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32 | On the allegation: Staff did not provide residents with a reappraisal. LPA De Leon reviewed the resident appraisal needs and service plan for R1. R1 had care plans done on 03/30/2022, 09/02/2022, 12/11/2023 and 09/16/2024. The plans for 2023 and 2024 were done on a different software program than prior plans completed. R1 suffered a fall with a fracture on 08/23/2024 which initiated the new service care plan on 09/16/2024 done by staff at the facility, R1 signed the plan, and it was emailed to R1’s Responsible party (RP) on 09/16/2024 for approval and signature. RP never received the email but in October R1’s fees increased, and the RP questioned why and how when there was no reappraisal, a new LIC 602A physicians report, or a meeting set up to discuss the changes. The facility said they had emailed her an updated service plan with the changes on 09/16/2024. The RP did sign the new service plan on 11/26/2024 and a new LIC 602A was done on 12/04/2024 to verify the changes being made to R1’s care fee increase. The facility did not follow the regulation for reappraisals, RP was not contacted, or a meeting arranged for R1’s change in condition and review of a new service plan before the facility billed for the increase therefore this allegation is Substantiated at this time.
On the allegation: Staff did not report incidents to appropriate parties. LPA De Leon reviewed records for R1 which revealed several incidents of R1’s confusion were faxed and sent to R1’s doctor on 1/13/2024, 04/04/2024, 06/01/2024, 06/18/2024, 07/16/2024 and 11/11/2024 but not all the incidents were reported to R1’s RP’s based on interviews. RP’s said the communication with the facility was not good and when the RP’s reached out to the facility and left messages, no one from the facility replied. On 12/05/2024 R1 was moved into the memory care (MC) unit, when R1’s family went to visit the facility R1 could not be found and staff said R1 was now in MC. R1’s belongings were not with R1 in the MC unit and family took R1 back to R1’s apartment in the assisted living portion of the facility. The facility moved R1 without notification to the family into the MC unit due to R1’s increased confusion. The facility said R1 could stay in AL during the day for meals but needed to go to MC in the evening, R1’s RP’s didn’t agree to this arrangement or get an eviction notice that R1 could no longer live in the AL portion of the building and only learned of it through a family member that tried to visit. The RP’s said the facility had all updated information and phone numbers for the RP’s and made no contact to discuss the movement of R1 therefore this allegation is Substantiated at this time.
Continued 9099-C |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
12/02/2025
Section Cited
CCR
87463(i) | 1
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7 | (i)When there is significant change in condition,...or once every 12 months,...the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's rep,... facility staff,...,Resident Participation.... This requirement was not met as evidenced by: | 1
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7 | Administrator agreed to read, review and train staff doing pre-appraisals, re-appraisals, generating new LIC 602A to the doctor and updating Service plans on Regulation 87463, provide proof of training with a list of staff to CCL. |
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14 | Based on records and interviews the licensee did not comply with the regulation above Staff conducted a reappraisal Service Plan and did not make contact with R1’s RP to go over or have a meeting to discuss, letting R1 sign and putting the new fees in effect which poses a potential health, safety and personal rights risk to residents in care. | 8
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Type B
12/02/2025
Section Cited
CCR
87466 | 1
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7 | ...residents are regularly observed for changes in physical,...social ...functioning...assistance is provided...observation reveals unmet needs.... attention of the resident's physician and the resident's person responsible,... This requirement was not met as evidenced by: | 1
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7 | Administrator agreed to train the staff that notifies doctors and RP’s in regulation 87466 and the facility policy and procedures for notifications, send proof of training and provide a current list of those staff to CCL. |
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14 | Based on interview and record review the Licensee did not comply with the regulation above Staff did not report to R1’s RP several dates and incidents that were faxed to the physician which possess a potential health, safety and personal rights risk to residents in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
12/02/2025
Section Cited
HSC
1569.655(a) | 1
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7 | (a) ...increases the rates of fees for residents or makes increases in any of its rate structures for services,...90 days’ prior written notice to the residents or the residents’ representatives...amount of the increase and the reason or reasons for the increase,,...This requirement was not met as evidenced by: | 1
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7 | Administrator agreed to train staff that handle rent and care increases in H&S code 1569.655, provide proof of training and list of staff who do the increases at the facility. |
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14 | Based on interview and record review the Licensee did not comply with the H&S code above. Facility mailed out notices, not all notives were received by the RP’s and some notices were not a full 60days notice which possess a potential health, safety and personal rights risk to residents in care. | 8
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