ANGELS II

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 S1 has a criminal record clearance, but was not associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2026 Plan of Correction Licensee agreed to send documents to get S1 associated to Regional office. Licensee also agreed to review section cited and provide a written plan to ensure future compliance then send to LPA via email by COB 03/12/2026

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 and record review, the licensee did not comply with the section cited above as R1 was observed with a full bed rail, but is not currently on hospice, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2026 Plan of Correction Licensee agreed to remove full bed rails, review section cited then provide a written plan to ensure future complaince then send to LPA via email by COB 03/12/2026

Official classification

Type B

Official code

87412(d)

Regulation authority

CCR

What the official deficiency says

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This requirement is not met as evidenced by: Deficient Practice Statement Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type B

Official code

87211(a)

Regulation authority

CCR

What the official deficiency says

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence.. This requirement was not met as evidenced by: Based on records review, R1 eloped from the facility on 01/17/2023, however this incident was not reported to CCL timely, which poses a potential health and safety risk to residents in care.

Official plan of correction

Licensee will submit a plan how they will ensure reporting requirements are met. Submit to CCL by due date

Deadline recorded: Apr 25, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

1569.312(a)

Regulation authority

HSC

What the official deficiency says

§1569.312(a) Basic services requirements. Basic services shall at a minimum include:(a)Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff did not supervise R1 which resulted in R1’s fall, sustaining traumatic subdural hematoma, resulting in death, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Licensee will submit a plan how you will ensure appropriate care and supervision to residents. Submit to CCL by due date

Deadline recorded: Apr 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis…This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Facility staff did not seek timely medical care when R1 fell and sustained facial and head injuries, yet was put to bed, which posed an immediate health and safety risk to resident in care

Official plan of correction

Licensee will submit a plan how you will ensure residents receive timely medical care. Submit to CCL by due date

Deadline recorded: Apr 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(f)(1)(5)

Regulation authority

CCR

What the official deficiency says

(f) Basic services shall at a minimum include:(1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c (5) Regular observation of the resident's physical and mental condition..... This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above.Facility staff failed to assess R1 completely for fall prevention and develop a service plan as R1 had a history of falls with visible injuries noted, which posed an immediate health and safety risk to residents.

Official plan of correction

Licensee will submit a plan how they will ensure appropriate care and supervision to residents. Submit to CCL by due date.

Deadline recorded: Apr 19, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities.Residents shall have all of the following....: To care, supervision, and services that meet their individual needs........ This requirement was not met as evidenced by: Based on the investigation, the licensee did not comply with the section cited above, as R1 was not properly supervised which led to an elopement, which poses an immediate personal rights risk to residents in care.

Official plan of correction

Licensee will submit a plan how they will ensure appropriate care and supervision to residents. Submit to CCL by due date.

Deadline recorded: Apr 19, 2024. 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

(f) The following shall be stored inaccessible to residents with dementia: (2) 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: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Bottle of tylenol observed on kitchen table accessible to others. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/21/2024 Plan of Correction Staff locked the tylenol bottle in the cabinet during visit.

Official classification

Type B

Official code

87470(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (B) Walls and window coverings in resident care areas shall be dusted or cleaned on a regular schedule to ensure they are safe and sanitary and when they are visibly contaminated or soiled. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPA observed living area and resident room walls window coverings with dust and stains. This poses a potential health, safety or personal rights risk to persons in care. Resident #1's room was observed with dirty napkins on the floor; urine stains on the bedding.

Official plan of correction

POC Due Date: 03/28/2024 Plan of Correction Licensee/Administrator shall develop a plan to ensure that the facility is maintained clean and sanitary at all times. Provide cleaning schedule as proof to ensure facility is maintained clean at all times.

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 three (3) out of three (3) staff files reviewed lacked required annual training. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/28/2024 Plan of Correction Licensee/Administrator shall ensure all staff receive the required annual training by POC date. Submit proof of training according to training requirements by POC due date 3/28/2024.

Official classification

Type B

Official code

1569.69(a)

Regulation authority

HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: 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 (3) out of three (3) staff files reviewed all three staff lacked proof of required annual medication training. This poses/posed a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/28/2024 Plan of Correction Licensee/Administrator shall ensure all staff handling residents medication receive the required annual medication training. Submit proof by POC by due date. proof of the required annual medication training for staff assigned to dispense medications to resident.

