Follow-up·January 22, 2026

Citations

4 citations recorded^*CCLD

• 87411(a)Type B

  87411(a) Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.... This requirement is not met as evidenced by: Based on interviews and records reviewed, the licensee failed to ensure a sufficient number of competent staff to meet R1’s needs. R1’s foot was swollen for several weeks, no one followed up with hospital visits, and ultimately R1’s toe became infected and had to be amputated. This poses a potential health risk to residents in care.

• 87466Type A

  87466 Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical, mental… functioning and that appropriate assistance is provided when such observation reveals unmet needs. When…deterioration …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 interviews and record reviewed, the licensee failed to ensure that appropriate assistance was provided to R1 when changes in their physical condition were found (swelling in foot and toe) resulting in the toe being amputated. Which posed a potential risk to the health, safety and personal rights of the resident in care.

  Read full inspector narrative
• 87211(a)(B)(D)Type B

  87211(a)(B)(D) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department...(B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety, or health of any resident... This requirement was not met as evidenced by: Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report associated with the incident for R1 that resulted in hospitalization and amputation of R1s toe. The facility did not have proof of certified confirmations that an LIC 624 was faxed to CCL. This violation poses a potential health, safety, or personal-rights risk to persons in care.

• 87405(b)(2)Type B

  87405(b)(2) Administrator - Qualifications and Duties. (b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by: Based on interviews and records reviewed, the Licensee/Administrator failed to adhere to Title 22 regulations, by properly ensuring facility staff were providing appropriate care for R1 in accordance with Title 22 regulations, which poses a potential health and safety risk to residents in care.

FAQ · About this visit

Common questions about this visit

Next steps