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Official classification

Type B

Official code

87463(h)

Regulation authority

CCR

What the official deficiency says

(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. 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 three out of five residents that did not have receive annual routine visits with a licesensed medical professional in the last 12 months which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/29/2025 Plan of Correction Licensee agrees to have all three residents receive an annual routine visit with a licensed professional and submit LIC602 to licensing or written documentation of resident and/or their representative refusal.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 two staff were missing annual training and one staff was miising postural supports, restricted health conditons and hospice training which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/29/2025 Plan of Correction Licensee agrees to have all three staff receive the required missing training and submit proof by POC due date.

Official classification

Type A

Official code

87465(a)(4)

Regulation authority

CCR

What the official deficiency says

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above as Administrator stated they administered a night time medication to one resident in the morning in error which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 07/21/2025 Plan of Correction Licensee agrees to notify the resident's physician about the error, and the Administrator will reeive medication training by thirf party and submit proof by 7/21/25.

Official classification

Type A

Official code

87468.1(a)(6)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(6) Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following...(6) To leave or depart the facility at any time and to not be locked into any..., building...This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as the front door had two chain locks which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC has been met. Door locks were removed during today's visit.

Deadline recorded: Dec 3, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(B)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days...(B) Any serious injury...under facility supervision. This requirement is not met as evidenced by: Based on records review, the licensee did not comply with the section cited above as they did not submit an incident report when R1 was diagnosed at St. John’s Medical Center Hospital on 04/09/2024 with a Urinary Tract Infection (UTI), which posed a potential health and safety risk to residents in care.

Official plan of correction

The licensee will submit a plan describing how you will ensure reporting requirements are followed. Submit proof to CCL by 12/05/2024.

Deadline recorded: Dec 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87204(a)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. 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 the facility retains 2 (two) residents that are identified by their physicians as total care which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 07/24/2024 Plan of Correction Licensee will contact CCL to obtain a waiver to retain total care residents and licensee will contact resident's physicians to provide an updated health screening identifying the resident's capabilities. Licensee will submit documentation to CCL no later than POC due date