Grace Retirement Village

87465 Incidental Medical and Dental Care (e) For every … medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, … and a label on the medication This requirement was not met as evidenced by: Based on documents and admission, the licensee had a nurse administer IV bags to R1 and R2 that were not labeled as theirs and could have been a different formulation than that ordered, which poses a potential health risk to persons in care.

Based on documents, the appraisals for R2, R6, R7, R8, R9, and R10 are more than a year old, which poses a potential safety risk to persons in care.

Based on documents, medication technician S8's medication training records do not document the number of hours or type of training and medication technician S9 had no medication training at the facility, which poses a potential health risk to persons in care.

Based on observation, out of the 12 bathroom faucets tested, all were within range except Room 123 which tested at 122 degrees F, which poses a potential safety risk to persons in care.

Based on documents, S4 and S5 did not have current first aid certificates in their files, which poses a potential health risk to persons in care.

Based on documents, S3's health screening is dated more than 6 months before their association date, S4 did not have a health screening in their file, and S9's health screening states they are positive for tuberculosis which S9 states is a mistake and S9's doctor stated over the phone they believe is a false positive and they will order a chest x-ray to confirm, which poses a potential health and safety to residents in care.

Based on documents, the physician's reports for R1 through R10 are on the old form and do not include required information, such as descriptions of behavioral expressions, which poses a potential safety risk to persons in care.

Based on documents, the admission agreement in R2's file was blank, which poses a potential personal rights risk to persons in care.

Based on documents, S5, S6, and S9 did not have records of their 40 hour initial training, which poses a potential health and safety risk to persons in care.

Based on documents, S2, S3, S4, S7, and S8, did not have records of their 20 hour continuing training, which poses a potential health and safety risk to persons in care.

Based on documents, the facility has a memory care unit but their training records indicate that no staff has received 12 hours of dementia initial training or 8 hours of dementia continuing training, which poses a potential safety risk to persons in care.

87211 Reporting Requirements (a) … (1) ... (D) Any incident which threatens the welfare, safety or health … unexplained absence of any resident. This requirement was not met as evidenced by: Based on interview and documents, the licensee did not report R1’s elopement on October 30, 2025, to the OCRO, which poses a potential safety risk to persons in care.

87464 Basic Services … (f) Basic services shall at a minimum include: (1) Care and supervision. This requirement was not met as evidenced by: Based on interview and documents, the licensee did not ensure R1 received care and supervision to meet their needs resulting in a second elopement in less than week, an altercation with police, and hospitalization, which poses an immediate safety risk to persons in care.

87465 Incidental Medical and Dental Care (i) Prescription medications which are not… returned to the issuing pharmacy … which are otherwise to be disposed of shall be destroyed in the facility…This requirement was not met as evidenced by: Based on admission, the licensee did not timely dispose of or destroy expired medications, which poses a potential health risk to persons in care.

87633 Hospice Care of Terminally Ill Residents … (k) The licensee shall maintain a record of dosages of medications that are centrally stored for each resident receiving hospice services in the facility. This requirement was not met as evidenced by: Based on documents and admission, the licensee did not ensure all the medications of R1, R2, and R3 were documented on their centrally stored medication records and medication administration records, which poses a potential health risk to persons in care.

87631 Healing Wounds (a)… (3) Residents with a stage one or two pressure injury… (B) All aspects of care performed by the medical professional and facility staff shall be documented in the resident's file. This requirement was not met as evidenced by: Based on admission and documents, the licensee did not ensure R1’s wound care from their hospice care team, or the repositioning care of the facility’s own staff, was documented in R1’s file, which poses a potential health risk to persons in care.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidenced by: Based on observation and interview, the licensee did not ensure the kitchen, first floor memory care, and second floor chapel were free of black mold, which poses a potential health risk to persons in care. CIVIL PENALTY ASSESSED.

… all residential care facilities for the elderly … shall maintain liability insurance covering injury to residents and guests in the amount of at least ... ($1,000,000) per occurrence and ... ($3,000,000) in the total annual aggregate... This requirement was not met as evidenced by: Based on documents, the licensee did not maintain liability insurance covering injury to residents and guests in the amounts required due to sub-limits on injuries typical in this facility type, which poses an immediate personal rights risk to up to 93 persons in care.

… all residential care facilities for the elderly … shall maintain liability insurance covering injury to residents and guests in the amount of at least ... ($1,000,000) per occurrence and ... ($3,000,000) in the total annual aggregate... This requirement was not met as evidenced by: Based on documents, the licensee did not maintain liability insurance covering injury to residents and guests in the amounts required due to sub-limits on injuries typical in this facility type, which poses an immediate personal rights risk to up to 93 persons in care.

