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1569.269 Enumerated rights; severability(a) Residents of residential care facilities for the elderly shall have all of the following rights:(6) 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.This requirement is not met as evidenced by: Based on records reviewed and interviewed shows R1 wound was manageable at a stage 2 but develop to a stage 4 because S1 did not follow the care instruction by not rotating R1 every two hours, left R1 in solid diaper, also S1 did not let R1 wound air out prior to changing R1.

87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment ... and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above, with 3 of 6 residents had an out of date Physician's Report (LIC 602) and 0 of 6 Appraisal & Needs and Services Plans (LIC 625) for residents, which poses a potential health, safety or personal rights risk to persons in care.

87705 Care of Persons with Dementia (RCFE) (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: Based on observation, the licensee did not comply with the section cited above in the unlocked kitchen drawer with sharp knives, which poses an immediate health, safety or personal rights risk to persons in care.

87303 Maintenance and Operation (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 is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above. The garage smelled of dog feces and urine, which poses a potential health, safety or personal rights risk to persons in 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 ... and not more than 120 degree F... This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above. The hot water was at 137.2 degrees Fahrenheit, which poses an immediate 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: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above with food that was kept in a locked drawer, which poses a potential health, safety or personal rights risk to persons in care.

87555 General Food Service Requirements (RCFE) (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. Based on observation, the licensee did not comply with the section cited above. There was less than 7 days of non-perishable and 2 days of perishable food, 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. Hot water temperature in the residents shared bathroom was measured at 140.1 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.

87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.This requirement is not met as evidenced by: Based on reviews of R1’s hospital medical records, it was revealed that on 8/15/2023 R1 was diagnosed with a Urinary Tract Infection (UTI). Based on interviews of all staff members and a lack of facility documentation staff were not documenting changes to R1’s attention nor bringing those changes to the attention of the resident's physician and the resident's responsible person, if any, which poses an immediate health, safety or personal rights risk to persons in care.

1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (10) To be free from neglect . . .This requirement is not met as evidenced by: Based on reviews of R1’s hospital medical records and interviews of Administrator Lorica Hipolito, S1, and S2, it was revealed that R1 was not fed by the staff on a regular basis, resulting in a medical diagnosis of severe protein-calorie malnourishment and weight loss on 8/15/2023, which poses an immediate health, safety or personal rights risk to persons in care.

87464 Basic Services (f) Basic services shall at a minimum include … (1) Care and supervision as defined in … Health and Safety Code section 1569.2(c) … "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered… This requirement is not met as evidenced by:Staff members stated that R1 was not being given fluids for as many as 3 days in a row on a regular basis. From the 8/15/2023 hospital medical records, R1’s dehydration superimposed on a Urinary Tract Infection (UTI) resulted in metabolic encephalopathy causing R1 to experience an altered mental state. This poses an immediate health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. Based on reviews of medical records from R1’s hospitalization on 8/15/2023, R1 was diagnosed with dehydration, severe malnourishment, an unstageable right ischial pressure injury, a Urinary Tract Infection (UTI), and experiencing an altered mental state due to metabolic encephalopathy caused by R1’s dehydration superimposed on R1’s UTI. It was R1’s responsible person, and not the facility staff, who called 911 to get R1 to the hospital, which poses an immediate health, safety or personal rights risk to persons in care.

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.This requirement is not met as evidenced by: Based on reviews of R1’s medical records from their hospitalization on 8/15/2023, it was revealed that R1 had an unstageable right ischial tuberosity pressure injury. R1 was retained in the facility despite having that unstageable right ischial tuberosity pressure injury, which poses an immediate health, safety or personal rights risk to persons in care.

(e) Each resident with dementia shall have an annual medical assessment ... and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above for 5 out of 5 residents, which poses a potential health, safety or personal rights risk to persons in care.

87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above for their fire extinguisher that was purchased in 2019, which poses a potential health, safety or personal rights risk to persons in care.

Based on interview & record review, the licensee did not comply with the section cited above facility did not conduct staff training on infection prevention, symptoms, transmission and PPE use by an individual trained in infection control which poses/posed a potential health, safety risk to persons in care.