Cambridge Court

87355 Criminal Record Clearance … (e) All individuals subject to a criminal record review … shall prior to working… (2) Obtain a California clearance… This requirement was not met as evidenced by: Based on admission and records, the licensee did not ensure S1 was background cleared prior to working at the facility for more than five days, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.

87411 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 was not met as evidenced by: Based on documents and interviews, the licensee did not ensure the facility had sufficient staff, including by having only one caregiver on February 28, 2026, resulting in rushed care for residents, which poses a potential safety risk to persons in care.

87211 Reporting Requirements (a) … (1) A written report shall be submitted to the licensing agency … within seven days of the occurrence of … (B) Any serious injury… This requirement was not met as evidenced by: Based on documents, the licensee did not ensure R1’s hospitalization on January 3, 2026, was reported to the OCRO, which poses a potential safety risk to persons in care.

87224 Eviction Procedures (a) The licensee may evict a resident ... Thirty (30) days written notice to the resident is required... This requirement was not met as evidenced by: Based on admission, the licensee did not follow the 30-day eviction procedure when they refused to accept R1 back from the hospital, which poses an immediate personal rights risk to persons in care.

Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained.. to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C) This req is not met as evidenced by: Based on observation, Licensee failed to ensure hot water is maintained between 105 and 120 degrees F. Water temperature measured 98.2 degrees F in resident restroom. This poses a potential health and safety risk to residents in care.

Based on record review, S1,S2 and S3 did not complete required 20 annual training hours, the licensee did not comply with the section cited above in 3 out of 4 personnel records reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, water temperatures checked in various grooming areas of the facility measured above 120 degree F, the licensee did not comply with the section cited above in 75 out of 75 residents, which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, disinfectants and cleaning solutions were found accessible in resident bathroom, the licensee did not comply with the section cited above in 1 out of 75 residents which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, S1 and S2 personnel records did not document initial training within four weeks of employment,the licensee did not comply with the section cited above in 2 out of 4 staff records reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.

Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement... This regulation was not met as evidenced by: Based on interviews conducted and file reviews the facility failed to follow their non-smoking policy as documented per facility's Admission Agreement. This poses a potential risk to resident’s health and safety while in care.

87465 Incidental Medical and Dental Care (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not provide required assistance with medications to one out of eight residents, which poses a potential health risk to persons in care.

This page was amended due to this second citation being created in error.

Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement... This regulation was not met as evidenced by: Based on interviews conducted and file reviews the facility failed to follow their non-smoking policy as documented per facility's Admission Agreement. This poses a potential risk to resident’s health and safety while in care.

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (...) (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 interviews conducted, it was determined that facility staff was locking R1's room at night regardless of the resident's agreement or not. This constitutes an immediate risk to the health, safety or personal rights of residents in care.

87470 Infection Control Requirements (a) A licensee shall ensure that infection control practices are maintained as follows: (1) All staff and volunteers shall perform hand hygiene.This requirement is not met as evidenced by: Based on evidence reviewed, it was determined that adequate hand hygiene measures had not been followed after staff handled bodily fluids and/or provided incontinence care to a resident with a urostomy. This constitutes a potential risk to the health, safety and personal rights of residents in care,

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (...) (3) To be free from (...) other actions of a punitive nature, such as (...) interfering with daily living functions such as eating, sleeping, or elimination. This requirement is not met as evidenced by: Based on evidence reviewed and interviews conducted, there were two documented instances of staff disregarding verbal requests to go back to bed. This constitutes an immediate risk to the health, safety or personal rights of residents in care.

(1) All facilities licensed for 16 or more (...) shall have a signal system which shall: (A) Operate from each resident's living unit. (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff (...) (C) Identify the specific resident living unit. This requirement is not met as evidenced by: Based on interviews conducted, the facility spend several days with a completely inoperant call system in October 2023. This constitutes a potential risk to the health, safety and personal rights of residents in care

87464(f): "Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code [meaning] the facility assumes responsibility for (...) ongoing assistance with activities of daily living without which the resident’s physical health (...) would be endangered. This requirement is not met as evidenced by: Based on interviews and records reviewed, facility failed to provide adequate supervision. This posed an immediate risk to the health and safety of individuals in care.