On of 7/31/2024 licensee agreed to be on a Non-Compliance plan. The areas of concern were identified as:

· Administrator Duties and Plan of Operation

· Staff Training

· Resident and staff records

· Resident Care and Personal Rights

· Insufficient Staffing

· Failure to clear deficiencies timely

· Medication Management

· Failure to follow through with TSP

Licensee was to ensure the following:

· Follow through with responding to and participating with the Technical Support Program

· Ensure compliance with areas including, but not limited to, staff training records, maintaining staff and resident records and pre-pouring of medication.

Continued on 809C...

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

· Ensuring personal rights of residents in care and ensuring resident needs are met.

On 4/23/26 LPA conducted a non-compliance (NCC) visit. Deficiencies were re-cited for identified NCC areas of concern. As of today, 7/14/26, the plans of correction to clear those deficiencies are still outstanding. So, as pertains to the failure to clear deficiencies timely, the licensee has failed to clear deficiencies. LPA discussed failure with licensee. Licensee provided LPA with plans of correction that were outstanding. LPA cleared deficiencies.

As pertains to resident and staff records. Resident and staff files complete. However, physician's report for resident (R1) shows resident as bedridden. Facility does not have bedridden clearance and R1 is not currently on hospice. However, LPA spoke with R1 and R1 is able to get out of the bed with assistance and is able to reposition himself while in bed when using side rails. LPA will not issue citation but licensee will get physician's report for resident (R1) updated to correct ambulatory status.

As pertains to medication management LPA and S1 did a spot check of medication. No deficiencies cited.

Also pertaining to medication management, deficiency of regulation 87465(h)(5) was cited on 2/11/26 because LPA and caregiver observed pre-poured medications in kitchen drawer. As of today, CCL has not received the plan of correction which required licensee/administrator to submit a LIC9098 self-certifying that facility will stop pre-pouring medications. At today's visit, licensee provided LPA with LIC9098. LPA cleared deficiency.

Facility’s physical plant was not identified as a NCC area of concern. However, a deficiency of regulation 87303(a) was cited at the annual inspection. As of today, the plan of correction to clear that citation has not been received. During today's visit, licensee provided LPA with proof of correction. LPA cleared deficiency.

As pertains to inadequate staffing. Facility has three (3) residents and two (2) caregivers on duty at all times per LIC500 dated 4/24/26. Per licensee, no changes to LIC500, LIC500 is current. No deficiencies cited.

LPA reviewed resident documentation. No deficiencies observed. Pertaining to the other areas of concern identified in the NCC plan, such as Administrator Duties and Plan of Operation, Resident Care and Personal Rights, and failure to follow through with TSP. Facility has a certified Administrator, followed through with TSP, and observing personal rights.

Exit interview conducted with licensee and a copy of this report was given.