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13 | Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit to determine the validity of the above-mentioned allegations. LPA met with Takyra Armstrong (Caregiver) and explained the reason for the visit.
The investigation consisted of the following: On 07/20/2023, LPA Mora obtained copies of the resident, staff rosters, and the facility sketches. LPA interviewed Administrator, Staff 1 - Staff 2 (S1 - S2), Resident 1 - Resident 7 (R1 - R7) and toured the facility. During today's visit, LPA Mora interviewed Administrator, Staff 3 - Staff 5 (S3 – S5), Resident 1 (R1), Resident 2 (R2), Resident 4 (R4), Resident 5 (R5) and Resident 7 (R7) and toured the facility.
The investigation revealed the following: regarding the allegation "facility is operating beyond the terms and conditions of their license", it is alleged that the facility is overcapacity and has a total of 7 residents. Facility is licensed to serve 6 residents. Interviews with Administrator and staff and tour conducted on 07/20/2023 confirmed that the facility did have a total of 7 residents. LPA observed the 7th resident in the office room. During today’s visit, LPA observed a total of 5 residents. (Continued to LIC 9099-C) |
| Substantiated | Estimated Days of Completion: |
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NARRATIVE |
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32 | Regarding the allegation " facility's plan of operation is not current", it is alleged that it is possible that the caregivers’ room was repurposed into a resident bedroom leading to the staff sleeping in the garage. Administrator stated that the garage and the room near the garage where both licensed as "Administrator Living Area" and she had beds in there because there are times that she and her children sleep in there or staff will ask to sleep in there. LPA reviewed the facility sketch in the Community Care Licensing Department (CCLD) records that was submitted during the application and pre-licensing process and observed that the facility sketch has the garage labeled as “garage” and the room near the garage is labeled as “office”. The pre-licensing visit conducted on 07/19/2019, list a staff room (most likely the office room) and a garage. There is no mentioned of “Administrator Living Area”. During the tour conducted on 07/20/2023, LPA observed bunk beds bunched up together on one side of the garage without any linens and a separate bed with linens and the room that is supposed to be the office was occupied by a resident. During today’s visit, the bunk beds without linens and the separate bed with linens are still in the garage and there is a TV with cable box, a heater, some clothes in a box next to the bed. The office room is vacant and there are some boxes being stored in there. Facility does not have any permits that allows them to use the garage as a living/sleeping area.
Regarding the allegation "facility does not provide a safe environment for the residents in care", it is alleged that there is a step down in the hallway leading from the kitchen area to the garage. The step down is not easily identified, and a piece of tile is missing in the area right below the step down and this could cause a trip hazard. During the tour on 07/20/2023, the LPA observed that as soon as you open the door from the kitchen area there is a hallway that leads to the garage and office room. The floor in the kitchen area is about 3-4 inches higher than the floor in this hallway which creates a step down and can be a tripping hazard. Staff interviewed stated that residents are not allowed to go into this area and that this door needs to be locked. During both tours, the LPA observed that the door was not locked.
Regarding the allegation "facility does not have auditory devices in all exits", it is alleged that there are no alarms on the doors leading to outside. During the tour on 07/20/2023, LPA observed that only the front door has an auditory device. There are 3 exit doors leading to outside that do not have an auditory device which are the back sliding door, the bathroom in bedroom #3, and the exit door in the office room. During today’s visit, all exit doors are missing an auditory device. Facility has dementia resident and are required to have auditory devices on all exit doors.
Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited and a civil penalty will be issued. Refer to LIC 9099-D and LIC 421IM. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
03/08/2024
Section Cited
CCR
87204(a) | 1
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7 | 87204 Limitations - Capacity and Ambulatory Status.
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time….
This requirement is not met as evidenced by:
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7 | Licensee will ensure that Title 22 Section Code 87204 are met at all times. Additionally, Licensee will write a statement that they will comply with this regulation and submit statement by 03/08/2024.
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 | 8
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14 | Based on observation and interviews, the licensee did not comply with the section cited above, which poses an immediate health, safety, or personal rights risk to persons in care. Facility was over capacity due to having a 7th resident. | 8
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14 | This deficiency will result in an immediate civil penalty for operating beyond the approved capacity.
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Type B
03/08/2024
Section Cited
CCR
87307(a)(2)(B) | 1
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7 | 87307 Personal Accommodations and Services.
(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building.
This requirement is not met as evidenced by:
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7 | Licensee will ensure that Title 22 Section Code 87307 are met at all times. Additionally, Licensee will write a statement that they will comply with this regulation and submit the statement to CCLD by 03/08/2024. |
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14 | Based on observation and interviews, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. Resident 6 was residing in a room licensed as "Office". | 8
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14 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
03/15/2024
Section Cited
CCR
87208(a)(7)(A) | 1
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7 | 87208 Plan of Operation.
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (7) Sketches, showing dimensions, of the following: (A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents and for bedridden residents, other than for a temporary illness or recovery from surgery as specified in Sections 87606(d) and (e).
This requirement is not met as evidenced by: | 1
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7 | Licensee will ensure that Title 22 Section Code 87208 are met at all times. Additionally, Licensee is to request a building permit to operate the garage as a staff room, and will submit permit and updated facility sketch to CCLD for approval or remove the bed from the garage and write a statement that they will use the garage as intended.
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14 | Based on observation and interviews, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. The garage is being used as a sleeping area for staff and there is no permits allowing this. Also, the garage was not licensed as a living/sleeping area for staff. | 8
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Type B
03/08/2024
Section Cited
CCR
87307(d)(4) | 1
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7 | 87307 Personal Accommodations and Services
(d) The following space and safety provisions shall apply to all facilities: (4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted.
This requirement is not met as evidenced by:
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7 | Licensee will ensure that Title 22 Section Code 87307 are met at all times. Additionally, Licensee will write a statement of how they will address the tripping hazard issue and submit the statement to CCLD by 03/08/2024. |
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14 | Based on observation and interviews, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. There is a step down when opening a door in the kitchen area leading to a hallway that leads to the garage. This step down is not noticeable and can be a tripping hazard. This door was unlocked when LPA visited the facility. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
03/08/2024
Section Cited
CCR
87705(j) | 1
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7 | 87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement is not met as evidenced by: | 1
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7 | Licensee will ensure that Title 22 Section Code 87705 are met at all times. Additionally, Licensee will install auditory devices on all exit doors by 03/08/2024. |
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14 | Based on observation and interviews, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. All exit doors did not have an auditory device. | 8
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13 | Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit to determine the validity of the above-mentioned allegations. LPA met with Takyra Armstrong (Caregiver) and explained the reason for the visit.
The investigation consisted of the following: On 07/20/2023, LPA Mora obtained copies of the resident, staff rosters, and the facility sketches. LPA interviewed Administrator, Staff 1 - Staff 2 (S1 - S2), Resident 1 - Resident 7 (R1 - R7) and toured the facility. During today's visit, LPA Mora interviewed Administrator, Staff 3 - Staff 5 (S3 – S5), Resident 1 (R1), Resident 2 (R2), Resident 4 (R4), Resident 5 (R5) and Resident 7 (R7) and toured the facility.
The investigation revealed the following: regarding the allegation "resident's room is used as a passageway", it is alleged that in order to access the room of R1, individuals will have to walk through the room of R2 and there is no other way to get to R1's room. (Continued to LIC 9099-C) |
| Unsubstantiated | Estimated Days of Completion: |
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