Palmcrest Grand Residence

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: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement was not met as evidence by: Based on interviews and record review, the licensee failed to ensure that (R#1) was provided with the necessary care and services to prevent them from falling a few times. This poses a potential health and safety risk to residents in care.

87466 Observation of the ResidentThe 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...This requirement was not met as evidence by: Based on interviews and record review, the licensee failed to ensure that the facility did not complete (R#1)’s Needs and Services Plan each time they return from the hospital and there was not written documentation on the treatment plan changes after each incident. This poses a potential health and safety risk to residents in care.

Based on record review, the licensee did not comply with the section cited above as the Administrator of record has not met the recertification requirements in Section 87407. Administrator has started the classes but has not yet completed the course work to fulfull the recertification requirements, which poses a potential health, safety or personal rights risk to persons in care.

87413 Personnel – Operations (a) In each facility: (3)The licensee shall provide for and encourage all personnel to report observations or evidence of such abuse, exploitation, or prejudice.This requirement is not met as evidenced by: Based on interviews by IB, Staff feared retaliation and were coerced/instructed not to cooperate/speak with authorized agencies about the incident 02/02/24. (A1) provided inconsistent statements to authorities. This poses a potential health, safety or personal rights risk to persons in care.

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d).... If the licensee is also the administrator, all requirements... shall apply. (5) Good character and a continuing reputation of personal integrity. This requirement is not met as evidenced by:Based on interviews by IB, Staff feared retaliation and were coerced/instructed not to cooperate/speak with authorized agencies about the incident 02/02/24. This violation poses a potential health, safety or personal rights risk to persons in care.

87355 Criminal Record Clearance(a) The Department...all individuals specified in Health and Safety Code section 1569.17 and shall...deny... employment...or presence in the facility, based upon the results of such review. This has not been met as evidenced by:The facility has allowed one (1), uncleared, staff member to be employed at the facility.

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: (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above as resident R1 prescribed medication was missed on 12/30/24-1/6/2025 which poses/posed a potential 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 socialfunctioning... appropriate assistance is provided when such observation reveals unmet needs. When changes such as... deterioration... a physical health condition is observed, resident's responsibleperson...the licensee shall ensure that such changes...brought to the attention of the resident's physician... This requirement is not met as evidenced by: Facility staff had knowledge of (R1’s) health condition with UTI associated with severe abdominal pains, and failed to seek medical attention in a timely manner. This violation poses a potential health, safety or personal rights risk to persons in care.

87413(3) Personnel – Operations(3) The licensee shall provide for and encourage all personnel to report observations or evidence of such abuse, exploitation, or prejudice.This requirement is not met as evidenced by: Based on interviews by IB, Staff feared retaliation and were coerced/instructed not to cooperate/speak with authorized agencies about the incident 02/02/24. (A1) provided inconsistent statements to authorities. This violation poses a potential health, safety or personal rights risk to persons in care.

87405 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. (d) The administrator shall have the qualifications..(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. (5) Good character and a continuing reputation of personal integrity. This requirement is not met as evidenced by:Based on interviews by IB, (A1) failed to carry out the policies and ability to conform to the applicable laws, rules and regulations. This violation poses a potential health, safety or personal rights risk to persons in care.

87224 – Eviction Procedures (b) The licensee may, grant approval for the eviction upon a finding of good cause. Good cause exists if the resident is engaging in behavior which is a threat to the mental and/or physical health or safety of himself or to the mental and/or physical health or safety of others in the facility. (c) The licensee shall, in addition to either serving the required thirty (30) days notice , sixty (60) days notice or seeking approval from the Department and service three (3) days notice on the resident, notify or mail a copy of the notice to quit to the resident's responsible person. This requirement is not met as evidenced by:Based on interviews by IB, (A1) wrongfully evicted (R2) by transporting to VA hospital and denied accessed to return to the facility. This violation poses a potential health, safety or personal rights risk to persons in care.

87211 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 is 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 incident resident #1 and #2. The facility did not have proof of certified confirmations LIC 624 was faxed to CCL. This violation poses a potential health, safety or personal rights risk to persons in care.

