Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
10/09/2023
Section Cited
CCR
87211(a)(1)(D)(a)
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7 | 87211(a)(1)(D) (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven | 1
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7 | Licensee agrees to submit a statement of understanding of the regulatory reporting requirements and submit reports of any elopements or any other incidents that have yet been unreported to licensing by POC date. |
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14 | days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by: Licensee did not ensure that a resident’s elopement from the facility on 10/16/2022 was reported to the Department, which poses a potential safety risk to residents in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
10/03/2023
Section Cited
CCR
87411(a)
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7 | 87411(a) Personnel Requirements – General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, | 1
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7 | Licensee agrees to submit a Plan of Correction by POC date to CCL stating how Licensee shall ensure that staff at all times be in sufficient numbers and competent to provide the services necessary to meet resident needs. |
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14 | sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by: Licensee did not ensure that staff were present in the facility supervising residents while staff were outside of the facility searching for a missing resident, which poses an immediate safety risk to residents in care.
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14 | Licensee shall submit a Plan by POC date about how the licensee will ensure that the Licensee will not make false statements about the facility, including to Department investigators. |
Type A
10/03/2023
Section Cited
CCR87207
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7 | 87207 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. This requirement was not met as evidenced by: | 1
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7 | Licensee shall submit a Plan by POC date about how the licensee will ensure that the Licensee will not make false statements about the facility, including to Department investigators. |
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14 | Licensee did not ensure that no false claims about a staff being on duty when a resident wandered from the facility were made to Department investigators during a complaint investigation, which poses an immediate safety risk to residents in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
10/03/2023
Section Cited
CCR
87468.1(a)(1)
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7 | 87468.1(a)(1): Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. | 1
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7 | Licensee will submit a Plan of Correction to CCL by POC date ensuring that no non-resident will reside or stay in a resident room. |
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14 | This requirement was not met as evidenced by: Licensee did not ensure that a licensee’s family member was sharing a resident bedroom with another resident while the family member was visiting the facility, which poses an immediate safety risk to residents in care. | 8
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Type A
10/03/2023
Section Cited
CCR87705(j)
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7 | 87705(j) 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 was not met as evidenced by: | 1
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7 | Licensee agrees to submit a Plan of Correction to CCL by POC date ensuring that auditory devices are installed to alert staff of resident exits if there are residents whose behaviors present a wandering hazard. |
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14 | Licensee did not ensure that auditory devices or other staff alerts were installed and operational when a resident with a wandering hazard wandered from the facility, which poses an immediate safety risk to residents in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
10/03/2023
Section Cited
CCR
87355(e)(1)
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7 | (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. | 1
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7 | Licensee agrees to submit a Plan of Correction to CCL by POC date to have any non-resident individuals living or working in the facility to be background clearance and be associated to the facility. |
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14 | This requirement was not met as evidenced by: Licensee has had two individuals living in the facility who did not have a clearance or criminal record exemption and were not associated to the facility, which poses an immediate safety risk to residents in care. | 8
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