Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
10/11/2021
Section Cited
CCR
87608(3)
| 1
2
3
4
5
6
7 | 87608 Postural Supports (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record... | 1
2
3
4
5
6
7 | Administrator will obtain a current hospice care plan which indicates the need for the postural support. |
 | 8
9
10
11
12
13
14 | This requirement was not met as evidenced by: LPA reviewed resident file and did not find a written order for the resident's half bed rails. | 8
9
10
11
12
13
14 | |
Type B
10/11/2021
Section Cited
CCR87608(a)(5)(B)
| 1
2
3
4
5
6
7 | 87608 Postural Supports (a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently on hospice care and..hospice care plan that specifies the need for full bed rails.This requirement was not met as | 1
2
3
4
5
6
7 | Administrator will obtain a current hospice care plan which indicates the need for the full rails. |
| 8
9
10
11
12
13
14 | evidenced by: Licensee did not comply with the section cited above by utilizing full bedrails for R1 who is on hospice however licensee does not have hospice care plan which indicates the need which poses an immediate health, safety personal rights risk to R1. | 8
9
10
11
12
13
14 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
10/11/2021
Section Cited
CCR
87555(b)(26)
| 1
2
3
4
5
6
7 | 87555(b) General Food Service Requirements (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. | 1
2
3
4
5
6
7 | Administrator will purchase food needed and provide a snapshot of food purchased. |
| 8
9
10
11
12
13
14 | This requirement was not met as evidenced by: Based upon LPA's observation the facility did not have an adequate supply of fresh fruits and vegetables and canned goods. | 8
9
10
11
12
13
14 | |
Type A
10/04/2021
Section Cited
CCR87705(j)
| 1
2
3
4
5
6
7 | 87705 Care of Persons with Dimentia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. | 1
2
3
4
5
6
7 | Administrator will ensure alarms have been properly repaired. Administrator will send paperwork from the company (Vivint) stating the alarm has been properly repaired. |
| 8
9
10
11
12
13
14 | This requirement was not met as evidenced by: Based upon LPA's observations, the alarm on all exit doors were not working. This poses an immediate health, safety and 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 A
10/04/2021
Section Cited
HSC
1569.311
| 1
2
3
4
5
6
7 | 1569.311 Carbon monoxide detectors required; inspection. Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility...This requirement is not met as evidenced by: | 1
2
3
4
5
6
7 | Administrator will provide a receipt and a picture showing the devices have been installed within the facility. |
| 8
9
10
11
12
13
14 | Based on observation and interviews, licensee failed to ensure the facility had one or more carbon monoxide detectors at the facility which poses an immediate health and safety risk to residents in care. | 8
9
10
11
12
13
14 | |
Type A
09/03/2021
Section Cited
CCR80020(a)
| 1
2
3
4
5
6
7 | Fire Clearance Violations, including, but not limited to, over capacity, ambulatory status, inoperable smoke alarms, and inoperable fire alarm systems. All facilities shall secure and maintain a fire clearance approved by the city or county fire department, | 1
2
3
4
5
6
7 | Adminstrator will notify the department in writing what steps were taken to clear this deficiency |
| 8
9
10
11
12
13
14 | This is not met as evidenced by observation and inteview the licensee did not comply with the regulation above by not ensuring the smoke detectors are operational which poses an immediate health,safety personal rights risk to persons in care. | 8
9
10
11
12
13
14 | This is a zero tolearnce violation therefore a civil penalty in the amount of $500 has been issued. Civil penalty will continue to accrue in the amount of $100 per day until plan of correction has been submitted. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
10/04/2021
Section Cited
CCR
87633(b)
| 1
2
3
4
5
6
7 | 87633(b) A current and complete hospice care plan shall be maintained ... for each hospice resident and include the following: This requirement is not met as evidenced by: | 1
2
3
4
5
6
7 | Licenseevwill obtain a copy of the hopsice care plan fro both residents and submit copies to the LPA as POC. |
| 8
9
10
11
12
13
14 | Based on record review the licensee did not comply with the section cited above by not obtaining hospice plans for R1 and R2. | 8
9
10
11
12
13
14 | |
Type B
10/11/2021
Section Cited
CCR87632(a)
| 1
2
3
4
5
6
7 | In order accept or retain terminally ill residents &... receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. This requirement was not met as evidenced by: Based on record | 1
2
3
4
5
6
7 | Licensee will Submit hospice care waiver request or exception to retain the two hospice residents. |
| 8
9
10
11
12
13
14 | review,the licensee did not comply with the section cited above by retaining 2 residents on hospice prior to obtaining an approved hospice waiver which poses an potential health, safety & 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
10/11/2021
Section Cited
CCR
87411(c)(1)
| 1
2
3
4
5
6
7 | 87411(c)(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: | 1
2
3
4
5
6
7 | Licensee/Administrator will provide first aid training to all staff and submit copies of certificates/cards as POC. |
| 8
9
10
11
12
13
14 | Based on record review, the licensee did not comply with the section cited above by not ensuring 5 out of 8 staff received first aid training which poses a potential health, safety or personal rights risk to persons in care. | 8
