Staffing, personnel, and training
Cited in 2 reports, with 7 deficiencies in total.
ALMA CARE SENIOR LIVING LLC
814 E. AVENIDA DE LOS ARBOLES, Thousand Oaks CA 91360
3 bedsLatest official report Aug 12, 2026Licensed
Additional info
- Telephone
- (805) 331-8320
- Licensee
- ALMA CARE SENIOR LIVING LLC
- Administrator
- HEREDIA, VICTOR
- Contact
- HEREDIA, VICTOR
- License first date
- Aug 12, 2024
- License effective date
- Aug 12, 2024
- District office
- WOODLAND HILLS N.ASC · (818) 596-4334
- Regional office
- 29
- Clients served
- 935 - ELDERLY
Summary
The available records show 3 Type A and 28 Type B deficiencies for this facility.
- Most recent inspection
- Aug 12, 2026
- Most recent deficiency
- Aug 12, 2026
No later report is available, so the records do not show what happened afterward.
What Type A and Type B mean
- Type A
- Violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
- Type B
- Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
At a glance
Counts cover the five-year public record. Typical figures are the median for the 218 Ventura County facilities licensed for 6 or fewer beds.
In the available public five-year record, CCLD published 4 reports for this facility: 2 inspections, 0 complaint investigations, and 2 licensing or administrative records.
Those records contain 3 Type A and 28 Type B deficiencies.
1 deficiencies have explicit official correction or clearance evidence in the loaded records.
- Official inspections
- 2
- Recorded deficiencies
- 31
- Type A deficiencies
- 3
- Type B deficiencies
- 28
- Substantiated complaints
- 0
- Repeated topics
- 2
Fewer than the typical 4
1 in the last 12 months
Well above the typical 2
2 in the last 12 months
More than the typical 1
1 in the last 12 months
Well above the typical 1
1 in the last 12 months
Most this size also have none
0 in the last 12 months
Last 36 months
Repeated topics
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
Medical and dental care
Cited in 2 reports, with 3 deficiencies in total.
Official report history
All preserved reports from the most recent to the oldest, sortable by report type.
Inspection
Medical and dental careType A
- Official classification
- Type A
- Official code
- 87465(a)(6)
- Regulation authority
- CCR
What the official deficiency says
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in one (1) out of two (2) residents medications were not documented on the CSMR (6 out of 17 of their medications were not documented) which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/13/2026 Plan of Correction Administrator will submit a self-certification confirming they have reviewed the regulation and submit to LPA by POC due date 08/13/2026. The Administrator will develop a written protocol for trained staff outlining procedures for receiving and centrally storing medications. The Administrator will review all received medications daily - weekly to ensure accuracy, proper documentation, and compliance by 08/26/26.
Plan of correction recorded
Correction not verified in available records
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 1569.625(b)(1)
- Regulation authority
- HSC
What the official deficiency says
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training. 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 in 2 out of 5 staff did not have their initial 40 hours of training and 6 hours of hands on medication training documented at the time of the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/26/2026 Plan of Correction The Administrator will include the required training documentation into staff files and submit proof of the current staff’s completed training by the POC due date. Administrator will ensure that initial training is documented moving forward.
Plan of correction recorded
Correction not verified in available records
Inspection
Facility condition and maintenanceType A
- Official classification
- Type A
- Official code
- 87307(e)(2)(A)
- Regulation authority
- CCR
What the official deficiency says
(e) The licensee shall supervise residents as needed and as determined by the resident's appraisal pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to or when there is use of the following items: (2) Fishponds, wading pools, hot tubs, swimming pools, or similar larger bodies of water. (A) The licensee shall ensure that the bodies of water specified above are inaccessible through fencing, covering, or other means when not in active use by residents. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in one (1) gate that has access to the pool was not properly locked which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2025 Plan of Correction During the visit, the Licensee Representative secured the gate, confirmed they would review Regulation 87307(e)(2)(A), and agreed to submit a written statement of understanding to LPA.
Corrective action observedRecorded in report dated Jul 31, 2025
Plan of correction recorded
Background checksType A
- Official classification
- Type A
- Official code
- 87355(k)
- Regulation authority
- CCR
What the official deficiency says
(k) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of volunteers that require fingerprinting and non-client adults residing in the facility. 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 in Volunteer #1 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: 07/31/2025 Plan of Correction The Licensee Representative agreed to associate staff with the facility and will reflect this change in Guardian.
Plan of correction recorded
Correction not verified in available records
Licensing and administrationType B
- Official classification
- Type B
- Official code
- 1569.618(b)(3)
- Regulation authority
- HSC
What the official deficiency says
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following: (3) Training to effectively interact with emergency personnel in the event of an emergency call, including an ability to provide a resident’s medical records to emergency responders. 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 as the staff roster did not indicate another on call staff which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/08/2025 Plan of Correction The licensee’s representative agreed to hire a staff member, designate them as on-call, and include them on the staff roster.
