Courtyard Plaza

Maintenance and Operation. 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, as water temperature measured in four (4) out of the eight (8) resident rooms were below 105 degree F; one out of eight rooms was above 120 degree F. This poses a potiential health and safety risk to residents in care.

Criminal Record Clearance-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: Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility. Gregory LaRue(DOH 11/12/25) requested an criminal record exemption but has not received approval to be present at the facility. $500 Civil Penalties were assessed.

87355 Criminal Record Clearance.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 Walter Perez, worked at the facility on 10/28/25 for one day. Rosa Garcia(DOH 2/9/17) & Consuelo Rodriguez(DOH 3/18/17). No criminal record clearance or transfer were obtained for all 3 staff prior to being present at the facility.$1100 -Civil Penatlies were assessed.

87355(e)(3) All individuals subject to a criminal record review... shall prior to working, ...(3) Request a transfer of a criminal record clearance as specified in Section 87355(c) orThis requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above as the Administrator had fingerprint clearance but was not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above per tour of the resident rooms - bedrooms #111, 126, 220, 221, 226 the horizontal blinds on the window and doors were observed missing slates or were broken which poses/posed 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 per tour of the back parking lot, all the facility dumpsters stored in the back parking lot containing discarded items, including food items were left wide open which poses/posed 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 per the rooms inspected, bedrooms #231 and bedrooms #236 contained only one dresser each. The other residents were using their desk drawers as dressers whiich poses/posed 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 per water temperature tested in bedroom #i201 read 121.8, bedroom # 206 read 121.4 and bedroom #236 read 93.2 degrees Fahrenheit which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above, as painting supplies were accessible in an unlocked storage closet and in the hallway, which poses an immediate health and safety risk to persons in care.

87303(e)(2) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets.. shall deliver.. hot water.. 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 LPAs observation, the licensee failed to ensure hot water temperature measured within 105 to 120 degrees F in resident rooms which poses an immediate health, and safety risk to residents in care.

Reappraisals(a)The pre-admission appraisal shall be updated...as frequently as necessary to note significant changes…(3) Any illness, injury…or change in the health care needs... specified in Sections 87455(c) or 87615, Prohibited Health Conditions.This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above. Facility failed to update R1’s appraisal with change of condition when R1’s pressure injuries worsened, and R1 was not compliant with Home Health care plan, which posed a potential health and safety risk to residents in care.

1569.312(a) Basic services requirements: Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above, Licensee failed to coordinate care when R1’s pressure injuries worsened and R1 was not compliant with treatment, resulting in stage 3 pressure injuries, which posed an immediate health and safety risk to residents in care.

Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes… and that appropriate assistance is provided when such observation reveals unmet needs…the licensee shall ensure…changes are documented and brought to the attention of the resident's physician…This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. The facility failed to communicate R1’s worsening pressure injuries/wounds with R1’s physician which attributed to R1’s stage 3 pressure injuries while in care, which posed an immediate health and safety risk to residents in care.

87463(c) Reappraisals(c):The licensee shall arrange a meeting with… a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition…This requirement is not met as evidenced by: Based on records review and interviews, the licensee did not comply with the section cited above. Facility failed to have a level of care meeting to discuss R1’s change of condition when R1’s pressure injuries were worsening, and R1 was not compliant with Home Health care plan, which posed a potential health and safety risk to residents 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, as the exit/ back door leading to the parking lot contained a double action door latch, which poses an immediate health and safety risk to residents in care.

87468.2(a)(4)...In addition to the rights listed… residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs... This requirement is not met as evidenced by: Based on staff interviews, file review, and incident report review the licensee did not comply with the cited section by not providing proper care and supervision which resulted in R1 sustaining a hip fracture which posed an immediate health and safety and personal rights risk to R1.