La Posada

Planned Activities. In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to participate in accordance with their interests and abilities....This requirement was not met evidenced by: Based on record review and interviews, the findings indicate that the facility did not have an Activity Director since the end of 2024. An activity assistant was responsible for activities, but the staff member went on leave and was off occassionally, and as a result planned activities did not occur. This posed a potential health, safety, and personal rights risk to persons in care.

General Food Service Requirements. The following food service requirements shall apply: Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents.This requirement was not met evidenced by: Based on interviews, in the month of July 2025 the facility experienced staff shortages that affected meal service preparation and meal times services, causing residents to wait from 20-45 minutes for their lunch and/or dinner meals. This posed a potential health, safety, and personal rights risk to persons in care.

Personal Accommodations and Services. Toilets and bathrooms shall be conveniently located......This requirement was not met evidenced by: In July 2025, staff began locking the 1st floor public restrooms because a resident fell twice in the public restroom. Housekeepers were instructed to lock the restroom. As as result, some residents had incontinence accidents because they were not allowed to use the restroom and did not make it in time to their room bathroom. This posed a potential health, safety, and personal rights risk.

Based on record review, the licensee did not comply with the section cited above in that the facility did not provide proof that an emergency drill was conducted within the last quarter, 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 in that rooms, 101, 104, 106, 107,110, 111, 112, 113, 202, 211, 311, 320 did not have a mattress pad, which poses a potential health, safety or personal rights risk to persons in care.

Based on record review and kitchen observation, the licensee did not comply with the section cited above in that residents R4 & R8 have renal/kidney disease (dialysis) that require a renal diet, but they are not being served the modified diet, which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that staff (S7-S9's) files were not available for review, 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 in that on 2/26/26 LPAs observed the Memory Care Unit multi-purpose activity room refrigerator was unlocked and had tweezers in the freezer. In addition, the arts/crafts storage cabinet was unlocked and contained nail polish and nail polish remover, which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that staff (S4 & S6) do not have health screening/TB clearance on file, which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that residents (R2, R7, R8, R9 & R10) medical assessments are more than 12 months old, ranging from 11/2022 - 1/2025, which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that staff (S2, S3 & S5) do not have proof of 1st Aid/CPR training in their files, which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that residents (R1-R4) were missing physician ordered medications, which poses an immediate health, safety or personal rights risk to persons in care.

General Food Service Requirements. The following food service requirements shall apply: Between-meal nourishment or snacks shall be made available for all residents unless limited by dietary restrictions prescribed by a physician. This requirement was not met evidenced by: Based on observation on 2/6/2025, the Memory Care Unit did not have adequate inventory of snacks in the refrigerator or cabinet, and interviews revealed snacks in the memory care unit were not always provided in between meal times. This poses a potential health, safety, and personal rights risks to persons in care.

Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below..... This requirement was not met evidenced by: Based on record review and interviews conducted staff did not notify R1's responsible party of the bruise staff observed on 1/17/25 under R1's right eye. Responsible party observed the bruise on 1/20/25. Note: Staff did not submit an incident report to CCL as required. This posed a potential health and safety risk to persons in care.

Additional Personal Rights of Residents in Privately Operated Facilities...... shall have all of the following personal rights: (4) 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 interviews and records review, the findings indicate that on several dates in the month of Jan. 2025 caregiver staff did not reposition hospice resident (R1) every 2 hours as required. R1 had a pressure injury. This posed an immediate health and safety risk to the resident.

Personnel Requirements - General. All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following....(3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. Based on interviews and record review, the findings indicate noc shift (S8) repositioned bedridden resident (R1), and the following day (1/17/25) staff observed bruising under R1's eye. This posed a potential health and safety risk to resident in care.

Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon. Based on record review, the findings indicate that resident (R1) was prohibited visits from former staff (S5). R1's family invited former staff to the facility when R1's was close to dying. This posed a potential health, safety, and personal rights risk to the resident in care.

Personal Rights of Residents in All Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents ..... shall have all of the following personal rights: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. Based on interviews, on 5/30/24 former staff (S10) handled Memory Care Unit resident (R2) in a rough manner by grabbing arm which caused bruising, instead of using redirection techniques. S10 was terminated. This posed a potential health and safety risk to the resident in care.

Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement was not met by evidence of: On 7/1/2024, at approximately 6:30 PM Memory Care Unit resident (R1) climbed out of a 1st floor bedroom window, fell, and sustained head injuries and dislocated shoulder. Staff responsible for supervision of residents in activity room was assisting another resident in the bathroom. This posed an immediate health, saferty, and personal rights risk to persons in care.

Incidental Medical and Dental CareThe following requirements shall apply to medications which are centrally stored: All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. Based on interviews and record review, med-tech staff altered resident medications by using house supply and labeling the medications with electronic MAR information instead of obtaining medication refills in a timely manner. This posed an immediate health, safety, and personal rights risk to persons in care.

Personnel Requirements-General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement was not met by evidence of: On June 4, 2021 at approximately 1:30 pm resident (R1) eloped out of the facility after exiting the memory care unit delayed egress door without staff knowlede when staff (S6) exited out, and did not ensure the door closed properly. This posed an immediate safety risk to this resident in care.

Personal Rights of Residents in All Facilities. In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents ..... shall have all of the following personal rights: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. Based on interviews, on 5/30/24 former staff (S10) handled Memory Care Unit resident (R2) in a rough manner by grabbing arm which caused bruising, instead of using redirection techniques. This posed a potential health and safety risk to the resident in care.

Incidental Medical and Dental Care Services. If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. Based on record review and interviews, med-tech staff were logging in the electronic (MAR) database that medications were administered but did not administer the medications. This posed an immediate health, safety, and personal rights risk to persons in care.

Resident Records. The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.This requirement is not met as evidenced by: Based on interviews, a resident's medical file was lost/missing from the med-tech room. Staff did not find the file. A new file was created. This poses a potential health, safety, and personal rights risk to persons in care.

Personal Rights of Residents in All Facilities. Residents in all residential carefacilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Based on interviews, during (Jun 2024-Aug. 2024, PM staff were not locking the front doors at 7 PM as required. On 8/3/24, at midnight R1’s family stopped by the facility to check if the front doors were locked. They were found unlocked. On 8/1/24, Administration staff were notified of the concern. This posed a potential health and safety risk to residents in care.

Incidental Medical and Dental Care Services. A plan for incidental medical and dental care shall be developed by each facility…..the licensee may assist persons with self-administration as needed. This requirement is not met as evidenced by: Based on interviews and MAR record review, med-tech staff failed to order and obtain a refill for “Latanoprost 0.005 %” eye drops and on 7/6/24 asked family to order the refills and pick up the medication. Additionally, on 8/8/24 medication Donepezil HCL 5mg was not administered at the physician order time, and was given at 6 PM, instead of bedtime. This posed an immediate health and safety risk to the resident in care.

Incidental Medical and Dental Care...The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.This requirement was not met evidenced by: Based on interviews and records review, facility staff did not comply with the section above. On 7/31/2024, R1 sustained a hand injury at 7AM, and med-tech staff failed to arrange for timely medical attention which resulted in R1 being transported to the hospital until after 10 PM. This posed an immediate health and safety risk to resident in care.

Basic Services. Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement was not met evidenced by: Based on record review and interviews conducted, the findings indicate that on7/31/2024 (R1) sustained a right hand injury while the resident was transferred from the shower chair to the toilet by 1 staff instead of 2 staff, which posed an immediate health and safety risk to the resident.

Reporting Requirements. Each licensee shall furnish to the licensing agency such reports..... A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below.... Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement was not met evidenced by:On 7/31/2024, resident (R1) sustained a right hand injury that resulted in an open flesh wound tear of approximately 4 inches, while the resident was transferred from the shower chair to the toilet. Facility faxed the incident report until 8/14/24, which posed a potential health and safety risk.

Managed Incontinence.... the licensee shall be responsible for the following:Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met evidenced by: Based on record review and interviews the findings indicate that on multiple dates R1 was not provided incontinence care at least every 2 hours as required, and on 8/10/24, R1’s bed sheets were soiled with urine and the resident had not received incontinence care. This posed a potential health and safety risk to the resident in care.

