Walnut Creek Willows

Ensure hazardous items are locked and not unattended

87309 Storage Space and Access(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions...and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by not having Clorox Bleach and Shurgard HP disinfectant chemicals inaccessible to residents in unlocked laundry room and Clorox Bleach under cabinet in memory care unit which poses an immediate health and safety risk to persons in care.

Provide resident hot water for personal care

87303 Maintenance and Operation(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by not having water temperatures maintained at 105-120 degrees F. in residents' shared bathrooms. Water temps measured at 94.3 and 97.5 degrees F. in assisted living memory care units which poses an health and safety risk to persons in care.

Notification to department after hospice care starts

87632 Hospice Care Waiver(d) If the Department grants a hospice care waiver..to ensure the well-being of terminally ill residents and of all other facility residents, which shall include, but not be limited to, the following requirements: (2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice. Based on file review and interview, the licensee did not comply with the section cited above by not notifying Licensing of residents (R2-R10) with a notice of hospice services initiated within 5 working days which poses an health and safety risk to persons in care.

Conformance with applicable laws and regulations

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)...(2) Knowledge...ability...the applicable laws, rules and regulations.This requirement is not met as evidenced by: Based on record reviews, the licensee did not comply with the section cited above in by completing the required 2hrs minumum courses with a approved CCLD vendor to cover policy procedures, laws and staff requirements in regards to staff trainings. The training certificates were for other topics and previous dates other than the proposed 12/10/25 class date. This poses a potential health, safety or personal rights risk to persons in care.

Records available to licensing agency for inspection

87506 Resident Records(d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.This requirement is not met as evidenced by: Based on file review and interview, the licensee did not comply with the section cited above by not having resident records for R1-R8 available for Licensing review including but not limited to admission agreements, emergency contact info., physician's reports, appraisals/Appraisal Needs and Services, hospice care plans, home health care plans, care notes, MARS, doctor's orders which poses an health and safety risk to persons in care.

Allow licensing inspection and controlled record removal

87412 Personnel Records(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:This requirement is not met as evidenced by: Based on file review and interview, the licensee did not comply with the section cited above by not having staff records available including but not limited to staff schedules for Nov '25 thru Feb '26, LIC 500 (staff roster) and staff contact information which poses an health and safety risk to persons in care.

(a) The facility shall be...in good repair at all times...This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having disrepair flooring in residents rooms with tiles cracked, buckling and lifting which poses a potential health and safety risk to persons in care.

Keep bath, laundry and kitchen floors clean

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by not having shower floors clean, resident bedroom floors repaired with cracks, tile bulkling in assisted living and memory care units which poses an health and safety risk to persons in care.

87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall. (I) Equipment shall be removed from the facility when no longer in use by the resident.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by not having oxygen tanks secured in a stand/wall and removed when resident was discharged or passed away which poses an health and safety risk to persons in care.

87555 General Food Service Requirements(23) All readily perishable foods... shall be stored in covered containers at appropriate temperatures.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having food in the freezer uncovered and not in a food container in memory care unit which poses a potential health and safety risk to persons in care.

Conformance with applicable laws and regulations

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)...(2) Knowledge...ability...the applicable laws, rules and regulations.This requirement is not met as evidenced by: Based on record reviews, interviews and observations, the licensee did not comply with the section cited above in by not having RCFE specific 20 hours staff annual trainings completed since annual inspection on 06/03/25. Which poses a potential health, safety or personal rights risk to persons in care.

Certified administrator requirements and substitute coverage

87405 Administrator - Qualifications and Duties a) All facilities shall have a qualified and currently certified administrator. ...shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility...The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.This requirement is not met as evidenced by: Based on LPA's visits 08/15/25, 7/29/25, 6/10/25, 6/3/25, 4/10/25, 3/13/25 and 1/15/25 the Administrator was not available. There has been multiple deficencies citations and the designated substitute does not meet the qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section which poses a potential health, safety or personal rights risk to persons in care.

Conformance with applicable laws and regulations

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)...(2) Knowledge...ability...the applicable laws, rules and regulations.This requirement is not met as evidenced by: Based on record reviews, interviews and observations, the licensee did not comply with the section cited above in by not having RCFE specific 20 hours staff annual trainings completed since annual inspection on 06/03/25. Which poses a potential health, safety or personal rights risk to persons in care.

Grounds for eviction listed for residents

(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days’ written notice to the resident is required except as otherwise specified in paragraph (5). This requirement was not met as evidence by: Based on interviews and record review the Licensee did not comply with the section cited above in giving proper notification for eviction, which poses a potential personal risk for persons in care.

