Fire safety and emergency preparednessType A
- Official classification
- Type A
- Official code
- 87203
- Regulation authority
- CCR
What the official deficiency says
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, the licensee did not comply with the section cited above as it was observed during test of the hard wired smoke detectors and combination smoke/carbon monoxide detectors that the fire rated door located between the resident rooms and the hallway leading to the common areas did not automatically activate which poses an immediate health, safety or personal rights risk to persons in care
Official plan of correction
POC Due Date: 03/20/2026 Plan of Correction Administrator will contact Fire Marshall or a certified fire protection technicians to come an assess facility's fire door today. During todya's visit assessment was completed. Partial POC Cleared. Administrator will provide proof of completed repairs within 2 weeks of the scheduled appointment.Until repairs are completed Administrator agrees to keep the door closed at all times.
Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(h)(6)
- Regulation authority
- CCR
What the official deficiency says
87465 (h)(6) Incidental Medical and Dental Care (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 is not met as evidenced by: Deficient Practice Statement The Administrator did not comply with the regulation cited above by not ensuring LIC 622 medication record was properly filled out and used to document current resident’s medication which poses a poses a potential risk to the health and safety of residents in care.
Official plan of correction
POC Due Date: 04/03/2026 Plan of Correction Administrator agrees to complete centrally stored medication records for each resident by 04/03/2026.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(a)
- Regulation authority
- CCR
What the official deficiency says
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 as Staff #1 did not have a health screaning form and had other missing documents available for LPA review which poses a potential health, safety risk to persons in care.
Official plan of correction
POC Due Date: 04/03/2026 Plan of Correction Administrator agrees to submit missing documets to LPA prior to POC due date.
Fire safety and emergency preparednessType B
- 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 record review, the licensee did not comply with the section cited above as thier last drill was conducted on 12/2025 and interviewes revealed that staff did not remember to conduct an emergency drill prior to LPA's visit which poses a potential health, safety risk to persons in care.
Official plan of correction
POC Due Date: 04/03/2026 Plan of Correction Administrator agreed to set up an alarm on their calendar and conduct drills every quarter as required. Also, a drill will be conducted and submitted to LPA before POC due date.