COUNTRY ROSE ASSISTED LIVING

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's/staff observation and interview, the licensee did not comply with the section cited above by ceiling needs patchwork which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2026 Plan of Correction Licensee agrees to submit pictures as proof of repairs needed were resolved to CCL by POC due date to clear the citation.

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's/staff observation, interview and record review, the licensee did not comply with the section cited above in one out of three staff did not have health screening including TB test on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2026 Plan of Correction Licensee agrees to submit proof that staff (S1) has a health screning including TB test on file by POC due date to clear the citation.

Official classification

Type B

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's/staff observation, records review and interview, the licensee did not comply with the section cited above by not obtaining a valid administrator certification after their certificate expired in 2024, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2026 Plan of Correction Licensee agreed to submit supporting documentation to the Department's certification unit and will send proof of submission to CCL by POC due date to clear the citation.

Official classification

Type B

Official code

87465(h)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: This requirement is not met as evidenced by: Deficient Practice Statement Based onLPA's/staff observation, interview and record review, the licensee did not comply with the section cited above by not maintaining a Centrally Stored Medication Log which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2026 Plan of Correction Facility to review and update the Centrally Stored Medication Log by POC due date, 4/3/2026 to clear the citation and will submit self-certification form that all resident's medications were updated in the CSMD to clear the citation.

Official classification

Type B

Official code

87463(i)

Regulation authority

CCR

What the official deficiency says

(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's/staff observation, interview and record review, the licensee did not comply with the section cited above in two out of four resident's care plans where not signed by their responsible parties which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2026 Plan of Correction Licensee agreed to review care plans with resident's responsible parties and will submit to CCL a self-certification form ensuring that care plans have been signed by POC due date 4/3/26.

Official classification

Type B

Official code

87608(a)(5)(A)

Regulation authority

CCR

What the official deficiency says

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's/staff observation, interview and record review, the licensee did not comply with the section cited above in one out of four residents do not have a bed rail form on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2026 Plan of Correction Licensee agrees to obtain bed rail order for resident (R2) and will submit to CCL self-certification form (LIC 9098) certifying that bed rail order for R2 is on file.

Official classification

Type B

Official code

87506(d)

Regulation authority

CCR

What the official deficiency says

Type B - 87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, & copy upon demand during normal business hours…This requirement was not met as evidence by: Based on LPA's record review and interview with Licensee, the facility did not have available resident’s (R1, R2, R3 & R4) care plans when requested by CCL, which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee agreed to review regulation 87506 regarding resident records and will retain at the facility resident's records to be available to the licensing agency for review as stated by regulation. Licensee will submit self-certification (LIC9098) form acknowledging understanding of regulation 87506 by POC due date.

Deadline recorded: Nov 26, 2025. 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

(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 LPAs/Licensee observation, interview and record review, the licensee did not comply with the section cited above in two out of three staff did not have a health screening including TB on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/25/2025 Plan of Correction Licensee agrees to obtain health screenings for two staff (S1 and S2) and will submit LIC503 health screening form for two staff to CCL by POC due date in order to clear the deficiency.

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 LPAs/Licensee observation and interview, the licensee did not comply with the section cited above in eleven food containers with grains, beans, rice, etc were not storage in a safety manner by not having expiration and open dates on them which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/25/2025 Plan of Correction Licensee agrees to revise food containers needing dates including open and expiration times and will submit a picture of them to CCL by POC due date to clear the citation.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPAs/Licensee observation, interview and record review, the licensee did not comply with the section cited above in two out of five residents do not have an updated care plan on file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/25/2025 Plan of Correction Licensee agrees to update resident's care plans and will submit them as proof of correction by POC due date to clear the citation.

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA/staff observation, records review and interview with licensee and resident (R2) in care, the licensee did not comply with the section cited above in one out of five residents (R2) who is bedridden was properly located in a bedroom that it was cleared by the Fire Department as a bedridden room, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/22/2024 Plan of Correction Licensee to certify on LIC 9098 R2 has been relocated to a bedridden room or provide another option to CCL that would allow R2 occupy room#2 by POC due date to clear the citation.