Official classification

Type B

Official code

87463(c)

Regulation authority

CCR

What the official deficiency says

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. 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. Resident #3's needs and services plan was observed over a year old. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/28/2024 Plan of Correction Licensee/Administrator shall complete get signatures and submit to LPA a copy of the updated Needs and services plan for Resident #3 by POC date.

Official classification

Type B

Official code

1569.695(d)

Regulation authority

HSC

What the official deficiency says

(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. 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. Licensee/Administrator did not review the Emergency Disaster Plan annual since developed. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/28/2024 Plan of Correction Licensee/Administrator shall review the Emergency Disaster Plan and update accordingly; if no updates needed then it should be signed and dated when it was reviewed annually. Submit copy of reviewed Emergency Disaster Plan with signature page. Also submit a letter of understanding the importance of ensuring that this procedure is followed annually.

Official classification

Type B

Official code

87606(f)(3)

Regulation authority

CCR

What the official deficiency says

(f) To accept or retain a bedridden person, a facility shall ensure the following: (3) Staff records include documentation of staff training specific to Care of Bedridden Residents. 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 (3) out of three (3) staff records reviewed no staff had record of this training. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/28/2024 Plan of Correction Licensee/Administrator shall ensure staff receive the above required training and submit proof of training by POC due date.

Official classification

Type B

Official code

87609(b)(4)

Regulation authority

CCR

What the official deficiency says

(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s). 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. One out of five resident files reviewed identified that Resident #3 is receiving home health service; no written agreement between facility and home health agency was observed on file. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/28/2024 Plan of Correction Licensee/Administrator shall meet with the home health agency and develop an agreement to meet this requirement. Submit proof of written agreement by POC date.

Official classification

Type B

Official code

87625(b)(3)

Regulation authority

CCR

What the official deficiency says

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. Two out of five clients observed in their room with full urine bottles; one full sitting on the night stand/on the other several urine bottles on and near resident's bed. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/28/2024 Plan of Correction Licensee/Administrator shall meet with staff; provide in-service and ensure resident rooms are clean and bottles filled with urine are emptied.

Official classification

Type B

Official code

87465(h)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: 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 four (4) out of five (5) resident medications reviewed it was observed that staff are not logging in all prescribed/nonprescribed medications on the Centrally Stored Record log for the four residents. This poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/28/2024 Plan of Correction Licensee/Administrator shall conduct a medication audit and provide training to staff on record keeping. Provide copy of the in-service training provided by POC date. Ensure all resident medications are logged on the Centrally Stored log and provide a copy of the centrally stored log for all four residents (R1,R2,R3,R4) by POC date.

Official classification

Type B

Official code

87468.1

Regulation authority

CCR

What the official deficiency says

Personal Rights of Residents in All facilities (9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement is not met as evidence by: Based on interview with Licensee/ administrator, licensee did not comply with the above regulation. Licensee did not communicate or provide records to former resident's family representative despite the several attempts made by requestor/family representative.

Official plan of correction

Licensee/Administrator eventually sent records to the requestor and informed LPA that due to the pending litigation her attorney advised her not to communicate with requestor. Requestor confirmed receipt of former resident's records POC cleared.

Deadline recorded: Mar 21, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.652(a)(c)

Regulation authority

HSC

What the official deficiency says

Termination of admission agreement upon death of resident; removal of resident’s property; refund of fees paid; notice of contract termination and refunds: (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed...... This requirement is not met as evidence by: Based on interviews and records reviewed Administrator did not comply with section cited above. R1's family was not issued the correct refund for unused rent following removal of belongings on 3/13/2023. This posed a potiential personal rights risk to

Official plan of correction

Administrator stated that she communicate with the deceased resident's (R1's) family and provide the correct refund amount totaling $3,193.56. Submit proof of correction by 8/30/2023. residents in care.

Deadline recorded: Aug 30, 2023. 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...This requirement was not met as evidenced by: Based on Observation, the licensee did not comply with the section cited above, as the facility did not maintain clean carpets, refrigerator and freezer which poses a potential health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Clean and disinfect refrigerator and frezzer and provide proof to CCL no later than 8/8/22. 2. Deep clean carpets and remove stains and provide proof to CCL no later than 8/8/22. 3. Declutter the garage and provide proof to CCL no later than 8/8/22.

Deadline recorded: Aug 8, 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: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPA observed knives stored in an unlocked drawer in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/07/2022 Plan of Correction Staff secured the knives and scissors in a locked drawer. Administrator will provide evidence of training staff on securing dangerous items to CCL on or before 03/07/22.