87468.1 Personal Rights...in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of... personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This has not been met as evidenced by: Licensee did not provide R1 with dignity in their personal relationships with staff; as through interviews, S1 has been named and confirmed through six (6) out of eleven (11) total interviews

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 … brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidenced by: Based on interviews and record reviews the licensee failed to ensure that appropriate assistance was provided to R1 when changes in their physical and mental functioning, R1 was observed which posed an immediate risk to the health, safety and personal rights of residents in care.

Reappraisals. The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and … if any, when there is significant change in the resident’s condition, …first, as specified in Section 87467, Resident Participation in Decision Making. This requirement was not met as evidenced by: Based on interviews and record reviews the licensee failed to ensure that R1 was reappraised following a change in their medical condition after hospitalization, which posed an immediate risk to the health, safety and personal rights of residents in care.

87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation....(2) Safety measures to address behaviors such as wandering, aggressive behavior ....This requirement is not met as evidenced by: Based on interview, observation, and record review, the licensee failed to ensure that the facility prevented the resident from absconging from the memory care unit and being found in the facility parking lot which poses a health risk to residents in care.

Health and Safety Code (HSC)1569.655(a) If a licensee..the licensee shall provide no less than 60 days’ prior written notice to the residents or the residents’ representatives setting forth the amount of the increase,..reason..the increase,..general description..additional costs, except for...a change in the level of care of the resident. This subdivision...fee-for-service arrangement with residents. This is not met as evidenced by: Based on interviews with residents and through record reviews, the licensee failed to provide the amount of the increase in a timely manner.

87224 Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. This requirement is not met as evidenced by: Based on interview, observation, and record review, the licensee failed to ensure the resident was given proper eviction notice prior to resident not being allowed to return from the hospital which pose a health and safety risk to residents in care.

87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation....(2) Safety measures to address behaviors such as wandering, aggressive behavior ....This requirement is not met as evidenced by: Based on interview, observation, and record review, the licensee failed to ensure that the facility prevented the resident from absconging from the memory care unit and being found in the facility parking lot which poses a health risk to residents in care.

Resident records...The licensee and all employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.this requirement is not met as evidence by: based on records review and interviews conducted, the licensee did not provide R1's record to authorized representatvie upon request. This poses a personal rights risk to residents in care.

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report..to the licensing agency and to the person responsible.. within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include..attending physician's name, findings, and treatment, if any; and disposition of the case.This is not met as evidenced by lack of paper trail between reporting party and licensee.

Based on observation, interview, record review, the licensee did not comply with the section cited above as facility staff is assisting residents with glucose testing and insulin injections. Facility staff are not appropriately skilled professionalswhich poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee failed to comply with the section cited above as room 424 there was a lock on the outside of the bathroom door preventing resident from accessing the bathroom which poses/posed a personal rights risk to persons in care.

Based on interview and record review, the licensee failed to ensure the current administrator on record 9Peggy Clark) has received their recertification which poses/posed a potential 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...Licensee/Administrator failed to observe or conduct - at least annually - an assessment.. BasBased on interviews, observations and records the licensee failed to observe or conduct - at least annually - an assessment or re-appraisal of Resident #1’s level of care during the time Resident #1 lived at the facility when there were notable changes in R1 car needs.

87705:Care of Persons With Dementia; C:Licensees who accept and retain residents with dementia...(5) Each resident with dementia shall have an annual medical assessment ...(A) When any medical assess...This requirement is not met as evidenced by: Licensee/Administrator failed Based on interviews, observations and records the licensee failed to tMaintain a medical assessment and re-appraisal which resulted in Resident #1’s multiple falls due to the need for appropriate supervision by staff for safety.

87405 Administrator - Qualifications and Duties: D; By retaining a resident without maintaining a medical assessment... This requirement is not met as evidenced by: Licensee/Administrator did not display knowledge of requirements Based on inteviews, observations and records Licensee/Administrator did not display knowledge of requirements for providing care and supervision appropriate to Resident #1 who had a high, fall-risk history.

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 interviews, observations and records the licensee failed to ensure that the facility is kept free from roaches. This poses a potential health & safety risk to residents in care.