Plan of correction recorded
Correction not verified in available records
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(f)(1)
- Regulation authority
- CCR
What the official deficiency says
(f) Emergency care requirements shall include the following: (1) The name, address, and telephone number of each resident's physician and dentist shall be readily available to that resident, the licensee, and facility staff. 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 (2) of two (2) reisdents did not have the following which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will ensure that the name, address, and telephone number of each resident’s physician and dentist are readily accessible to the resident, the licensee, and facility staff, in accordance with emergency care requirements, and will submit proof of completion to the LPA by the POC due date.
Plan of correction recorded
Correction not verified in available records
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87470(c)(1)(C)
- Regulation authority
- CCR
What the official deficiency says
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (C) An Infection Control Training Plan. 1. Initial training requirements for new facility staff shall be addressed in the plan, with training to be provided by the Infection Control Lead before staff works independently with 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 one (1) of two (2) staff did not have the appropriate training which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will develop and include an Infection Control Training Plan in the Plan of Operation, ensuring new staff receive required training from the Infection Control Lead before working with residents by POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Hazardous items and storageType B
- Official classification
- Type B
- Official code
- 87309(a)
- Regulation authority
- CCR
What the official deficiency says
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in two (2) packs of matches and one (1) lighter was accessible to residents in care which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 07/31/2025 Plan of Correction POC cleared on site. Staff relocated the items to the locked storage area.
Official record says corrected or clearedOn or before Jul 31, 2025
Plan of correction recorded
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87415(a)(1)
- Regulation authority
- CCR
What the official deficiency says
(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency: (1) In facilities caring for less than sixteen (16) residents, there shall be a qualified person on call on the premises. 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 no staff was indicated on the staff rsoter which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will ensure that overnight supervision staff are trained in first aid, familiar with the facility’s emergency procedures, and that a qualified person is on call on the premises by POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(a)(11)
- Regulation authority
- CCR
What the official deficiency says
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 (2) of two (2) staff did not have the above listed document which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will maintain personnel records for the licensee, administrator, and all employees, including health screenings, and will ensure staff complete the required screenings by the POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(b)
- Regulation authority
- CCR
What the official deficiency says
(b) Personnel records shall be maintained for all volunteers and shall contain the following: 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 (2) of two (2) staff did not have the above listed document which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will ensure that complete personnel records are maintained for all volunteers, as required by the POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87411(d)
- Regulation authority
- CCR
What the official deficiency says
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: 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 one (1) of two (2) staff did not have the required training which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will ensure all personnel have appropriate on-the-job training or related experience for their assigned roles, and will verify safe and effective job performance by the POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(c)
- Regulation authority
- CCR
What the official deficiency says
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. 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 one (1) of two (2) staff did not have the required training which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will ensure verification of required staff training and orientation is maintained in personnel records by the POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87613(a)(2)(B)
- Regulation authority
- CCR
What the official deficiency says
(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs. (B) Training shall be completed prior to the staff providing services to the resident. 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 one (1) of two (2) staff did not have the required training which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will ensure that facility staff receive specialized care training from a licensed professional prior to providing services to residents, and will complete this by the POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 1569.625(b)(1)
- Regulation authority
- HSC
What the official deficiency says
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on 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 one (1) of two (2) staff did not have the required training which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will ensure staff complete the required 40-hour training—including dementia care, specialized topics, and hands-on instruction—prior to working independently with residents, with full compliance by the POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Dementia careType B
- Official classification
- Type B
- Official code
- 1569.626(a)(1)
- Regulation authority
- HSC
What the official deficiency says
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. 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 one (1) of two (2) staff did not have the required training which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will ensure all direct care staff complete the required 12 hours of dementia care training—six hours prior to independent work and six hours within the first four weeks of employment—by the POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Dementia careType B
- Official classification
- Type B
- Official code
- 1569.626(a)(2)
- Regulation authority
- HSC
What the official deficiency says
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (2) Eight hours of in-service training per year on the subject of serving residents with dementia. This training shall be developed in consultation with individuals or organizations with specific expertise in dementia care or by an outside source with expertise in dementia care. In formulating and providing this training, reference may be made to written materials and literature on dementia and the care and treatment of persons with dementia. This training requirement may be satisfied in one day or over a period of time. This training requirement may be provided at the facility or offsite and may include a combination of observation and practical application. 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 one (1) of two (2) staff did not have the required training which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will ensure all direct care staff complete eight hours of annual dementia care training, developed with appropriate expertise, by the POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.69(a)(2)
- 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: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. 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 one (1) of two (2) staff did not have the required training which poses/posed a potential health, safety or personal rights risk to persons in care and send proof to LPA.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will ensure that staff assisting with self-administered medications in small facilities complete 10 hours of initial training—6 hours of shadowing before assisting and 4 hours of additional instruction within two weeks of hire—by the POC due date.
