LAUREL HEIGHTS

Official classification

Type A

Official code

87465(a)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidenced by: Based on records review, the facility failed to assist resident #1 with medication prescribed and instead, gave resident #1 another resident’s medication which poses an immediate health and safety risk to resident in care.

Official plan of correction

Executive Director stated that since the incident staff was pulled from med-tech duties provided in-service and retrained on medication management and prior to resuming medtech duties staff was supervised by Health and Wellness Director on 3 medication passes.

Deadline recorded: Apr 30, 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

87303(a) Maintenance and Operation.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 Based on observations the ED did not comply with the section cited above as the main door automatic system was observed to be in disrepair which poses a potential health and safety risk to persons in care.

Official plan of correction

ED has schedule a company to come an fix the main door. A video showing ADA push plate in operable condition shall be submitted to LPA before POC due

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

Official classification

Type B

Official code

87217(b)

Regulation authority

CCR

What the official deficiency says

Safeguards for Resident Cash, Personal Property, and Valuables: Every facility shall take appropriate measures to safeguard residents'... personal property and valuables which have been entrusted to the licensee or facility staff. This requirement is not met as evidenced by: Based on interviews conducted and records review, licensee did not comply with the section cited above. Staff made fraudulent bank and credit card transactions using resident #1's bank and credit card. This posed a potential personal rights risk to residents in care.

Official plan of correction

Executive Director (ED) reported/confirmed that the corporate staff was terminated as of 7/2/2025. ED agreed to provide a plan on how they will maintain future compliance with section cited. Submit plan of correction by 7/16/2025.

Deadline recorded: Jul 9, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

87355(e)(1) Criminal Record Clearance (e)...pursuant to Health and Safety Code Section 1569.17(b)...(1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement is not met as evidenced by: Based on record review and interview, LPA found 2 staff that were not associated to the facility. The licensee did not comply with the section cited above in 2 counts which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

Executive Director will associate staff members to the facility and/or update LIC 500 to remove emloyees that are not longer working in the facility.

Deadline recorded: Apr 4, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87208(a)(5)

Regulation authority

CCR

What the official deficiency says

87208(a)(5) Plan of Operation. (a)The licensee shall have and maintain a current, written definitive plan of operation for the facility... The plan and related materials shall contain the following: (5) Staffing plan, qualifications and duties.This requirement is not met as evidenced by: Based on observation and interviews ED did not comply with the above section by not ensuring plan of operation documentation is being kept readily available to licensing departments which poses a potential health, safety and personal rights risk to resident in care.

Official plan of correction

ED shall write a statement of understanding and complete/update a LIC 500 form when necessary and have it readily available for when licensing department request it. LPA expects administrator to have updated LIC 500 before POC due date.

Deadline recorded: Apr 11, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(g)

Regulation authority

CCR

What the official deficiency says

(g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, the licensee did not comply with the section cited above as R1 had personal grooming and hygiene items accessible in an unlocked cabinet which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/15/2024 Plan of Correction The Licensee agreed to review Regulation cited and submit a statement of Understanding to CCL by 07/15/2024.

Official classification

Type A

Official code

87705(g)

Regulation authority

CCR

What the official deficiency says

(g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items. This requirement is not met as evidenced by: Deficient Practice Statement Based on LPA's observation, the licensee did not comply with the section cited above as R1 had personal grooming and hygiene items such as: Gillet shaving cream, Cetaphil skin cleanser, Crest Toothpaste, and an electric shaver accessible on the bathroom counter, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/20/2023 Plan of Correction The Licensee has agreed to review Regulation 87705 on Dementia and submit Statement of Understanding to CCL by 08/01/2023.

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’s observation during the physical plant tour, the licensee did not comply with the section cited above as the trash cans in the memory care unit bedrooms and bathrooms as well as the common area restrooms did not have a tight-fitting cover/lid, which poses a potential health risk to persons in care.

Official plan of correction

POC Due Date: 08/01/2023 Plan of Correction The Licensee has agreed to replace trashcans with covers/lids and submit proof to CCL by 08/01/2023.

Official classification

Type B

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. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of ...This requirement is not met as evidence by: Based on observation and interview, the license failed to comply with the sections cited above as the handicap push button and fire places are not functional, the facility currently has a leak, and the elevator needs to be reset frequently which poses a potential health and....continued...

Official plan of correction

The Administrator shall submit a plan by 02/10/2023 on how they will ensure resident's personal rights, and health and safety is not affected until repairs can be completed. and safety and personal rights risk to residents in care.

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

Official classification

Type A

Official code

1569.269(a)(10)

Regulation authority

HSC

What the official deficiency says

1569.269 Enumerated rights; severability (a)(10) Residents of residential care facilities for the elderly shall have all of the following rights: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above by ensuring R1 was free from verbal abuse and R2 was free from physical abuse by S1 which poses an immediate health and personal rights risk to persons in care.

Official plan of correction

S1 was terminated on 10/22/22. Administrator stated that they will provide documentation of staff training personal rights training and mandated reporting.

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

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Based on LPA's observation and interviews, the licensee did not comply with the section cited above as the licensee did not ensure that S1, S2, S3, S4, S5 and S6 were associated to the facility prior to allowing S1, S2, S3, S4, S5 and S6 to work which poses an immediate safety risk to persons in care.

Official plan of correction

S1, S2, S3, S4, S5 and S6 require to obtain criminal transfer. Staff associated S1, S2, S3, S4, S5 and S6 through Guardian System during the facility visit. Staff stated that they will not employ staff unless they are associated with the facility.

Deadline recorded: Oct 19, 2022. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(f)(1)

Regulation authority

CCR

What the official deficiency says

87705 Care of Persons with Dementia (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's observation and record review, the licensee did not comply with the section cited above as scissors were observed in an unlocked beauty salon accessible to residents which poses an immediate health and safety risk to persons in care.

Official plan of correction

Staff locked beauty salon during facility visit. Staff also had staff change out the locking mechanism so that the door is now self-locking. Staff stated that they will provide documentation of staff training regarding regulation 87705(f)(1) to CCL by 10/28/22.

Deadline recorded: Oct 19, 2022. 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 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: 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: Based on LPA's observations and record review, the licensee did not comply with the section cited above as toxic substances were observed accessible to residents which poses an immediate health risk to persons in care.

Official plan of correction

Staff locked beauty salon door. Staff also had staff change out the locking mechanicsm so that the door is now self-locking. Staff placed toxic chemicals in a locked housekeeping cart. Staff stated that they will provide documentation of scheduled staff training regarding regulation 87705(f)(2) to CCL by 10/28/22.

Deadline recorded: Oct 19, 2022. A deadline is not proof that correction was completed.