Official classification

Type A

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA/staff observations and interviews with the licensee, the licensee did not comply with the section cited above in three food items located in the food pantry of the facility that were found expired which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/22/2024 Plan of Correction Facility staff immediately discarded the cans identified as expired. Licensee will develop a facility policy on this food requirement and review with each staff. Licensee agrees to submit the policy to CCL as proof of correction by POC date.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA/staff observation, records review and interviews with the licensee, the licensee did not comply with the section cited above in one out of five residents (R2) when spot of medications and their records were reviewed. R2 have not been given their medication as prescribed by their physician which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/22/2024 Plan of Correction Licensee to ensure all residents receive their medication as prescribed by their physician. Licensee agrees to submit a plan of how they will ensure medication is properly given to the residents as prescribed by their physician by POC due date.

Official classification

Type B

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA’s records review and interviews conducted with Licensee did not ensure that CCL was notified of incident involving R2's hospitalization, which poses a potential health & safety risk to residents in care.

Official plan of correction

POC Due Date: 04/05/2024 Plan of Correction Licensee to ensure all incidents that threaten the safety of residents are reported to CCL per regulation. Administrator to review regulation, and will conduct training for all staff on reporting requirements. Signed statement that the regulation was reviewed & sign in sheet for all staff trained to be submitted by POC due date.

Official classification

Type B

Official code

87412(a)

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: This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA/staff observation, records review and interview with licensee, the licensee did not comply with the section cited above by not ensuring that staff (S1) had a complete personnel file which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/05/2024 Plan of Correction Licensee to ensure that all staff have a complete file with all personnel records required by Title 22 Regulations # 87412 (a) at the facility for CCL to review. Licensee to submit CCL with a LIC 9098 self-certification that staff files are complete according to regulations by POC due date.

Official classification

Type B

Official code

87465(a)(6)

Regulation authority

CCR

What the official deficiency says

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA/staff observation, records review and interview with the licensee, the licensee did not comply with the section cited above in five out of five resident's medications where not entered into the Centrally Stored Medication log accordingly which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/05/2024 Plan of Correction Facility to submit LIC9098 self-certifying they have conducted staff training on how to properly keep records of medications on CSML to CCL by POC due date to clear the deficiency.

Official classification

Type B

Official code

87203

Regulation authority

CCR

What the official deficiency says

Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, the licensee did not comply with the section cited above in one out of one fire extinguisher has not been serviced within the last year which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/24/2023 Plan of Correction Licensee to submit pictures of updated tags or receipt showing that fire extinguisher has been serviced 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 observation the licensee did not comply with the section cited above in toxins including disinfectants were unlocked and accessible to residents in care under the sink located in resident's bathroom which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 02/11/2023 Plan of Correction Staff immediately locked door where toxins were found. Deficiency is cleared.

Official classification

Type B

Official code

87412(g)(1)

Regulation authority

CCR

What the official deficiency says

87412 Personnel Records (g) All personnel records shall be maintained at the facility & shall be available to the licensing agency for review. (1) The licensee shall be permitted to retain such records in a central administrative location provided that they are readily available to the licensing agency at the facility as specified in Section 87412(f). Based on observation, interview and record review, the licensee did not comply with the section cited above not having records available for Licensing to review during visit including updated personnel report which poses a potential health and safety risk to persons in care.

Official plan of correction

Licensee agrees to submit self certification that all resident/staff files are accessible for review and contain all required documents by POC due date.

Deadline recorded: Feb 10, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(2) Personal Rights of Residents in All Facilities (a) Residents in all RCFE shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA observation, interview and records review Licensee did not ensure that staff and residents are being monitored daily for symptoms of Covid19 and results documented as reflected in facility's mitigation plan and current CCL requirements. This poses an immediate risk to the health, safety and personal rights to the residents in care.

Official plan of correction

POC Due Date: 03/08/2022 Plan of Correction Licensee will ensure Personal Rights of residents are maintained. Licensee agrees to submit proof of training for daily screening and documentation of Covid19 symptoms for all staff to CCL by 3/8/2022.