9
10
11
12
13
14 | |
Type B
10/11/2021
Section Cited
HSC1569.69(a)
| 1
2
3
4
5
6
7 | 1569.69(a) Each residential care facility...shall ensure ... employee ... who assists residents with the self-administration of medications meets... training requirements: | 1
2
3
4
5
6
7 | Licensee/Administrator will schedule vendorized medication training for all staff who assist residents with medication. Verification of scheduled training with the trainers credentials will need to be submitted by |
| 8
9
10
11
12
13
14 | This requirement is not met as evidenced by: Upon review of the staff records, LPA observed staff has not completed the required medication trainnig. | 8
9
10
11
12
13
14 | 10/01/2021 and verification of completed training will need to be submitted to LPA by 10/11/2021. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
10/11/2021
Section Cited
HSC
1569.696(a)
| 1
2
3
4
5
6
7 | 1569.696(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care...the training requirements specified in .... The training shall include all of the following: | 1
2
3
4
5
6
7 | Licensee/Administrator will need to schedule vendorized training for all staff. Verification of scheduled10/02/2021 with the trainers credentials will need to be submitted to LPA by 10/11/2021 and verification of completed training will need to be submitted to LPA by 10/11/2021. |
| 8
9
10
11
12
13
14 | This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by not ensuring staff received the required training which poses a potential health, safety or personal rights risk to persons in care. | 8
9
10
11
12
13
14 | |
Type B
10/11/2021
Section Cited
HSC1569.625(b)
| 1
2
3
4
5
6
7 | 1569.625(b) Staff training; legislative findings; contents. (1) The department ...staff members ...who assist residents with personal activities of daily living to receive ... training. This training shall consist of 40 hours of training. ...(2) training requirements shall also include an additional 20 hours annually…. | 1
2
3
4
5
6
7 | Licensee/administrator will schedule vendorized training for all staff. Licensee/administrator will submit verification of scheduled training with the trainers credentials to LPA by 10/01/2021 and submit verification of completed training to LPA by 10/11/2021 |
| 8
9
10
11
12
13
14 | This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by not ensuring staff received the required training 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
10/11/2021
Section Cited
HSC
87405(a)
| 1
2
3
4
5
6
7 | 87405(a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by: | 1
2
3
4
5
6
7 | Licensee/Administrator will need to notify the department in writing how this deficiency will be cleared. |
| 8
9
10
11
12
13
14 | Based on observation, interview and record review, the licensee did not comply with the section cited above by not having a certified administrator working which poses a potential health, safety, personal rights risk to persons in care. | 8
9
10
11
12
13
14 | |
Type B
10/11/2021
Section Cited
HSC87468.1(a)(2)
| 1
2
3
4
5
6
7 | Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced | 1
2
3
4
5
6
7 | Licensee/Administrator will begin screening all residents, staff and visitors. Licensee/Administrator will create a sign in sheet which includes COVID symptom questions and recorded tempereatures. |
| 8
9
10
11
12
13
14 | by: Based on observation the licensee did not comply with the section cited above by not conducting routine symptom screening for resident,staff & visitors which poses an immediate health, safety, personal rights risk to persons in care. | 8
9
10
11
12
13
14 | Licensee will send a copy of the sign in sheet to LPA Spaeth. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
10/11/2021
Section Cited
CCR
87411(d)(5)
| 1
2
3
4
5
6
7 | 87411(d)(5) (d) All personnel shall be given training... This training ...shall provide knowledge of and skill in the following,.. for the job assigned and ... job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help. | 1
2
3
4
5
6
7 | Licensee/Administrator will schedule training for all staff to be provided by and individual certified in infection control infection prevention, symptoms, transmission and PPE use, and all sections listed in the department LIC808 Mitigation Plan. Training will need to be scheduled within 24 hours and completed within 7 days. Licensee/Administrator will email LPA with the credentials of the trainer and the scheduled training date and submit verification of training once completed. |
| 8
9
10
11
12
13
14 | This requirement was not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above by not providing staff training on infection prevention, symptoms, transmission and PPE use by any individual trained in infection control which poses an immediate health, safety or personal rights risk to persons in care. | 8
9
10
11
12
13
14 | |
Type B
10/11/2021
Section Cited
CCR87411(f)
| 1
2
3
4
5
6
7 | 87411 (f) Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by. | 1
2
3
4
5
6
7 | The Administrator agrees to provide CCL with a current, complete Personnel Report (LIC 500) This deficiency resulted in an absence of supervision which is a zero tolerance deficiency as per |
| 8
9
10
11
12
13
