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13 | Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegation. LPA met with staff, Arnold Makura, and advised him of the complaint. It was reported that the facility is licensed for six (6) clients and according to the license the clients should be ambulatory or on hospice but the clients currently in care may not meet those criteria. Today's investigation consisted of interviews with staff and residents, a physical plant inspection and record review. Facility currently has a census of four (4) residents. In addition to interviews with the residents, LPA requested for all four residents to demonstrate whether or not they can get up and go to the bathroom, or exit their rooms on their own. Per resident interview and resident demonstration, LPA was able to identify three (3) of the four residents to be non-ambulatory through interviews and their inability to get up and ambulate on their own. In addition, another Resident, (R6) refer to LIC 811, who just moved out, was also identified as non-ambulatory. Based on the information obtained the above allegation is Substantiated. Citation(s) issued on the 9099D. An immediate Civil Penalty (CP) of $500 for fire clearance issued. Licensee advised that CP of $100 will continue to accrue daily, until this deficiency is corrected. Copy of this report issued. |
| Substantiated | Estimated Days of Completion: |
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
05/01/2025
Section Cited
CCR
87202(a)(1) | 1
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7 | Fire Clearance: All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining (1)Nonambulatory Persons, licensee shall notify the licensing agency and | 1
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7 | As POC, the licensee will apply for the appropriate fire-clearnace to retain nonambulatory residents. If the fire clearance cannot be approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal, the licensee will need |
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14 | obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidenced by: LPA identified four residents that were non-ambulatory. | 8
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14 | to relocate the residents identified as non-ambulatory by May 8, 2025. An immediate Civil Penalty (CP) was assessed for $500 today for fire clearance violation. This CP will continue to accrue at $100/day if the licensee fails to correct this deficiency. |
Type A
05/01/2025
Section Cited
CCR
87608(5)(B) | 1
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7 | Postural Support: Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirment was not met as evidenced by: during investigation, LPA observed R4 | 1
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7 | As POC, licensee will remove or replace the bedrails to comply with 87608(5). A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. If R4 is receiving hospice care, licensee will produce a hospice care plan to specify the need for the full |
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14 | to have bedrails that extended beyond half the length of the resident's bed. R4 did not have a hospice care plan on file that specifies the need for full bed rails. | 8
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14 | bed rails. As proof this is corrected, POC due to the licensing agency by May 8, 2025. |
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13 | Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegation. LPA met with staff, Arnold Makura, and advised him of the complaint. It was reported that there is one staff member present seven days a week, 24 hours a day. When questioned about leaving the premises, staff stated that they occasionally step out for errands only after ensuring all patients are cared for and ready for bed. Today's investigation consisted of interviews with residents and staff.
Interviews with the four (4) residents do not corroborate with the allegation. Residents that were interviewed identified administrator and another staff or staff relief, come to facility daily. In addition to Arnold, there are two other staff, including the administrator that work here and come every day. Interview with Staff 1 (S1) and the administrator, deny the allegation, stating there is staff relief that come to facility every day. Based on the information obtained, it could not be proven that staff leaves residents unattended. Therefore, the allegation is deemed Unsubstantiated at this time. |
| Unsubstantiated | Estimated Days of Completion: |
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