Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
08/18/2026
Section Cited
CCR
87411(a) | 1
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5
6
7 | (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
This requirement was not met as evidence by: | 1
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7 | By POC facility agrees to permanently schedule at least two med-techs per shift (not including members of leadership) for each department and submit schedules to CCLD. |
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14 | Based on interview and record review, the licensee did not comply with the section cited above in not having any staff to administer memory care residents morning medications on 7/11/2026 which resulted in medication mismanagment due to all memory care residents missing their morning meds which posed an immedite health and personal rights risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
09/15/2026
Section Cited
CCR
87465(i) | 1
2
3
4
5
6
7 | (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following:
This requirement was not me as Evidence by: | 1
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7 | By POC Facility agrees to have all med-techs, and all members of the clinical team re-train in Incidental Medical and Dental Care by an approved CCLD vendor not previously used by the licensee of facility and provide training certificates to CCLD. |
| 8
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14 | Based on interview and record review, the licensee did not comply with the section cited above in R6's medication having been destroyed and observed mixed in with destroyed medications in the memory care med room destroy bin while not having the required documentation or any documentation recording the destruction which posed a potential personal rights risk to persons in care. | 8
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14 | |
Type B
08/18/2026
Section Cited
HSC
1569.69(a)(1) | 1
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3
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5
6
7 | (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:(1)In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment.
This requirement was not me as Evidence by: | 1
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7 | By POC facility agrees to audit all staff who are assisting with the self-administration of medications training records and remove all staff immediately who do not meet the requirements, provide the required training prior to allowing assisting with the self-administration of medications, and notify CCLD of the staff involved/retrained and who provided assistance with the self-administration of medications while other staff was being retrained. |
| 8
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14 | Based on interview and record review, the licensee did not comply with the section cited above in S2 assisting with the self-administration of medications prior to meeting the above training requirements/ qualifications and having no training record available for review which posed a potential safety and personal rights risk to persons in care. | 8
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14 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
09/01/2026
Section Cited
CCR
87211(a)(1)(D) | 1
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.(D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement was not met as evidence by | 1
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3
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5
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7 | By POC facility agrees to have all care staff, med techs, and managment team retrain on reporting requirements by a CCLD approved vendor not previously utilized by the facility or licensee and provide all training certificates to CCLD. |
| 8
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14 | Based on interview and record review, the licensee did not comply with the section cited above in not reporting the medication error as of 8/5/2026 that occured for all resident in memory care on 7/11/2026 in the morning to all of the required parties which posed an immedite personal rights risk to persons in care. | 8
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