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in by not having staff annual trianings for staff (S) S1-S10 including but not limited to direct care staff which poses a potential health, safety or personal rights risk to persons in care.

Request a transfer of criminal record clearance

(e) All individuals subject to a criminal record review... shall prior to working.. in a licensed facility: (3) Request a transfer of a criminal record clearance...This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having S11 associated to the facility, which poses an immediate health and safety risk to person in care.

Request a transfer of criminal record clearance

(e) All individuals subject to a criminal record review... shall prior to working.. in a licensed facility: (3) Request a transfer of a criminal record clearance...This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having S2 associated to the facility, which poses an immediate health and safety risk to person in care.

Based on record review, the licensee did not comply with the section cited above in by not having staff annual trianings for staff (S) S1-S10 which poses a potential health, safety or personal rights risk to persons in care.

Separate storage for cleaning chemicals

87555 General Food Service Requirements (b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in by not storing cases of Clorox Bleach and bottles of Fabuloso Multi-Purpose Cleaner in a area separate from food supplies which poses a potential health and safety risk to persons in care.

Grounds for eviction listed for residents

87224 Eviction Procedures(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5)This requirement is not met as evidenced by: Based on interviews and record review the licensee did not comply with the section cited above in by serving R1 with an appropriate eviction notice after deciding not to accept R1 back to the facility once R1 was discharged from the hospital ER which posed a potential health and safety risk and personal rights to persons in care.

87307 Personal Accommodations and Services(c) Individual privacy shall be provided in all toilet, bath and shower areas.This requirement is not met as evidenced by: Based on interviews, licensee did not comply with the section cited above in by not ensuring R1’s privacy while showering which posed a potential health, safety or personal rights risk to persons in care.

87468.1 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. (b) All residents in all residential care facilities for the elderly shall be protected from all of the actions specified in this subsection. (5) Willfully and repeatedly fail to use a resident’s preferred name or pronouns after being informed of the resident’s preferred name or pronouns in a clear manner.This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in by not according dignity and respect with bathing, showering, toileting, and addressing residents by their preferred names and pronouns which poses a potential health, safety or personal rights risk to persons in care.

Residents in private facilities have the following rights

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: Based on observation and interview the licensee did not comply with the section cited above in by ensuring that camera with audio does not violate a residents' right to privacy and dignity as required by existing regulations. Including but not limited to all clients and residents maintain privacy and dignity rights that could be violated by negligent and/or abusive surveillance practices which poses a potential health, safety or personal rights risk to persons in care.

Right to personal privacy in daily care

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights...87468.1, Personal Rights of Residents in All Facilities,...residential care facilities for the elderly shall have all of the following personal rights:(1) To have a reasonable level of personal privacy in accommodations...This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above in by violating R1's personal rights to privacy including but not limited to picking up R1's phone and looking at messages when they are not present which poses a potential safety or personal rights risk to persons in care.

Right to sufficient care and qualified staff

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on observation, interview and record review, the licensee did not comply with the section cited above by not, including but not limited to, responding to residents' call buttons in a timely manner and addressing the residents' care needs after turing off the call light which poses a potential health, safety or personal rights risk to persons in care.

Resident care and supervision skills

87411 Personnel Requirements – General(d) All personnel shall be given on the job training...This training...shall provide knowledge of and skill in the following, as appropriate for the job assigned... (3) Skill and knowledge required...including the ability to communicate with residents.This requirement is not met as evidence by: Based on interview, the licensee did not comply with the section cited above by ensuring staff has the ability to communicate with residents when providing care which poses an health, safety and personal rights risk for persons in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (5) To be served food of quality and quantity necessary to meet their nutritional needs.This requirement is not met as evidence by: Based on observation, licensee did not comply with the section cited above by not serving hot food that should be hot, nutritious and of quality and quantity which poses an health, safety and personal rights risk for persons in care.

§1569.261 Legislative intent; fundamental rights for residents of residential care facilities (b) In establishing this bill of rights, the Legislature intends that persons residing in residential care facilities for the elderly be treated with dignity, kindness, and respect, and that their civil liberties be fully honored. Based on interviews the licensee did not comply with the section cited above in by treating residents with dignity, kindness and respect including but not limited to how staff communicates while giving care to residents in care which poses a potential health and safety risk and personal rights to persons in care.

Right to sufficient care and qualified staff

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on interviews the licensee did not comply with the section cited above in by responding to call light buttons timely, changing diapers including but not limited to making sure residents' are completely cleaned after soiled diaper changes during NOC shift and between shift changes which poses a potential health, safety risk and personal rights to persons in care.

