Medication handling and storageType A
- 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 observation, the licensee did not comply with the section cited above as a mucus relief medication was left unsecured in the hallway drawer accessible to clients in care which poses an immediate health or safety risk to persons in care.
Official plan of correction
POC Due Date: 12/15/2025 Plan of Correction The medication was secured by the Administrator at the time of the visit. POC cleared.
Health conditions and treatmentsType A
- Official classification
- Type A
- Official code
- 87608(a)(5)(B)
- Regulation authority
- CCR
What the official deficiency says
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. 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 a resident who was not on hospice had full bed rails installed on their bed which poses an immediate personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/15/2025 Plan of Correction Bed rail was removed and replaced with half rails at the time of the visit. POC cleared.
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87307(d)(6)
- Regulation authority
- CCR
What the official deficiency says
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. 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 bedroom #1's emergency exit door was blocked by a chair which posed a potential safety risk to persons in care.
Official plan of correction
POC Due Date: 12/15/2025 Plan of Correction Chair was removed at the time of the visit. POC cleared.
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(c)(2)
- Regulation authority
- CCR
What the official deficiency says
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. (2) Documentation of staff training shall include: 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 in-service trainings did not have the name of the trainer or the number of training hours per subject which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/29/2025 Plan of Correction Licensee Representative agreed to submit their template that they will utilize to track in-service trainings to CCLD no later than POC due date.
Staffing, personnel, and trainingType B
- 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 as one (1) employee did not have the required annual trainings in their staff file which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/29/2025 Plan of Correction Licensee Representative agreed to conduct the required trainings with the identified employee and to submit proof of completed training to CCLD no later than POC due date.