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA record review, the licensee did not comply with the section cited above in [1] out of [3] residents. Resident R1 did not have a current appraisal on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/16/2024 Plan of Correction Facility to submit to CCL a current Appraisal Needs and Services plan for R1 by POC due date. Appraisal shall be signed by all required parties.

Official classification

Type B

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA and Licensee observation, the licensee did not comply with the section cited above in that kitchen drawer containing sharp knives not locked, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/16/2024 Plan of Correction Facility to conduct staff training on how to properly store sharp knives and other items that could danger the residents by POC due date. Training log to be submitted to CCL by POC due date as well.