RESIDENCE AT DEAN LLC, THE

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 record review, the licensee did not comply with the section cited above as the fire clearance does not include a converted garage/staff room, and the facility fire extinguisher has not been serviced annually, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/15/2025 Plan of Correction Facility Designee agreed to discuss with Licensee and Administrator and obtain proof of permitting/construction to the facility, will have the fire extinguisher serviced, and submit a new LIC 200 and facility sketch to CCLD by POC due date. If proper permits were not secured for the construction, Licensee will contact CCLD to modify the plan of correction before POC due date.

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 observation and record review, the licensee did not comply with the section cited above as 1 (one) staff (Staff #1 - S1) does have criminal record clearance, but was not associated to this facility and has been working at this location for at least 2 (two) months, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/15/2025 Plan of Correction During today's visit, LPA associated S1 in Guardian to this facility. Licensee will send a statement of understanding of this regulation to CCLD by POC due date.

Official classification

Type A

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. 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 2 (two) of 2 (two) residents' medications observed were prepared in advance for 9 (nine) days and stored in weekly medication boxes, which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/15/2025 Plan of Correction Facility Designee agreed to discontinue preparing medications in advance as of today's visit. Licensee will schedule an approved vendor or certified medical professional to conduct a medication training for all facility staff, including management. Proof of scheduled training will be sent to CCL by POC due date. Proof of training to include documentation of training topics covered, duration of training, trainer information, and attendees will be sent to CCL upon completion.

Official classification

Type A

Official code

1569.69(b)

Regulation authority

HSC

What the official deficiency says

(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. 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 Administrator is not present in the facility and no other staff files reviewed had annual medication training (last training was initial training in 2022 or 2023,) which poses an immediate health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/15/2025 Plan of Correction Facility Designee will communicate with Licensee. Licensee will schedule an approved vendor or certified medical professional to conduct a medication training for all facility staff, including management. Proof of scheduled training will be sent to CCL by POC due date. Proof of training to include documentation of training topics covered, duration of training, trainer information, and attendees will be sent to CCL upon completion.

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405 Administrator Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. Deficient Practice Statement Based on observation and interview the licensee did not comply with the section cited above as the administrator is scheduled to be present M-F 09:00AM-01:00PM, however has not been present at any time when LPA has visited the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/26/2025 Plan of Correction Facility Designee agreed to discuss with Licensee and Administrator a plan for coverage at the facility. Licensee will put in writing an administrative oversight plan for the facility and submit to CCLD by POC due date.

Official classification

Type B

Official code

87412(a)

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: 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 Administrator's file is not complete and/or present at the facility, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/26/2025 Plan of Correction Facility Designee contacted Administrator during the visit to request the file be brought to the facility, however this was unable to be completed. Facility Designee will ensure Administrator file is complete and is sent to CCLD by POC due date.

Official classification

Type B

Official code

1569.618(c)(3)

Regulation authority

HSC

What the official deficiency says

(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. 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 in as the 1 (one) overnight staff, who is scheduled to work 7 (seven) days a week does not have CPR or first aid training, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/26/2025 Plan of Correction Facility designee agreed to ensure S2 receives both CPR and first aid training and will send proof of training to CCL by POC due date.

Official classification

Type B

Official code

87465(e)

Regulation authority

CCR

What the official deficiency says

(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information. 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 Resident #1 (R1) had over the counter medications and no prescription orders for these medications, which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/26/2025 Plan of Correction Facility Designee agreed to obtain physician's orders for all residents' medications and label all medications according to physician's orders. Designee will sent proof of physician's orders and labeled medications to CCL by POC due date.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. 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 2 (two) of 2 (two) residents have half bedrails on their beds and neither resident had written physician's orders indicating the need for bed rails which poses a potential personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/26/2025 Plan of Correction Facility Designee agreed to obtain physician's orders for both residents' bedrails and submit proof to CCL by POC due date.

Official classification

Type B

Official code

87632(d)(2)

Regulation authority

CCR

What the official deficiency says

(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. 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 Resident #2 (R2) was admitted to the facility on 04/01/2025 and was admitted to hospice care on the same date, but no notification was received at CCL indicating a resident is receiving hospice services, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/26/2025 Plan of Correction Facility designee agreed to discuss with licensee and ensure Licensee submits notification of R2's admit to hospice care. Licensee will ensure all staff, including licensee and Administrator are trained on reporting requirements and hospice care waiver reporting requirements by a qualified professional (approved vendor or health care professional) and proof of completed training will be sent to CCL by POC due date.

Official classification

Type B

Official code

87211(a)(1)

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 of the occurrence of any of the events...if any; and disposition of the case. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the above cited section, as no incident or death reports from the date of licensure to the present time have been received at CCLand there were at least 2 (two) deaths and a fall incident, which poses a potential safety risk to persons in care.

Official plan of correction

Facility designee agreed to ensure all incident and death reports are submitted timely. A statement of understanding of the section related to reporting requirements will be signed by Administrator, Licensee representatives, and all facility designees and sent to CCL by POC due date.

Deadline recorded: Aug 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87217(j)

Regulation authority

CCR

What the official deficiency says

87217 Safeguards for Resident Cash, Personal Property, and Valuables (j) Upon the death of a resident, all cash resources, personal property, and valuables of that resident shall immediately be safeguarded. 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 did not have a record of any items brought into the facility, nor were items safeguarded or documented upon R1's death, which posed a potential personal rights risk to persons in care.

Official plan of correction

Facility Designee agreed to ensure residents' belongings are inventoried upon move in and safeguarded at the facility. A statement of understanding of this regulation section will be signed and sent to CCL by POC due date.

Deadline recorded: Aug 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87507(g)(5)(A)

Regulation authority

CCR

What the official deficiency says

87507 Admission Agreements (g) (5) (A) Facility policy concerning refunds, including the conditions under which a refund for advanced monthly fees will be returned in the event of a resident’s death, pursuant to Health and Safety Code section 1569.652. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the above cited section, as the facility's Admission Agreement states residents on hospice care will not receive a refund, which is not allowed per regulation and poses a potential personal rights risk to persons in care.

Official plan of correction

Facility Designee agreed to discuss with Licensee Representative. Admission Agreement will be modified and sent to CCL for approval by POC due date.

Deadline recorded: Aug 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 in three out of three areas of concern - bathroom, kitchen, laundry cabinets left unlocked with cleaning detergents/chemicals accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/13/2024 Plan of Correction The back-up administrator locked all of the cabinets. Licensee will conduct training with all staff regarding keeping dangerous items inaccessible to residents. Licensee will submit evidence of training to CCL on or before 9/13/2024.

Official classification

Type A

Official code

87355(e)

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: 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 out of seven staff; S1 does not have a criminal record clearance, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/05/2024 Plan of Correction The back-up administrator called another staff in to take over caregiver duties until S1 can get fingerprint cleared and assoicated to the facility.

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 one out of seven staff who did not have a health screening on file, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/13/2024 Plan of Correction Licensee will have S1 get a health screening and provide CCL with evidence of the health screening on or before 9/13/2024.

Official classification

Type B

Official code

87506(b)(15)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. 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 out of four residents (R1) were missing a pre-admission apprasaisal and four residents were missing their appraisal/needs and services plan which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/28/2023 Plan of Correction Administrator agrees to complete all residents appraisals and needs and services plans and submit proof to CCL by 9/28/23.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 quarterly disaster drills were not documented for any shift which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/28/2023 Plan of Correction Administrator stated that they will conduct a disaster drill for each shift on 9/15/23 and submit proof to CCL by 9/28/23.