A PEACE OF HOME

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 observation and interview, the licensee did not comply with the section cited above as two fire extinguishers were not serviced annually and two (2) unapproved bedrooms were constructed in the facility garage without proper building permits or fire clearance which poses an immediate safety risk to persons in care.

Official plan of correction

POC Due Date: 12/19/2025 Plan of Correction Administrator purchased new fire extinguishers at the time of the inspection. Administrator agreed to remove the constructed bedrooms from the garage and agreed to submit proof of removal of the structures to CCLD no later than POC due date.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (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 as the water temperature was measured in the resident bathrooms to be between 129.3 and 133.3 degrees Fahrenheit which poses an immediate health risk to persons in care.

Official plan of correction

POC Due Date: 12/19/2025 Plan of Correction Administrator agreed to submit proof of an appropriate water temperature in the resident bathrooms to CCLD no later than POC due date.

Official classification

Type A

Official code

87615(a)(1)

Regulation authority

CCR

What the official deficiency says

87615(a)(1) Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained... (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as R1 had a left foot unstageable pressure ulcer and a coccyx stage 3 pressure ulcer and R1 was not admitted to hospice care at that time, which posed an immediate health risk to persons in care.

Official plan of correction

The Administrator agreed to submit a corrective action plan outlining specific steps to ensure future compliance with all admission, retention, care, assessment and relocation regulations.

Deadline recorded: Nov 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(d)

Regulation authority

CCR

What the official deficiency says

The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. This requirement is not met as evidenced by: Based on interviews and records review the licensee did not comply with the section cited above as the Administrator did not demonstrarte sufficient knowledge, and qualifications as an Administrator, admitting & retaining R1 with a prohitivive health condition which poses an immideate

Official plan of correction

Licensee agreed to review reg cited and submit a statement of understanding, along with a written plan on how they will ensure future compliance then send to LPA via email by COB 11/03/2025. health, safety or personal rights risk to persons in care.

Deadline recorded: Nov 3, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(c)(2)

Regulation authority

CCR

What the official deficiency says

87465(c)(2) Incidental and Medical Care: ....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 observation and record review, the licensee did not comply with the section cited above when there was an unexplainable overcount of four (4) of R1’s prescribed medications and an undercount of one (1) of R1’s medications which poses an immediate health and safety risk to residents in care.

Official plan of correction

POC Due Date: 12/19/2024 Plan of Correction Licensee agrees to provide written statement of Plan in Place to ensure medications are administered as prescribed including but not limited to accurately recording start date, medication count, and timely noting date/time medications are administered. Written statement will be provided to LPA via email no later than POC due date 12/19/2024.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided... ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person… This requirement is not met as evidenced by: Based on interviews, R1’s resident representative/physician was not notified when R1 had a change of condition, which posed a potential health and safety risk to residents in care.

Official plan of correction

Licensee will submit a plan on how you will ensure residents' representatives/physicials will be notificed of change in condition. Submit plan to CCL by 03/31/202

Deadline recorded: Mar 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(a)(1)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (a)(1) (a) (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as staff did not obtain timely medical attention for R1 when R1 was discovered with multiple bruises and unable to walk on their own, and was later diagnosed with a fractured left femur, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee will submit plan how you will ensure residents receive timely medical care. Submit to CCL by 03/27/2023.

Deadline recorded: Mar 24, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

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…The licensing agency may require any facility to provide additional staff whenever it determines through... This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as the facility has one caregiver from 7:30 pm to 7:30 am which poses a potential safety and personal rights risk to persons in care.

Official plan of correction

Administrator stated that they will provide an updated LIC500 which reflects additional staffing to meet the residents needs to CCL by 3/11/22.

Deadline recorded: Mar 11, 2022. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(26)

Regulation authority

CCR

What the official deficiency says

(b) The following food service requirements shall apply: (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 LPA's observations, the licensee did not comply with the section cited above as the facility did not have a one week supply of nonperishable vegetables and fruit which poses a potential health and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/06/2021 Plan of Correction Administrator stated that they wll provide documentation of a one week supply of nonperishable vegetables and fruit to CCL by 12/6/21.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (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 LPA's observation, the licensee did not comply with the section cited above as the hot water temperature in a resident bathroom read at 141.3 degrees F. which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 12/02/2021 Plan of Correction Administrator turned down water heater temperature during facility visit.

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's observations, the licensee did not comply with the section cited above as R1's medication was observed in the kitchen refrigerator accessible to residents which poses an immediate health risk to persons in care.

Official plan of correction

POC Due Date: 12/02/2021 Plan of Correction Assistant Administrator placed R1's medications in a locked garage refrigerator during facility visit. Administrator stated that they will provide documentation of staff medication training to CCL by 12/13/21.