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13 | At approximately 8:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to open an investigation into the above allegations. LPA met with Executive Director Alma Peralta, interviewed staff and residents and reviewed documents. Based on interviews conducted and documents reviewed, the facilities call system is not operating fully. When a resident activates the system, the call is received at the front desk but does not directly notify caregivers as it should. During normal business hours, the front desk person receives the residents request for assistance who then radios the caregivers to relay where assistance is needed. After hours, caregiving staff are to check the computer system, at the front desk, frequently to provide assistance. This after hours process has resulted in many response times beyond 20 minutes to assist a resident.
Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
This report was reviewed with Alma Peralta and Appeal rights were given.
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| Substantiated | Estimated Days of Completion: |
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
07/14/2025
Section Cited
CCR
87303(a) | 1
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7 | 87303 Maintenance and Operation:(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. This requirement is not met as evidenced by: | 1
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7 | Licensee shall develop a written plan to address repair options for call system and methods to ensure residents receive timely assistance from staff. Written plan shall be submitted to CCLD by 07/14/2025. |
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14 | Licensee did not ensure resident pendant alert system was fully operational. This poses a potential Health, Safety or Personal Rights risk to persons in care. | 8
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Type B
07/14/2025
Section Cited
CCR
87411(a) | 1
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7 | 87411 Personnel Requirements - General:(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on records reviewed, Licensee did not ensure residents | 1
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7 | Licensee shall develop a written plan to address repair options for call system and methods to ensure residents receive timely assistance from staff. Written plan shall be submitted to CCLD by 07/14/2025. |
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14 | received timely assistance as noted in the Resident Hand Book. This poses a potential Health, Safety or Personal Rights risk to persons in care. | 8
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