Residents in private facilities have the following rights

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on observation, interview and record review, the licensee did not comply with the section cited above by not, including but not limited to, responding to residents' call buttons in a timely manner and addressing the residents' care needs after turing off the call light which poses a potential health, safety or personal rights risk to persons in care.

Separate storage for cleaning chemicals

87555 General Food Service Requirements (b) The following food service requirements shall apply: (25) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in by not storing cases of Clorox Bleach and bottles of Fabuloso Multi-Purpose Cleaner in a area separate from food supplies which poses a potential health and safety risk to persons in care.

87555 General Food Service Requirements (b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food...(15) All persons engaged in food preparation and service...food services sanitation practices which protect the food from contamination.This requirement is not met as evidence by: Based on observation, interview and record review, the licensee did not comply with the section cited above by not including but not limited to having staff practicing safe food sanitation when preparing and serving food. In addition, serving food that is of good quality, taste and is not cold to residents which poses a potential health, safety or personal rights risk to persons in care.

Right to personal privacy in daily care

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights...87468.1, Personal Rights of Residents in All Facilities,...residential care facilities for the elderly shall have all of the following personal rights:(1) To have a reasonable level of personal privacy in accommodations...This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above in by violating R1's personal rights to privacy including but not limited to picking up R1's phone and looking at messages when they are not present which poses a potential safety or personal rights risk to persons in care.

Residents in private facilities have the following rights

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: Based on observation and interview the licensee did not comply with the section cited above in by ensuring that camera with audio does not violate a residents' right to privacy and dignity as required by existing regulations. Including but not limited to all clients and residents maintain privacy and dignity rights that could be violated by negligent and/or abusive surveillance practices which poses a potential health, safety or personal rights risk to persons in care.

87555 General Food Service Requirements(b) The following food service requirements shall apply: (17) In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service...This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in by not having a full-time qualified employee by formal training responsible for food services which poses a potential health, safety or personal rights risk to persons in care.

87224(a)(2)(f) Eviction Procedures: A licensee of a licensed residential care facility for the elderly shall...(2) Provide each resident...with a written notice.... The notice shall include all of the following: (F) The contact information for the local long-term care ombudsman, including address and telephone number. Based on record review the licensee did not comply with the section cited above. The eviction notice did not include contact information which poses a potential health, safety or personal rights risk to persons in care.

87555 General Food Service Requirements(b) The following food service requirements shall apply: (17) In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service...This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in by not having a full-time qualified employee by formal training responsible for food services which poses a potential health, safety or personal rights risk to persons in care.

87307 Personal Accommodations and Services(c) Individual privacy shall be provided in all toilet, bath and shower areas.This requirement is not met as evidenced by: Based on interviews, licensee did not comply with the section cited above in by not ensuring R1’s privacy while showering which posed a potential health, safety or personal rights risk to persons in care.

Grounds for eviction listed for residents

87224 Eviction Procedures(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5)This requirement is not met as evidenced by: Based on interviews and record review the licensee did not comply with the section cited above in by serving R1 with an appropriate eviction notice after deciding not to accept R1 back to the facility once R1 was discharged from the hospital ER which posed a potential health and safety risk and personal rights to persons in care.

Clean linen quantity and hygiene supplies

87307 Personal Accommodations and Services(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care...(C) Clean linen...The quantity shall be sufficient...This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in by not having clean bath towels, hand towels and wash cloths with sufficient quantity for residents in care at all times which poses a potential health, safety or personal rights risk to persons in care.

87468.1 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. (b) All residents in all residential care facilities for the elderly shall be protected from all of the actions specified in this subsection. (5) Willfully and repeatedly fail to use a resident’s preferred name or pronouns after being informed of the resident’s preferred name or pronouns in a clear manner.This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above in by not according dignity and respect with bathing, showering, toileting, and addressing residents by their preferred names and pronouns which poses a potential health, safety or personal rights risk to persons in care.

§1569.686 Licensee notificacified events..(a) A licensee shall notify the department, the State Long-Term Care Ombudsman, all residents, and, if applicable, their legal representatives, in writing, within two business days, and shall notify all applicants for potential residence, and, if applicable, their legal representatives, prior to admission, of any of the following events, or knowledge of the event: (3) The licensee files for bankruptcy.This requirement is not met as evidenced by: Based on interview with the licensee did not comply with the section cited above in by not notifying the Department, Ombudsman and Residents of filed bankruptcy which poses a potential health, safety or personal rights risk to persons in care.

80087 Buildings and Grounds(a) The facility shall be...in good repair at all times...This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having disrepair flooring in residents rooms and hallways which poses a potential health and safety risk to persons in care.