Plan of correction recorded
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468(c)
- Regulation authority
- CCR
What the official deficiency says
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. 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 required posting was not posted at the time of the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will ensure personal rights, nondiscrimination notices, and complaint information are prominently posted in publicly accessible areas by the POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468(c)(1)
- Regulation authority
- CCR
What the official deficiency says
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities shall be posted as applicable to the facility. 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 required posting was not posted at the time of the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will ensure that all applicable personal rights, nondiscrimination notices, and complaint information are clearly posted in accessible locations by the POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468(c)(2)
- Regulation authority
- CCR
What the official deficiency says
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: 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 required posting was not posted at the time of the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will ensure that reporting agency information—including emergency contacts and procedures for filing confidential complaints—is clearly posted in accessible areas by the POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468(c)(2)(A)
- Regulation authority
- CCR
What the official deficiency says
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. 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 required posting was not posted at the time of the visit which poses/posed a potential health, safety or personal rights risk to persons in care and send proof to LPA.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will ensure that complaint and emergency reporting information—including a 20” x 26” PUB 475 poster or equivalent—is prominently posted in the facility’s main entryway by the POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468(d)
- Regulation authority
- CCR
What the official deficiency says
(d) Licensees shall post the personal rights, nondiscrimination notice, and complaint information specified above in English, and, in any other language in which at least five (5) percent of the residents can only read that other language. 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 required posting was not posted at the time of the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will post all required notices in English and any additional language read by 5% or more of residents, by the POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 87468.1(a)(4)
- Regulation authority
- CCR
What the official deficiency says
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (4) To be informed by the licensee of the provisions of law regarding complaints and of procedures for confidentially registering complaints, including, but not limited to, the address and telephone number for the complaint receiving unit of the Department, and how to contact the Community Care Licensing Division of the California Department of Social Services, and the long-term care ombudsman regarding grievances in regard to the facility. 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 one (1) of two (2) residents did not have the required document signed and in their file which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will inform all residents about legal complaint procedures, including contact details for the Department, Community Care Licensing Division, and the long-term care ombudsman, by the POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Not classified in the sourceType B
- Official classification
- Type B
- Official code
- 1569.267(d)
- Regulation authority
- HSC
What the official deficiency says
(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented. 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 one (1) of two (2) staff did not have the required training which poses/posed a potential health, safety or personal rights risk to persons in care and send proof to LPA.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will ensure all staff receive initial and ongoing training to uphold and implement residents’ rights, by the POC due date.
Plan of correction recorded
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 1569.157(h)
- Regulation authority
- HSC
What the official deficiency says
(h) The text of this section with the heading “Rights of Resident Councils” shall be posted in a prominent place at the facility accessible to residents, family members, and resident representatives. 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 required posting was not posted at the time of the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will post the ‘Rights of Resident Councils’ text in a prominent, accessible location at the facility by the POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Resident rightsType B
- Official classification
- Type B
- Official code
- 1569.158(d)
- Regulation authority
- HSC
What the official deficiency says
(d) A family council shall be provided with adequate space on a prominent bulletin board or other posting area for the display of meeting notices, minutes, information, and newsletters. 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 required posting was not posted at the time of the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will ensure the family council has adequate space on a prominent posting area for notices, minutes, and newsletters by the POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Medication handling and storageType B
- Official classification
- Type B
- 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 in one staff medication (Ozempic) was not left in the accessible refrigerator which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Plan of Correction was cleared on site. Staff relocated the medication to the secured staff room. The Licensee Representative has agreed to review Regulation 87465(h)(2) and will submit a statement of understanding by POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Medication handling and storageType B
- Official classification
- Type B
- Official code
- 87465(h)(4)
- Regulation authority
- CCR
What the official deficiency says
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. 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 Resident #2 medication (MIRTAZAPINE 15 MG) was not documented correctly and did not have the medication rx number listed which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative has agreed to conduct a medication record audit to ensure all medications are properly documented by the POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(d)
- Regulation authority
- CCR
What the official deficiency says
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: 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 (2) of two (2) residents did not have PRN letters which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative has agreed to contact residents’ prescribing physicians to obtain PRN authorization letters for all PRN medications by POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87212(c)
- Regulation authority
- CCR
What the official deficiency says
(c) Emergency exiting plans and telephone numbers shall be posted. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in Emergency exiting plans and telephone numbers were not posted at the time of the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 08/14/2025 Plan of Correction The Licensee Representative will ensure to update and post Emergency exiting plans and telephone numbers by POC due date and send proof to LPA.
Plan of correction recorded
Correction not verified in available records
Licensing recordNot an inspection of the operating facility
No deficiencies recorded in this report
Licensing recordNot an inspection of the operating facility
No deficiencies recorded in this report
Source and limits
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
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