Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
01/24/2025
Section Cited
HSC
1569.695(f)(2)
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5
6
7 | HEALTH AND SAFETY CODE
A facility shall have a set of keys available to facility staff on each shift for use during an evacuation that provides access to all occupied resident units, facility vehicles, all exit doors, all cabinets...or files that contain elements of the emergency disaster plan, | 1
2
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5
6
7 | Spare set of emergency ksys will be maintained and separate from everyday use keys.
Proof of correction to be sent to CCLD BY DUE DATE |
 | 8
9
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14 | including... food supplies & protective shelter supplies. This requirement was not met, as extra set of keys is not maintained in the event of an emergency. Licensee failed to maintain spare set of keys, which poses a potential health, safety or personal rights risk. This was discussed w/ administrator on 1/30/24. | 8
9
10
11
12
13
14 | |
Type B
01/24/2025
Section Cited
CCR87609(b)(4)(B)
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2
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5
6
7 | ALLOWABLE HEALTH CONDITIONS/ USE OF HOME HEALTH AGENCIES
..Written agreement shall include day and evening contact information for the HH agency...method of communication between the agency & facility, which may include verbal contact, electronic mail, or logbook. | 1
2
3
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5
6
7 | Administrator to ensure that home health visiting nurses document each visit.
Plan/proof of correction to be sent to CCLD BY DUE DATE |
| 8
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14 | This requirement was not met, as there are no progress notes maintained from home health providers whenever they visit a resident. Licensee failed to ensure maintenance of HH notes from visiting providers, which poses a potential health, safety or personal rights risk. This was discussed with administrator on 1/30/24. | 8
9
10
11
12
13
14 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
01/24/2025
Section Cited
HSC
1569.69(b)
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2
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5
6
7 | HEALTH AND SAFETY CODE
Each employee who received training, passed the examination required in paragraph (5) of subdivision (a), who continues to assist with the self-administration of medicines, shall also complete 8 hours of training on med -related issues in each succeeding 12- | 1
2
3
4
5
6
7 | Staff who handle and administer clients' medications will receive annual required medications training.
Proof of corrction to be sent to CCLD BY DUE DATE. |
| 8
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12
13
14 | month period. This requirement was not met, as S1 & S ____ who manage and administer clients' medications, have not received annual medication training for 2024. Licensee failed to ensure that staff who handle medications receive required training, which poses a potential health, safety or personal rights risk. S1 received 1 hour of med training in 2024 & there is no record that S __ received any medication training in 2024. | 8
9
10
11
12
13
14 | |
Type B
01/24/2025
Section Cited
HSC1569.626(a)(2)
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5
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7 | HEALTH AND SAFETY CODE
All RCFEs shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: 8 hours of in-service training per year on the subject of serving residents with dementia. This requirement was not met, as there is no | 1
2
3
4
5
6
7 | Staff #3 and #4 will receive required annual dementia training.
Proof of correction to be sent to CCLD BY DUE DATE. |
| 8
9
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13
14 | record that staff #3 and #4 received ANY training in 2024. Licensee failed to ensure that staff received required training, which poses a potential health, safety or personal rights risk to clients in care. | 8
9
10
11
12
13
14 | |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
01/24/2025
Section Cited
CCR
87465(h)(6)
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2
3
4
5
6
7 | iNCIDENTAL MEDICAL CARE
A record of centrally stored prescription medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started & expiration, | 1
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7 | Medications will be recorded on Centrally Stored Medications Records upon RECEIPT.
Proof/plan of correction will be sent to CCLD BY DUE DATE |
| 8
9
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12
13
14 | prescription number and instructions.
This requirement is not met, as 2 OTC meds for client #2, OTC Senna and Rx Vit D3 for C5, & medications received but not yet started, are not recorded on CSMR. This poses a potential health, safety or personal rights risk to clients in care. | 8
9
10
11
12
13
14 | |
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5
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7 | | 1
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7 | |
| 1
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7 | | 1
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7 | |