Health screening and fitness requirements

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in by not having health screening and negative TB results which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in by not having a Emergency Disaster Plan which poses a potential health and safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in by not reporting to the local fire dept oxygen in use for R1 and R2 which poses a potential health and safety risk to persons in care.

Health screening and fitness requirements

Based on record review, the licensee did not comply with the section cited above in by not having health screening and negative TB results which poses a potential health, safety or personal rights risk to persons in care.

Fingerprints and criminal records of individuals in contact with clients...record exemption from the State Department of Social Services before his or her initial presence in a residential care facility for the elderly.

Maintain physician order documentation in resident record

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. Based on interview, the licensee did not comply with the section cited above in by not having a written order from a physician for a bed rail for R1 which poses a potential health, safety or personal rights risk to persons in care.

Certified administrator requirements and substitute coverage

(a) All facilities shall have a qualified and currently certified administrator...This requirement is not met as evidence by: Based on observation and interview, the licensee did not comply with the section cited above in by not having an Administrator available which poses a potential health, safety or personal rights risk to persons in care.

(k) Whenever a certified administrator assumes or relinquishes responsibility for administering a residential care facility for the elderly, he or she shall provide written notice, within thirty (30) days, to:(1) The local licensing office responsible for receiving information regarding personnel changes at the licensed facility with whom the certificate holder is or was associated, and Based on observation and interview, the licensee did not comply with the section cited above in by not providing written notice to CCLD the personnel changes which poses a potential health, safety or personal rights risk to persons in care.

80087 Buildings and Grounds(a) The facility shall be...in good repair at all times...This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having disrepair flooring in residents rooms and hallways which poses a potential health and safety risk to persons in care.

87211 Reporting Requirements(b) Any suspected physical abuse that results in serious bodily injury of an elder...shall be reported to the local ombudsman...This requirement is not met as evidenced by: Based on record review and interview, the Administrator did not comply with the section above for not reporting to the local ombudsman and submitting SOC341 which posed a potential health and safety risk to persons in care.

Fire approval and staff access to unlock systems

87705 Care of Persons with Dementia(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by not having cleaning disinfecting solutions (Fabuloso) inacessible to residnts which poses a potential health and safety risk to persons in care. During visit Administrator locked the disinfective cleaning spray.

87608 Postural Supports(1) Postural supports shall be limited to appliances or devices...used to achieve proper body position and balance, to improve a resident's mobility...restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc.(A) Physician-prescribed orthopedic devices such as braces or casts, used for support of a weakened body part or correction of body parts, are considered postural supports.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having a doctor's order for postural support fo R1 which poses a potential health and safety risk and persoanl rights to persons in care.

Based on record review, the licensee did not comply with the section cited above in by having record of letter sent to fire department which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in by not having current Appraisal Needs and Services Plans for residents in care which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in by not having staff scheduled with CPR Training which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in by not having responsible substitute at the facility which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in by not having a facility manager available when Administrator is absent which poses a potential health, safety or personal rights risk to persons in care.

Passageways and stairways kept clear

Based on observation, the licensee did not comply with the section cited above in by having bikes, ladders, mirrors, mattresses etc..inaccessible to residents in care which poses a potential health, safety or personal rights risk to persons in care.

Ensure hazardous items are locked and not unattended

Based on observation, the licensee did not comply with the section cited above in by having toxic chemicals inaccessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.

RCFE complaint poster posting requirements

Based on observation, the licensee did not comply with the section cited above in by having Complaint Poster accessible to which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in by not having an administrator on the premises which poses a potential health, safety or personal rights risk to persons in care.

Fire approval and staff access to unlock systems

Based on observation, the licensee did not comply with the section cited above by having cleaning solution accessible to residents which poses an immediate health and safety risk to persons in care.

Care of Persons with DementiaThe following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors: Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility. This requirement was not met as evidenced by: Staff left delayed egress door wide open and Resident R1 left the facility unassisted which posed an immediate health & safety risk to residents in care.

Reporting RequirementsThe licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator... This requirement is not met as evidence by: Based on investigation, licensee did not comply with the section cited above by not giving written notice to CCLD within 30 days for administrator change which poses a potential health and safety risk to the residents in care.

(c) (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement was not met as evidenced by no staff attending to 13 memory care residents in activity room for 20 minutes which posed a potential health & safety risk to residents in care

Care of Persons with DementiaThe following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors: Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility. This requirement was not met as evidenced by: No staff was attending the memory care residents left in the north wing with the delayed egress door wide open which posed a potential health & safety risk to residents in care.

Maintain facility in clean, safe, sanitary condition

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by broken A/C and hot temperature (79F & higher on other days) which posed an immediate health & safety risk to residents in care.