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32 | Continued from 809...
Per agreement during office meeting with licensee on 3/29/2024, licensee was to review and submit their Plan of Operation to ensure facility's compliance with Title 22 regulations going forward. As of today, 5/16/2024 licensee has not provided CCL with review of Plan of Operation (deficiency cited, see 809D). 87208
Per agreement during office meeting with licensee on 3/29/2024, licensee was to send over Health Screen, Training, and 1st Aid/CPR for new employee at Fallen Leaf Dr. As of today, CCL has not received the required documentation (deficiency cited, see 809D).
CCL review of facility's training materials provided by Licensee do not meet regulation. Licensee to submit updated training materials that meet regulation by 5/23/2024. Once training materials are approved by CCL, licensee to conduct required training in order to fulfill respective plan of corrections for deficiencies cited and re-cited today.
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
**An immediate civil penalty in the total amount of $250 has been issued for repeat violation of regulation 87465(h)(2) and an immediate civil penalty in the total amount of $250 has been issued for repeat violation of regulation 87705(f)(2). See LIC421FC**
Exit interview conducted with Licensee and a copy of this report was given
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
05/30/2024
Section Cited
CCR
87458(a)
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7 | 87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year... This requirement was not met by licensee as evidenced by: | 1
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7 | Facility to submit pictures of Physician's report for R1 that is signed by their physician by plan of correction due date. |
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14 | Based on LPA observation the Physician's Report for new resident R1 was not signed by a physician. Per LPA interview with licensee, the unsigned Physician's report is the only one retained by facility for R1, which poses/posed a potential health, safety or personal rights risk to persons in care. | 8
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Type B
05/30/2024
Section Cited
CCR87208(a)
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7 | 87208 Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation.
This requirement was not met by licensee as evidenced by: | 1
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7 | Facility to submit to CCL the facility's Plan of Operation by plan of correction due date. |
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14 | Per agreement during office meeting with licensee on 3/29/2024, licensee was to review and submit facility's Plan of Operation. Licensee has not submitted Plan of Operation to CCL, which poses a potential health, safety or personal rights risk to persons in care. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
05/17/2024
Section Cited
CCR
87465(h)(2)
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7 | 87465 (h) The following requirements shall apply to medications...centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees....This requirement is not met as evidenced by: | 1
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7 | Facility to submit to CCL a plan to train staff to properly store medications. Plan due by plan of correction due date. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 5/31/2024. Training log to include: |
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14 | Based on LPA observation the licensee did not comply with the section cited above in that med cart in living room was unlocked which poses an immediate health, safety or personal rights risk to persons in care. | 8
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14 | name of trainer, name of course, staff attendees and hours completed. A civil penalty in the amount of $250 is being assessed for repeat violation within 12 months. |
Type A
05/17/2024
Section Cited
CCR87705(f)(2)
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7 | 87705 (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication... cleaning supplies and disinfectants. This requirement was not met by licensee as evidenced by: | 1
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7 | Facility to submit plan on how they will store toxins to be in compliance by plan of correction due date. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 5/31/2024. Training log to include: |
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14 | Based on LPA observation, the licensee did not comply with the section cited above in that the hallway closet containing toxins was unlocked and accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care. | 8
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14 | name of trainer, name of course, staff attendees and hours completed. A civil penalty in the amount of $250 is being assessed for repeat violation within 12 months. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
06/06/2024
Section Cited
CCR
87465(h)(5)
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7 | 87465 (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: | 1
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7 | Facility to train staff to properly store medications. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 6/6/2024. Training log to include: name of trainer, name of course, |
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14 | Based on: LPA observation, the licensee did not comply with the section cited above as unlocked drawer in kitchen contained pre-poured medication. Due to Licensee’s failure to respond to and work with CCL's TSP to correct identified concerns, deficiencies are being re-cited. | 8
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14 | staff attendees, and hours completed. |
Type B
06/06/2024
Section Cited
CCR87303(f)(2)
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7 | 87303(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens. This requirement is not met as evidenced by: | 1
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7 | Facility to train staff to properly store syringes. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 6/6/2024. Training log to include: name of trainer, name of course, staff attendees and hours completed. |
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14 | Based on LPA observation, the licensee did not comply with the section cited above in that syringe for insulin was found accessible, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited. | 8
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
06/06/2024
Section Cited
CCR
87412(a)(11)
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7 | 87412 (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening...This requirement is not met as evidenced by: | 1
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7 | Facility to submit to CCL health screen with clear TB for S1 and S3 by plan of correction due date. |
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14 | Based on LPA record review, the licensee did not comply with the section cited above in that staff (S1) did not have health screen, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited. | 8
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Type B
06/06/2024
Section Cited
HSC1569.625(b)(2)
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7 | HSC 1569.625 (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...
This requirement is not met as evidenced by: | 1
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7 | Facility to submit proof of training to CCL for S1, S2, and S3 by plan of correction due date. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 6/6/2024. |
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14 | Based on LPA record review, the licensee did not comply with the section cited above in that training records for staff not available, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited. | 8
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14 | Training log to include: name of trainer, name of course, staff attendees and hours completed. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
06/06/2024
Section Cited
CCR
87555(b)(9)
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7 | 87555(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.
This requirement is not met as evidenced by: | 1
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7 | Facility to conduct staff training on how to properly store opened food items. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 6/6/2024. |
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14 | Based on LPA observation, the licensee did not comply with the section cited above in that opened food items in refrigerator were not covered or labeled, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.
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14 | Training log to include: name of trainer, name of course, staff attendees and hours completed. |
Type B
06/06/2024
Section Cited
CCR87555(b)(23)
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7 | 87555(b) The following food service requirements shall apply: (23) All readily perishable foods...capable of supporting... growth of micro-organisms...shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by: | 1
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7 | Facility to conduct staff training on how to properly store cooked food items. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 6/6/2024.
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14 | Based on LPA observation, the licensee did not comply with the section cited above in that a bowl of cooked pasta left out overnight, which posed a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.
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14 | Training log to include: name of trainer, name of course, staff attendees and hours completed.
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
06/06/2024
Section Cited
CCR
87705(f)(1)
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7 | 87705 (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by: | 1
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7 | Facility to conduct staff training on how to properly store sharp knives and items that could danger residents by plan of correction due date. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL |
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14 | Based on LPA observation, the licensee did not comply with the section cited above in that kitchen drawer containing sharp knives not locked, which poses/posed a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited. | 8
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14 | by no later than 6/6/2024. Training log to include: name of trainer, name of course, staff attendees and hours completed. |
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