Based on record review, the licensee did not comply with the section cited above in that resident R1’s Medication Administration Record (MAR) dated Nov. 2024 listed 2 medication that were not filled. Acetaminophen 325 mg, 2 tabs every 4 hours PRN for fever over 100DF & Acetaminophen 325 mg 2 tabs every 6 hrs PRN for mild pain. This poses an immediate health and safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that 6 out 11 staff files do not have required annual training hours, 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 in that 12 out 22 resident rooms and a kitchen sink hot water readings measured between 120 DF- 124.2 DF, which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that 9 out 11 staff files had expired 1st Aid/CPR training and/or no proof of training, which poses a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that staff (S5 & S10) did not have health screenings or TB clearance on file, which poses a potential health, safety or personal rights risk to persons in care.

Admission Agreements. The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. This requirement was not met evidenced by: Based on record review of email correspondence, R1's family never received a copy of the admission agreement after it was signed, until multiple requests later. On 8/5/24, the copy was provided, but R1 was admitted on 11/17/23.

Observation of the Resident . The licensee shall ensure ...When changes ... 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. Based on record review, staf observed deterioration of physical health condition in R1 since early Jan. 2024, but did not bring to the attention the resident's change in condition, nor was a medical exam requested. This poses a potential health and safety risk to persons in care.

Incidental Medical and Dental Care. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. Based on record review and interviews conducted, the findings indicate that R1 had a decline in health since Jan. 2024, with change in condition, which prompted R1's doctor to inform staff on 7/9/24, that a Cardiologist and Pulmonologit consult was needed. Per record review, staff did not follow up or obtain referral documentation.

Incidental Medical and Dental Care Services. If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. Based on record review, med-tech staff did not dispense medications to at least 10 residents as directed by Physician; records indicate some residents went 2-5 days without medications, which poses an immediate health, safety or personal rights risk to persons in care.

Oxygen Administration - Gas and Liquid. (3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas.This requirement is not met as evidenced by: Based on observation, rooms 301, 314 & 326 have oxygen tanks in their rooms, and a "No Smoking-Oxygen in Use" sign was not posted outside resident room doors, which poses/posed a potential health, safety or personal rights risk to persons in care.

Basic Services. Basic services shall at a minimum include: Arrangements to meet health needs, including arranging transportation, as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met evidenced by: Based on interviews conducted and record review, the findings indicate that resident (R1) missed dialysis appointments on June 6, 2024 & July 4, 2024, because the facility did not ensure the resident was transported to appointments via Access transport, and/or facility van, or other alternate arrangement. This poses an immediate health and safety risk to persons in care.

87468.2 Additional Personal Rights of Residents...(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.This requirement is not met as evidenced by: Based on interviews, records review conducted by Investigator Santana, the licensee did not comply with the section cited above in which due to lack of care and supervision contributed to a delay in obtaining timely medical attention for R1.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) 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 interviews, records review conducted by Investigator Santana, the licensee did not comply with the section cited above in which due to lack of care and supervision, R1 sustained a left hip fracture as a result of a fall while under the care of the facility.

87211 Reporting Requirements..(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in ..(B) Any serious injury as determined..and occurring while the resident is under facility supervision.This requirement is not met as evidenced by: Based on interview and records review, the Administrator failed to meet the reporting requirement and did not submit an Unusual Incident/Injury Report to CCL concerning R1's fall on 10/14/2022 which poses/posed a potential health, safety or personal rights risk to residents in care.

Incidental Medical and Dental Care. If the resident's physician has stated in writing that the resident is unable to determine his/her own need ........ facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: Once ordered by the physician the medication is given according to the physician's directions. Based on records review and interviews, med-tech staff failed to order R1's insulin medication and on 10/5/23 the resident ran out of insulin resulting in dangerously elevated blood sugar levels; which posed an immediate health and safety hazard to the resident.

Personnel Requirements - General(d) All personnel shall be given on the job training or have related experience in the job assigned to them.... (4) Knowledge required to safely assist with prescribed medications which are self-administered. This requirement was not met evidenced by: Based on interviews and record review, on 10/29/23 med-tech left another resident's medications in R1's room and asked the resident to take the medications, which posed an immediatel health and safety risk to persons in care.