Incidental, Medical, and Dental Care: (2) Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidenced by: Meds not given to R1: Oxycodone (3x a day as needed) on 01/13/22, 01/18/22, 01/20/22, 01/24/22, 01/25/22, 01/29/22. (Cont) Fentanyl (every 72 hours) on 01/04/22, 01/07/22, 01/10/22, 01/19/22, 01/25/22, 01/28/22, and 01/31/22 at 8:00 a.m. Methadone (every 6 hours) on 01/01/22, 01/02/22, 01/08/22, 01/15/22, 01/16/22, 01/22/22, 01/23/22, 01/29/22, 01/30/22.

Incidental, Medical, and Dental Care: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintainedfor at least one year and includes:This requirement is not met as evidenced by: A review of R1's MAR for the month of January 2022 did not document (staff initials) Oxycodone, Fentanyl, Methadone, Tramadol, Gabapentin were administered to the resident.

87705 Care of Persons with Dementia :(c) Licensees who accept and retain residents with dementia..(3) In addition to...(A) Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living; Based on observation, interviews facility faciled to clean R1 face after drinking cocnut water and failed to notice ants in R1 bed which poses an immediate health, safety risk to residents

85072 Personal Rights:(B)The licensee shall insure that each client is accorded the following personal rights.(2)To have the facility inform his/her relatives and authorized representative.... Based on observation, interviews, video, facility failed did meet resident's hygiene needs which posed an immediate health, safety risk to residents

All resident 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. Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement has not been met as required: During todays visit, LPAs requested to review resident #1's and was informed that they were not availble. They were locked in a location and the Administrator had the key which can poses a potential health risk to residents 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 interviews and observations LPA confirmed that there was a water leak which came from another bathroom on the floor above. Staff confirmed a water leak and damage to resident room which poses a potential health, safety or personal rights risk to person in care.

All resident 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. Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement has not been met as required:During todays visit, LPAs requested to review resident #1's and was informed that they were not availble. They were locked in a location and the Administrator had the key.

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, interviews facility faciled to control ant problems and LPA Calderon witness ant problems in room 103 which poses an immediate health, safety

Care of Persons with Dementia. Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:Each resident ...shall have an annual medical assessment ... shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by: Based on Record reviews the licensee failed to ensure that an annual medical assessment was conducted for residents with dementia, a medical assessment was not conducted for resident number 5 within the last 12 months which poses a potential health and safety risk to clients in care.

Reappraisals. The licensee shall arrange a meeting..., when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.This requirement was not met as evidenced by: Based on Record reviews the licensee failed to ensure that reappraissal meetings were conducted once every 12 months, 5 out of 10 resident records reviewed did not indicate that needs and services plan meetings were conducted within the last 12 months which poses a potential health and safety risk to clients in care.

87468 Personal Rights:(a) Residents in residential care facilities for the elderly shall have personal rights which include, but are not limited to, those listed in Sections 87468.1, Personal Rights of Residents in All Facilities,..(1) "Privately operated facility" means a residential care facility for the elderly that is licensed to an individual, firm, partnership. his requirement is not met as evidenced by: Based on observation, interviews and video it is confirmed that there were ants on R1 face and body and ant issues for the total facility which poses an immediate health, safety

87465(a)(2)The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical...facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement was not met by : Facility failed to transfer resident to the hospital, which presented an immediate health and safety risk to resident in care.

87468.2(a)(8) Additional Personal Rights of Residents in Privately Operated Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents ...shall have ...rights: To be free from neglect...humiliation, intimidation, and verbal...abuse. This requirement was not met as evidenced by: Based on interviewes and record reviewes the licensee failed to ensure that residents were free from verbal abuse, residents and staff interviews indicate that R1 was being verbally abused between February and December 2020, which poses a potential health and safety risk to clients in care.

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care..(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement is not met as evidenced by: Based on observation, interviews, the front door was locked and a code must be used to open the front door and interview with the administrator confirmed they locked the front door which poses an immediate health, safety risk to person in care.

87625 Managed Incontinence (b) In addition to Section 87611...(2) Ensuring that incontinent residents are checked...(3) Ensuring that incontinent residents are kept clean and dry...This requirement is not met as evidenced by: Based on interviews LPA Calderon confirm that caregivers are not changing bed sheets for residents beds when needed which poses an immediate health,risk to persons in care.