Routine inspection·March 24, 2026

Citations

10 citations recorded^*CCLD

• 87411(a)Type A

  Facility personnel sufficiency and competence

  Per CCR 87411(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, there were only two staff on schedule overall for three residents on hospice at the time of the complaint being filed, with no provisions for time off or unscheduled absences. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.

• 1569.269(a)(21)Type B

  Enumerated rights; severability (21) “To have prompt access to review all 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 is not met as evidenced by: Based on records reviewed, R1’s authorized representative requested R1’s file on April 18, 2022, and had not received applicable documentation at the time of the present complaint being filed in July 2022. This constitutes a potential risk to the health, safety and personal rights of individuals in care.

• 1569.605Type A

  Per Health and Safety Code, “On and after July 1, 2015, all residential care facilities for the elderly (…) shall maintain liability insurance covering injury to residents and guests (…) caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees”. This requirement is not met as evidenced by:Based on records review, facility insurance coverage lapsed prior to its renewal in February 2022. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.

• 1569.72(c)Type A

  Per HSC "bedridden persons may be admitted to, and remain in, residential care facilities for the elderly that secure and maintain an appropriate fire clearance”.This requirement is not met as evidenced by:Based on records reviewed and interviews conducted, R1 was bedbound and unable to reposition independently, which made R1 effectively bedridden. No such provision is allowed is the facility’s fire clearance. This constitutes an immediate risk to the health and safety of individuals in care. CIVIL PENALTY ASSESSED.

• 87211(a)(1)(D)Type B

  Reporting Requirements (1) : “A written report shall be submitted to the licensing agency.. within seven days of the occurrence of any of the events.. Any incident which threatens the welfare, safety or health of any resident.. This requirement was not evidenced by: Based on a review of records, the Licensee did not submit an incident report to Community Care Licensing regarding a fall R1 sustained while in care of the facility. This constitutes a potential risk to the health, safety and personal rights of individuals in care.

• 87213Type A

  Financial plan and required reporting obligations

  Per CCR 87213, “The licensee shall have a financial plan (…) that assures sufficient resources to meet operating costs for care of residents”.This requirement is not met as evidenced by: Based on records reviewed, bank statements provided failed to evidence a minimum of three months’ operating costs on hand. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.

• 87411(c)(6)Type B

  Training documentation requirements

  Per CCR “The licensee shall maintain documentation pertaining to staff training in the personnel records”. This requirement is not met as evidenced by: Based on records reviewed during the investigation, no initial or annual training was documented. This constitutes a potential risk to the health, safety and personal rights of individuals in care.

• 87458(a)Type B

  Obtain baseline medical assessment before resident admission

  Medical Assessment: “(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record”. This requirement is not met as evidenced by: Based on records reviewed during the investigation, the physician report on file for R1 was not signed. This constitutes a potential risk to the health, safety and personal rights of individuals in care.

• 87458(c)(1)(A)Type B

  Record findings for communicable tuberculosis conditions

  Per CCR 87458(c)(1)(A), “prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment (…) made within the last year, to be kept in the resident's record. (c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis”. This requirement is not met as evidenced by: Based on records reviewed, the medical assessment obtained upon R1’s admission fails to include any information. This constitutes a potential risk to the health, safety and personal rights of individuals in care.

• 87463(b)Type B

  Document required significant condition changes

  Per CCR 87463(b): “The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition”. This requirement is not met as evidenced by: Based on records reviewed, R1’s change of condition towards active transitioning is not documented. This constitutes a potential risk to the health, safety and personal rights of individuals in care.