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Official classification

Type A

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

87705(b)(2)Care of Persons with Dementia - Safety measures to address behaviors such as wandering. This requirement is not met as evidenced by:* **Based on observations of LPA on 8/7/2026, Resident R1 eloped from facility without continued staff supervision; the facility failed to take adequate safety measures to address behaviors such as wandering for resident R1 which poses an immediate Health, Safety risk to residents in care.

Official plan of correction

Licensee/applicant agrees to ensure elopement plan is followed. Licensee/applicant to conduct staff training regarding elopment and wandering behaviors. Proof of training with participants signature, trainer, & date of training; and elopement plan training dates to be submitted to CCL by 8/17/2026. **An immediate repeat civil penalty in the amount of $500 is assesed.

Deadline recorded: Aug 14, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87307(b)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accommodations and Services (b) Toilets and bathrooms shall be conveniently located. The licensed capacity shall be established based on Section 87158, Capacity, and the following: (1) At least one toilet and washbasin for each six (6) persons.. This requirement is not met as evidenced by:Based on LPA's observations,there was only one bathroom in service for 8 residents, not 6, which is stated in regulation which poses a potential risk to the residents in care.

Official plan of correction

Licensee to self- verify that there is at least one bathroom per 6 residents and send LPA notification by 8/17/2026.

Deadline recorded: Aug 14, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87405(b)

Regulation authority

CCR

What the official deficiency says

87405 Administrator - Qualifications and Duties (b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee.This requirement was not met as evidenced by: the list of Administrator Certification List, S1 was not found on the Current or pending list of administrators, which is a potential risk to the residents in care.

Official plan of correction

Licensee to ensure that there is a certified Administrator to submit proof of renewal submission or facility to submit change of Administrator within 10 days. Licensee/applicant to submit proof to CCL by POC date 8/18/26.

Deadline recorded: Aug 17, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87705(b)(2)

Regulation authority

CCR

What the official deficiency says

87705Care of Persons with Dementia(b)In addition...the plan of operation shall address the needs of residents with Dementia (b)(2)Safety measures to address behaviors...wandering, ingestion of toxic materials. This requirement is not met as evidenced by: Based on Incident and reports from outside parties that resident (R1) was allowed to go outside the facility unattended, which according to R1's physician's report is not allowed. This poses an immediate helath, safety, or personal rights risk to persons in care.

Official plan of correction

POC: Licensee to ensure all residents whose physician's reports require residents not to leave facility unattended are supervised. Licensee to provide proof of audit of 602's for all residents currently in facility by 6/5/2026. A civil penalty of $500 has been assessed Per Health & Safety Code 1568.0822(a)(3).

Deadline recorded: Jun 4, 2026. A deadline is not proof that correction was completed.

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. This requirement is not met as evidenced by: Based on LPA's interviews and records review, the licensee did not comply with the section cited above in that Licensee did not have a documented Administrator in place within 30 days. This poses a potential risk to health, safety or personal rights to persons in care.

Official plan of correction

Licensee to submit documents for placement of Administrator to CCL by 6/11/2026.

Deadline recorded: Jun 4, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (1)A written reort shall be submitted to the licensing agency and to the person responsible for the resident within 7 days of the occurrence of any of the events specified in (A) through (D) below...This requirement is not met as evidenced by: Based on LPA's records review of facility and outside agencies the licensee failed to notify the deaprtment within 7 days of R1's elopement which poses a potential risk to the health and safety of residents in care.

Official plan of correction

LIcensee to ensure incidents are reported per regulation. Licensee agrees to review regulation 87211 and conduct training for all staff on reporting requirements. Evidence of completed training to be submitted to CCL by POC date of 6/11/2026.

Deadline recorded: Jun 4, 2026. 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

87355 Criminal Record Clearance (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,LPA confirmed that there was one uncleared staff (S1) on the facility grounds, which poses an immediate health, safety or personal rights risk to persons in care, which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/10/2026 Plan of Correction Licensee to self certify that the adult observed in the facility during today's inspection will get finger print clearance. Licensee to submit proof that this process has been intiated to CCL by POC due date 04/10/2026.Civil Penalty issued.

Official classification

Type A

Official code

87355(e)(2)

Regulation authority

CCR

What the official deficiency says

87355(e)(2) 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:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by: Deficient Practice Statement This requirement is not met as evidenced by: During today's visit staff S2 had fingerprint clearance but was not associated to this facility. This is an immediate risk to the residents in care.

Official plan of correction

POC Due Date: 04/09/2026 Plan of Correction Facility to send in written statement they understand regulation and requirements. Licensee stated that they will take care of this immediately. Program Director submitted the paperwork necessary for the transfer of S2 in Guardian system during LPA's visit. Civil Penalty issued.