14 | Based on interview, the licensee did not comply with the section cited above by not having qualified staff on the premises at nights resulting in absence of supervision for the 2 residents in care which poses an immediate health, safety personal rights risk to persons in care. | 8
9
10
11
12
13
14 | Health & Safety Code 1597.58 which states that an immediate Civil Penalty of $500 will be assessed at the time of the citation and an additional $100 per day until the deficiency is corrected. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
10/11/2021
Section Cited
CCR
87468(a)(1)
| 1
2
3
4
5
6
7 | Residents in all residential care facilities shall have all of the
following personal rights: (1)To be accorded dignity in their personal relationships with staff. This requirement was not met as evidenced by: | 1
2
3
4
5
6
7 | The Administrator agrees to provide CCL with a current, complete and correct Personnel Report (LIC 500) that documents sufficient |
| 8
9
10
11
12
13
14 | Based on observation, interview, the licensee did not comply with the section by R1 by placing a baby monitor in resident room to monitor residents at night which poses an immediate health, safety and personal rights risk to persons in care. | 8
9
10
11
12
13
14 | staffing and includes designated on-call staff with contact information and estimated response time to the facility in an emergency. |
| 1
2
3
4
5
6
7 | | 1
2
3
4
5
6
7 | |
| 1
2
3
4
5
6
7 | | 1
2
3
4
5
6
7 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
10/11/2021
Section Cited
CCR
87465(h)(6)(6)
| 1
2
3
4
5
6
7 | 87465 (h)(6) (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications ... is maintained for at least one year and includes… This requirement is not met as evidenced by:Based on interview and record | 1
2
3
4
5
6
7 | Licensee will complete centrally stored medication and destruction records for all residents and submit copies to the LPA as POC. |
| 8
9
10
11
12
13
14 | review, the licensee did not comply with the section cited above by not completing/retaining centrally stored medication & destruction record for 2 out of 2 residents which poses a potential health, safety and personal rights risk to persons in care | 8
9
10
11
12
13
14 | |
Type B
10/11/2021
Section Cited
CCR87465(b)(c)(d)
| 1
2
3
4
5
6
7 | Licensee is required to have PRN authorization letter on file signed by a physician to determine whether or not the residents can communicate the need and/or symptoms clearly for the as needed (PRN) medication. This requirement is not met as | 1
2
3
4
5
6
7 | Licensee will contact residents Physicians to obtain PRN authorization letters for
all residents who they provide medication assistance to.
|
| 8
9
10
11
12
13
14 | evidenced by: Based on record review, the licensee did not comply with the section cited above by not
obtaining PRN authorization letters for 2 residents which poses a potential health,safety or personal rights risk to persons in care. | 8
9
10
11
12
13
14 | Copies of the PRN authorization letters will need to be submitted as POC. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
10/08/2021
Section Cited
CCR
87205(b)
| 1
2
3
4
5
6
7 | 87205 (b) Accountability of Licensee Governing Body-(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. This requirement is not met as evidenced by: | 1
2
3
4
5
6
7 | Licensee will resolve the corporation status and ensure that it is active. Proof of resolution will
need to be submitted as POC.
|
| 8
9
10
11
12
13
14 | the licensee did not comply with the section cited above by not ensuring that the corporation remains active which poses a potential health, safety and personal rights risk to persons in
care. | 8
9
10
11
12
13
14 | |
Type B
10/11/2021
Section Cited
HSC1569.605
| 1
2
3
4
5
6
7 | Liability insurance; coverage requirements On and after July 1, 2015, all residential care facilities for the elderly...shall maintain liability insurance covering injury to residents and guests...This requirement was not
| 1
2
3
4
5
6
7 | Licensee will review the health and safety code, obtain liability insurance as required by the health and safety code.
|
| 8
9
10
11
12
13
14 | met as evidenced by: Based on interview, the licensee did not comply with the section cited above as the failing to obtain/maintain liability insurance which poses a potential health, safety, personal rights risk to persons in care. | 8
9
10
11
12
13
14 | Copy of the current liability insurance certificate will need to be
submitted as POC. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
10/11/2021
Section Cited
CCR
87305(a)
| 1
2
3
4
5
6
7 | 87305(a) Alterations to Existing Building or New Facilities Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Based on observations, the
| 1
2
3
4
5
6
7 | Licensee will notify the department in writing how this deficiency has been cleared. |
| 8
9
10
11
12
13
14 | licensee did not comply with the section cited above by building unpermitted staff rooms in the garage which poses an immediate health, safety and personal rights risk to persons in care and staff.
| 8
9
10
11
12
13
14 | |
Type A
10/11/2021
Section Cited
CCR87207
| 1
2
3
4
5
6
7 | False Claims: No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
| 1
2
3
4
5
6
7 | The licensee will submit a written explanation why the false/misleading statements were made and what steps will be taken to prevent a repeat of this deficiency. |
| 8
9
10
11
12
13
14 | This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above by providing
false/misleading statement regarding the designated facility administrator.
| 8
9
10
11
12
13
14 | |