Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
10/25/2024
Section Cited
CCR
87463(a)
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4
5
6
7 | (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:
This requirement is not met as evidenced by:
| 1
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3
4
5
6
7 | Administrator will submit self-certification that ANS was updated for R2-R9 and placed in their files to CCLD by POC date. |
 | 8
9
10
11
12
13
14 | Based on file review, the licensee did not comply with the section cited above in by not having updated Appraisal Needs and Services (ANS) for R2-R9 which poses a potential health and safety risk to persons in care. | 8
9
10
11
12
13
14 | |
Type B
10/31/2024
Section Cited
CCR87623(b)(2)(B)
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6
7 | 87623 Indwelling Urinary Catheter
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:
(2) Ensuring that the bag and tubing are changed by an appropriately skilled professional should the resident require assistance.
| 1
2
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5
6
7 | Administrator will submit an exception letter for R7 and R9 with supporting documents that includes but not limited to a Physician's Report (LIC602A), Home Health Care Plan, ANS, and staff that was trained by an appropriate licensed health professional to CCLD by POC date. |
| 8
9
10
11
12
13
14 | Based on observation, interview and file review, the licensee did not comply with the section cited above in by not having documentation of the foley catheter for R7 and R9 in their files including but not limited with a home health care plan, updated Appraisal Needs and Services (ANS) Plan, In-Training staff roster if applicable for whom is caring for the catheter bag which poses a potential health and safety risk to persons in care. | 8
9
10
11
12
13
14 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
10/25/2024
Section Cited
CCR
87211(a)(1)
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2
3
4
5
6
7 | (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 of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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6
7 | Administrator will read the regulation and self certify that they understand this regulation moving forward. |
| 8
9
10
11
12
13
14 | Based on record review and interview with staff, the licensee did not comply with the section cited above by not sending notification (LIC624) to Licensing when R6 was hospitailzed which poses an immediate health and safety risk to persons in care. | 8
9
10
11
12
13
14 | |
Type B
10/31/2024
Section Cited
CCR87458(c)
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6
7 | (c) The licensee shall obtain an updated medical assessment when required by the Department.
This requirement is not met as evidenced by:
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4
5
6
7 | Administrator agreed to schedule doctor's appointments and submit copies of updated LIC602A to CCLD by POC date. |
| 8
9
10
11
12
13
14 | Based on record review, the licensee did not comply with the section cited above in by having Physician's Reports that were over a year old and not updated for R2, R3, R4, R6, R7 and R9 which poses a potential health, safety or personal rights risk to persons in care. | 8
9
10
11
12
13
14 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
11/15/2024
Section Cited
HSC
1569.618(c)(3)
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5
6
7 | (c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (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: | 1
2
3
4
5
6
7 | Administrator agreed to submit First Aid and CPR training certificates for S3-S9 to CCLD by POC date. |
| 8
9
10
11
12
13
14 | Based on record review, the licensee did not comply with the section cited above in by not having First Aid and CPR training certificates updated for S3-S9 which poses a potential health and safety risk to persons in care. | 8
9
10
11
12
13
14 | |
Type B
11/15/2024
Section Cited
CCR87411(f)
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4
5
6
7 | (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:
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5
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7 | Administrator agreed to obtain health screenings and negative TB test results for S3 and S9 and a negative TB test for S7 and submit copies to CCLD by POC date. |
| 8
9
10
11
12
13
14 | Based on record review, the licensee did not comply with the section cited above by not having health screening and TB test for S3 and S9 and TB test for S7 which poses a potential health and safety risk to persons in care. | 8
9
10
11
12
13
14 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
11/15/2024
Section Cited
HSC
1569.625(b)(2)
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5
6
7 | (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:
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3
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5
6
7 | Administrator agreed to send a detailed plan to CCLD on how they will complete the trainings and send the transcripts/certificates of the completed trainings for S2-S9 to CCLD by POC date. |
| 8
9
10
11
12
13
14 | Based on file review, the licensee did not comply with the section cited above in by not having annual trainings on file and completed for S2-S9 which poses a potential health, safety or personal rights risk to persons in care. | 8
9
10
11
12
13
14 | |
Type B
10/24/2024
Section Cited
CCR87458(b)(1)
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2
3
4
5
6
7 | (b) The medical assessment shall include, but not be limited to:
(1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility.
This requirement is not met as evidenced by: | 1
2
3
4
5
6
7 | Administrator agreed to submit an negative TB result for R5 to CCLD by POC date. |
| 8
9
10
11
12
13
14 | Based on record review, the licensee did not comply with the section cited above in by not having on file an negative TB result for R5 which poses a potential health and safety risk to persons in care.
| 8
9
10
11
12
13
14 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
10/31/2024
Section Cited
CCR
87506(a)(b)
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2
3
4
5
6
7 | (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
(b) Each resident’s record shall contain at least the following information:
This requirement is not met as evidenced by:
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2
3
4
5
6
7 | Administrator agreed to complete the resident file for R6 and submit a copy of all documents to CCLD by POC date. |
| 8
9
10
11
12
13
14 | Based on record review, the licensee did not comply with the section cited above in by not having on file a complete resident file for R6 including but not limited to Admission's Agreement, Physician's Report, consent form, Personal Rights, appraisal, Emergency/ID info. and medication list which poses a potential health, safety or personal rights risk to persons in care. | 8
9
10
11
12
13
14 | |
Type B
11/08/2024
Section Cited
CCR87303(a)(1)(c)
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5
6
7 | (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. (c) All window screens shall be clean and maintained in good repair.
This requirement is not met as evidenced by:
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3
4
5
6
7 | Administrator agree to submit a detailed plan on how the repairs will be done and submit photos to CCLD by POC date. |
| 8
9
10
11
12
13
14 | Based on observation, the licensee did not comply with the section cited above in by having chest drawer furniture, chairs, ladders, wood, washing machine, recliner, wood loctaed in the front/side/back yards. Flooring in common areas including but not limited to the main hallway was not clean and in disrepair where there are cracks and edges missing/cracked. The floors in the kitchen, bathrooms, resident rooms were not clean and windows/window screens were not clean which poses a potential health, safety or personal rights risk to persons in care. | 8
9
10
11
12
13
14 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
10/31/2024
Section Cited
CCR
87555(b)(16)
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4
5
6
7 | 87555 General Food Service Requirements
(b) The following food service requirements shall apply: (16) In facilities licensed for sixteen (16) to forty-nine (49) residents, one person shall be designated who has primary responsibility for food planning, preparation and service. This person shall be provided with appropriate training.
This requirement was not met as evidenced by: | 1
2
3
4
5
6
7 | Administrator agreed to submit an updated Food Safety certificate for S4 to CCLD by POC due date. |
| 8
9
10
11
12
13
14 | Based on file review, Licensee did not comply with the section cited above in by having an updated Food Service certification on file for S4, the certificate expired in 2021 which poses a potential health and safety risk to persons in care.
| 8
9
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14 | |
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5
6
7 | | 1
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5
6
7 | |
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5
6
7 | | 1
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7 | |