False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met evidenced by: Based on record review, the findings indicate that on 10/10/23, staff faxed to CCLD an incident report that contained falsified information and omitted details of R1's incident (10/5/23), in which staff did not refill in time R1's insulin. The report stated that paramedics were called, but they were not. This poses a potential health and safety risk to persons.

Additional Personal Rights of Residents in Privately Operated Facilities. 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. Based on interviews and record review, between Nov. 2021- Feb. 2022, residents were not being showered at least 2 times per week due to staffing shortages related to the COVID-19 pandemic. This posed a potential health and safety risk to residents in care.

Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.This requirement was not met by evidence of: Based on interviews conducted and record review, between Aug. 2021- Feb. 2022, there were staff shortages, and so the facility hired registry staff, but still could not meet the needs of residents. This posed a potential health and safety risk to persons in care.

Basic Services. Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications..., as specified in Section 87608, Postural Supports. Based on record review and interviews conducted residents that required feeding assistance were being fed 30 minutes after food was serveda as a result of staff shortages between Nov. 2021 - Feb. 2022. This posed a potential health and safety risk to residents in care.

Based on record review, the licensee did not comply with the section cited above in that the last emergency drill was conducted on 7/6/2023, 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 above in that rooms 107, 110, 115, 218 did not have mattress pads, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that staff (S1) has worked at the facility since 2019, is cleared, but not associated to the facility; which poses an immediate health, safety or personal rights risk to persons in care. Civil penalty assessed.

Based on record review, the licensee did not comply with the section cited above in that during file review of resident files it was observed that residents' admission agreement forms on file and being provided to residents and their responsible parties are not of the current licensee, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that there are 23 residents enrolled in hospice services, but the facility only has a hospice waiver for 20; 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 in that there are discarded mattresses, chairs, and other furniture in the outdoor parking lot, the roof's rain gutter pipe had a missing pipe, the laundry room ceiling had exposed electrical wiring and an opened ceiling, and the parking lot floor had a steel beam sticking out of the ground,which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that staff (S2- S6) do not have 1st Aid/CPR certificates on file and/or have expired cards, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation during medication review, the licensee did not comply with the section cited above in that two (2) residents [R1 & R2} had unfilled PRN medications, which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that the Memory Care Unit had an unlocked drawer with 2 pairs of scissors and sharp office supplies, which poses an immediate health, safety or personal rights risk to persons in care.

Additional Personal Rights of Residents in Privately Operated Facilities.... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To protection of their property from theft or loss according to Health and Safety Code sections 1569.152, 1569.153, and 1569.154. This requirement was not met evidenced by:Based on record review and interviews, the findings indicate that staff (S1) took $10 from resident (R1) to buy lottery tickets, but never gave the lottery tickets to the resident. This poses a potential health and safety risk to residents in care.

Care of Persons with Dementia. 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 as specified in Section 87458, 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 in that annual assessments for two (2) Dementia residents R1 &R2 are older than 1 year; which poses/posed a potential health, safety or personal rights risk to persons in care.

Enumerated rights; severability. Residents of residential care facilities for the elderly shall have all of the following rights: To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement was not met evidenced by: Based on record review, the facility received a formal medical records request on Jan. 26, 2023 and failed to provide the records within 2 business days, as required per regulation; which poses a potential health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in that all the Memory Care unit rooms had window auditory alarms that do not have sound to alert staff. The alarm system registers in the front desk area that does not always have staff; which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in S1/Dining Services Director does not have a current Food Handling Training Certificate which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that residents (R1-R4) were missing medications; which poses an immediate health, safety or personal rights risk to persons in care.

Based on physical plant observations, the majority of rooms in the Memory Care unit had no mattress pads; rooms 102, 104, 108, 110, 212, 214, 216, 220, 309, 311 did not have mattress pads in the beds. This poses a potential health and safety risk.

Based on observation, the licensee did not comply with the section cited above in that the windows by the 2nd floor game room did not have window screens; which poses a potential health, safety or personal rights risk to persons in care.