VARENITA OF WESTLAKE

Official classification

Type A

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1...residents...shall have all of the following personal rights: (8) To be free from...financial exploitation... This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as S1 financially exploited R1 which posed an immediate health, safety, or personal rights risk to R1.

Official plan of correction

S1 was terminated on 12/02/2025. R1's responsible party was offered reimbursement. ED stated that the facility will conduct an in-service with all staff to review the theft and loss policy and resident rights. ED will submit proof to CCLD by the due date.

Deadline recorded: Dec 10, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

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 record review, the licensee did not comply with the section cited above as fire extinguishers were not serviced within 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: 09/30/2025 Plan of Correction ED scheduled fire extinguisher servicing during the visit. ED will send proof of serviced fire extinguishers to CCLD by the due date.

Official classification

Type B

Official code

87303(i)(1)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more...shall have a signal system which shall: This requirement is not met as evidenced by: Based on interviews, the licensee did not comply as R1 was without a pendant for a period of time which posed a potential health, safety, and personal rights risk to person(s) in care.

Official plan of correction

During the time of the visit, R1 was observed with a pendant. POC is cleared.

Deadline recorded: Jan 2, 2025. A deadline is not proof that correction was completed.

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 that two (2) staff members did not have a transfer of criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2024 Plan of Correction One (1) out of two (2) staff was associated to the facility during the time of the visit. Administrator ensures that the remaining staff member will not be working at the facility and is taken off the schedule for the week until they are associated. Administrator will submit proof of livescan to CCL.

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 that six (6) of six (6) staff were missing 40 hours initial and 20 hours annual training which poses a potential health, safety and personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2024 Plan of Correction Administrator will ensure that initial and annual training will be started by next week for all staff. Administrator will submit proof of training plan to CCL by 09/23/2024.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. 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 that three (3) out of six (6) staff did not have First Aid training which poses a potential health and safety rights risk to persons in care.

Official plan of correction

POC Due Date: 09/27/2024 Plan of Correction Administrator agrees to have staff complete First Aid training and submit proof of completion to CCL by 09/27/2024.

Official classification

Type B

Official code

87705(f)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: 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 that cleaning solutions and scissors were stored accessible to residents with dementia which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 09/23/2024 Plan of Correction WM Ghorbankhani and Maintenance Director (MD) Michael Cornejo locked the kitchen area during the time of the visit. MD plans to replace the door to the kitchen area. Administrator will ensure that drawers and cabinets containing cleaning solutions and sharps will remain locked and inaccessible to residents. Administrator will submit a statement of understanding of the section cited above to CCL by 09/23/2024.

Official classification

Type A

Official code

87468.1

Regulation authority

CCR

What the official deficiency says

87468.1 Personal Rights of Residents in All Facilities.(a) Residents in all RCFE..shall have all of the following personal rights (11)To have their visitors, including ombudspersons and... permitted to visit privately during reasonable hours and without prior notice...This requirement is not met as evidenced by: Based on interviews review, the licensee did not comply with the section cited above, as one visitors were prevented from visiting R1, which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC: Facility Administration staff will review regulation pertaining to visitors, and email the LPA Self-Ceritification by 01/05/2024.

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

Official classification

Type A

Official code

87411(f)

Regulation authority

CCR

What the official deficiency says

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interviews, the licensee did not comply with the section cited above in that One out of five staff files reviewed indicate staff do not have documentation showing negative TB tests which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/13/2023 Plan of Correction Licensee will provide TB results for staff without results to CCL or provide documentation showing the test is in process by the due date.

Official classification

Type A

Official code

87465(h)(1)(C)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers related to the medication itself, or due to physical arrangements in the facility and the condition or the habits of other persons in the facility, the medications are determined by either a physician, the administrator, or Department to be a safety hazard to others. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, record review and interviews, the licensee did not comply with the section cited above in medications were found in resident's room and resident's LIC 602 indicates resident cannot store/administer medications which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/13/2023 Plan of Correction Wellness DIrector immediately stored medications in the wellness office. Wellness DIrector will conduct training with staff on proper medication storage, send LPA an agreement to LPA by 9/13/23 that training will be finalized by 9/19/23. Agreement will include that training sign-in sheets will be sent to LPA by 9/19/23.

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 and interviews, the licensee did not comply with the section cited above in five out of five staff files indicate staff did not complete annual required training which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 09/19/2023 Plan of Correction Licensee has agreed to ensure that staff complete annual training and send sign-in sheets to CCL by due date.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

Request for a transfer of a criminal record clearance specified in Section 87355( c). This requirement is not met as evidenced by: Deficient Practice Statement Based on record review and interviews, the licensee did not comply with the section cited above in that one out of five staff files reviewed indicate that staff 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: 09/13/2023 Plan of Correction Licensee immediately associated staff to facility. No further action needed.

Official classification

Type A

Official code

87307(e)

Regulation authority

CCR

What the official deficiency says

87307(e) Personal Accommodations and Services. Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools, or similar bodies of water...through fencing, covering or other means. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as the facility had water fountains in the courtyard and in front of the building filled with standing water, which poses an immediate health and safety risk to persons in care.

Official plan of correction

The Administrator agreed to do the following: 1. Water features will be drained of water by end of the day, 1/20/2023. 2. Rocks would be placed in the water features to ensure water depth does not pose a hazard to residents in care. Send photos once completed. Immediate civil penalty assessed of $500.

Deadline recorded: Jan 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355(e)(2) Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2) Request a transfer of a criminal record clearance… This requirement is not met as evidenced by: Based on interviews and observations, the licensee did not comply with the section cited above, as one individual (S1) have been working at the facility without a criminal record transfer, which poses an immediate health and safety risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: 1. Ensure that S1 is associated to this location. Submit proof to CCL when this has taken place. Civil penalty assessed for $100 a day, for a maximum of 5 days.

Deadline recorded: Jan 20, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(2) Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on observations and interview, the licensee did not comply with the section cited above, as staff and guests within the community were not wearing face masks in the facility, which poses a potential personal rights risk to residents in care.

Official plan of correction

The Administrator agreed to do the following: Administrator agreed to hold training with all staff about proper mask-wearing and COVID-19 prevention protocol for staff and visitors and provide training records to CCL within seven (7) days.

Deadline recorded: Jan 27, 2023. A deadline is not proof that correction was completed.