Riverstone Terrace Senior Living Memory Care

Facility personnel sufficiency and competence

87411(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, sufficient support staff shall be employed to ensure provision of personal assistance and care as required….This requirement is not met as evidenced by: Based on interviews and records review, staff did not provide care and supervision when R1 went AWOL on 11/14/25, and facility was not aware until the facility was notified by R1’s family which poses an immediate health and safety risks to persons in care.

Record centrally stored prescriptions and refill data

87465 (h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year…This requirement is not met as evidenced by: Based on interview conducted, observation, and records reviewed, all R1’s current medications were not record in Centrally Stored Medication (Lic 622) record, poses/posed a potential health and safety and personal rights risk to the resident in care.

Record dose details and resident medication response

87465(d)(3) The date and time …medication was taken, the dosage taken, and the resident’s response shall be documented and maintained in the resident’s facility record.This requirement was not met as evidenced by: Based on observations, records reviewed, and interviews conducted, not all R1’s medication was record in R1’s Medication Administration Record (MAR), which poses/ posed a potential health and safety risk for the person in care.

First aid training requirements

87411 (c)(1) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.This requirement is not met as evidenced by: Based on records reviewed and interview conducted, S1 do not have First Aid, this poses an immediate health and safety risk for the residents in care.

Obtain required California clearance or exemption

87355 (e)(2) 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: (2) Obtain a California clearance or a criminal record exemption as required by the Department.This requirement is not met as evidenced by: LPA observed S1 not fingerprinted cleared and S2 who is fingerprinted cleared, not associated to facility were observed providing care for residents at the facility, which poses an immediate risk to the health and safety of the residents.

87411(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 and interview conducted with Administrator, the licensee did not comply with the section cited above when LPA reviewed staff files and observed no health screening were on file for S1, S2, and S3, which poses a potential health or personal rights risk to persons in care.

Document required staff training and orientation

87412(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.This requirement is not met as evidenced by: Based on records reviewed and interviews, administrator informed LPA that all staff have no trainings record on file. Two out of four staff file reviewed, staff do not the required trainings on file, which poses a potential health and safety risk for the person in care.

HSC 1796.45 Affiliated home care aides hired on or after January 1, 2016, shall submit to an examination 90 days prior to employment, or within seven days after employment, to determine that the individual is free of active tuberculosis disease.This requirement is not met as evidenced by: Based on records review and interview conducted with Administrator, S1, S2, and S3 do not have a TB result on file which poses a potential risk to the health and safety of the residents.

87303(e)(5)(A) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above when LPA and A1 observed in room A5, room B6, and room C9 with no nonskid mat or nonskid strip in bathroom showers, this poses an immediate health, safety or personal rights risk to persons in care.

Obtain required California clearance or exemption

87355(e)(2) 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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)This requirement is not met as evidenced by: During course of a complaint investigation for complaint 24-AS-20240911151955, it was found that S1, S2, S3, S4, and S5 were not associated to the facility which poses an immediate risk to the health and safety of the residents.

Resident care and supervision skills

87411(d)(3) Personnel Requirements - General Skill and knowledge required to provide necessary resident care and supervision…This requirement was not met as evidence by: Based on records review and interviews conducted, R1 sustained a fall and S1 found R1 next the resident’s bed. Staff failed to abide by the discharge instructions. Staff failed to contact emergency medical services until R1’s daughter instructions which poses an immediate health and safety risks to persons in care.

Give PRN medication by physician order

Based on records review, and observation, R1’s MARs were reviewed, and medications were audit and shown that staff did not administer medications as directed by physician, which poses an immediate health and safety risk for the person in care.

Notify agency before locking doors or gates

The following shall be stored inaccessible to residents with dementia: 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 when LPA, Memory Care Director, and Maintenance staff observed kitchen door in disrepair and unlock. Residents were present in the dining area when knives and cleaning chemicals were unlocked in the kitchen accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.

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, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.