Facility condition and maintenanceType A
- Official classification
- Type A
- Official code
- 87303(e)(2)
- Regulation authority
- CCR
What the official deficiency says
(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 degrees C) and not more than 120 degree F (49 degrees C). 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 hot water being dispensed from a resident restroom faucet was measured at 127.6 degrees which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2026 Plan of Correction The facility designated Administrator stated that the hot water temperature will be maintained between 105-120 degrees at all times. A statement of correction, along with proof of 72 hours of temperature measurements taken, to be completed and submitted into CCL by the due date for review by this LPA.
Licensing and administrationType A
- Official classification
- Type A
- Official code
- 1569.618(c)(3)
- Regulation authority
- HSC
What the official deficiency says
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 [2] out of [3] facility staff persons did not have updated first aid training which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2026 Plan of Correction The facility designated Administrator stated that an audit of all facility staff files will be conducted to make sure that they are complete and contain all of the required forms and documents at all times. A statement of correction, along with proof of updated First Aid Training for all facility staff, will be completed and submitted into CCL by the due date for review by this LPA.
Food serviceType A
- Official classification
- Type A
- Official code
- 87555(b)(26)
- Regulation authority
- CCR
What the official deficiency says
(26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in that there was not a sufficient supply of non perishable food items to meet the 7-day quantity requirement at all times which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2026 Plan of Correction The facility designated Administrator stated that this facility will maintain the required food supply quantities to be on hand at all times. A statement of correction, along with receipt of additional non perishable food items purchased, will be completed and submitted into CCL by the due date for review by this LPA.
Medication handling and storageType A
- 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 record review, the licensee did not comply with the section cited above in that the Medication Administration Record, with dispensing log in use at this time, were missing staff initials and reasons for medications that were either missed, refused, or not given on these documents which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/06/2026 Plan of Correction The facility designated Administrator stated that Medication Administration Record, and dispensing log in use, will be audited to make sure that they are properly documented and maintained to show proper dispensing of the medications to the residents at all times. A statement of correction, along with documented proof of training for no less than (1) hour in duration on the topic of medication handling, dispensing, and proper documentation for all facility staff to be submitted into CCL by the due date for review by this LPA.
Admission, assessment, and evictionType A
- Official classification
- Type A
- Official code
- 87458(a)
- Regulation authority
- CCR
What the official deficiency says
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. 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 [1] out of [3] facility resident files did not have a complete and updated medical assessment which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2026 Plan of Correction The facility designated Administrator stated that all facility resident files will be audited to make sure that they are complete and contain all of the required forms and documents at all times. A statement of correction, along with a copy of the updated medical assessment, will be completed and submitted into CCL by the due date for review by this LPA.
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(c)
- Regulation authority
- CCR
What the official deficiency says
(c) All window screens shall be clean and maintained in good repair. 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 there were window screens that had holes, rips, and tears in them as well as not being present behind the window which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/06/2026 Plan of Correction The facility designated Administrator stated that a review of all facility windows and window screens will be conducted to make sure that they are in good working order at all times without holes, rips, or tears in them. A statement of correction, along with receipts of services rendered for the repair/replacement of the window screens, will be completed and submitted into CCL by the due date for review by this LPA.
Staffing, personnel, and trainingType B
- 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 record review, the licensee did not comply with the section cited above in [3] out of [3] facility personnel records were incomplete missing required forms and documents which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/06/2026 Plan of Correction The facility designated Administrator stated that an audit of all facility personnel files will be conducted to make sure that they are updated and complete to contain all required forms and documents at all times. A statement of correction, along with copies of the updated and complete personnel files, will be completed and submitted into CCL by the due date for review by this LPA.