87208 Plan of Operation (a) … Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval… This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not notify LPA or obtain approval for a new memory care on the third floor not included in the facility’s plan of operation when the facility was licensed, which poses an immediate safety and personal rights 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 interviews and documents, the licensee did not report R1’s femur fracture to the OCRO, which poses a potential safety risk to persons in care.

87465 Incidental Medical and Dental Care (a)… (1) 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 as evidenced by: Based on interviews and documents, the licensee did not ensure R1 received proper wound assessment and care for their unstageable pressure injury, which poses an immediate health risk to persons in care. CIVIL PENALTY ASSESSED.

Resident Records 87506(a)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. (b) Each resident’s record shall contain at least the following information. This requirement was not met as evidence by: files for R1-R5 only had the Physician Report (LIC602), Appraisal/Needs and Services Plan, Personal Rights and Admission Agreement.

87615 (a) Prohibited health conditions. Persons who require health services for or have a health condition including, but not limited to those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by: Based on observations, interviews, and record review, the licensee retained R1 who had prohibited health condition of unstageable pressure injury while in care at the facility. The licensee failed to seek a higher level of care for R1. This poses an immediate health, safety and/or personal rights risk to residents in care.

87465 Incidental Medical and Dental Care (a)… (1) 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 as evidenced by: Based on interviews and documents, the licensee did not notify R1’s doctor or obtain a medical assessment after R1’s fall and did not obtain medical care for R1 in response to R1’s change of condition, which poses an immediate health risk to persons in care. CIVIL PENALTY ASSESSED.

87211 Reporting Requirements (a) … (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days … shall include the resident's name, age, sex and date of admission; date and nature of event… This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not provide a written report of R1’s fall to the OCRO or R1’s responsible party, which poses a potential health risk to persons in care.

87465 Incidental Medical and Dental Care. (a) … (5) ... Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician. This requirement was not met as evidenced by: Based on documents and interviews, the licensee did not ensure R1 received assistance with medications by offering R1 oxygen and giving R1 Tylenol which were not prescribed, which poses an immediate health risk to persons 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 documents and interviews, the licensee did not ensure R1 received assistance with medications by not giving them their prescribed medications for multiple days, which poses an immediate health risk to persons in care.

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee... This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not maintain personnel records for 4 staff, which poses a potential safety risk to persons in care.

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance… This requirement was not met as evidenced by: Based on admission and documents, the licensee did not ensure S4, S5, and S7 were background cleared prior to working at the facility, which poses an immediate safety risk to persons in case. CIVIL PENALTY ASSESSED.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidenced by: Based on observations, the licensee did not ensure 4 fire extinguishers were inspected within the last year, which poses a potential safety risk to persons in care. CIVIL PENALTY ASSESSED.

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance… This requirement was not met as evidenced by: Based on admission and documents, the licensee did not ensure staff Sung Ae Byun and Carlota Olguin were background cleared prior to working at the facility, which poses an immediate safety risk to persons in case. CIVIL PENALTY ASSESSED.

Based on observation, the facility's fire extinguishers have not been inspected since 2023, which poses a potential safety risk to persons in care. CIVIL PENALTY ASSESSED.

Based on Guardian records and interview, S1 is background cleared but is not associated to the facility and has been working at the facility for a long time, which poses a potential safety risk to persons in care.

Based on documents, the facility has been allowing R1 to store and administer their own medications, but R1's physician's report indicates R1 is not able to store or administer their own medications, which poses a potential safety risk to persons in care.

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance… This requirement was not met as evidenced by: Based on interviews and documents, the licensee did not S1 was background cleared prior to working at the facility for at least 5 days, which poses an immediate safety risk to persons in case. CIVIL PENALTY ASSESSED.

87468.1 Personal Rights of Residents in All Facilities (a) … (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews, the licensee does not ensure memory care residents’ dignity when they are kept in only diapers and a shirt overnight, which poses an immediate personal rights risk to persons in care.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidenced by: Based on observation and interviews, the licensee did not ensure the memory care unit was free for mild bad odors, which poses a potential personal rights risk to persons in care. CIVIL PENALTY ASSESSED.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times… This requirement was not met as evidenced by: Based on observation, the licensee did not ensure resident rooms 104, 112, 113, 114, and 116 were free of black mold, which poses a potential health risk to persons in care. CIVIL PENALTY ASSESSED.

All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not being met as evidenced by, LPA observed 49 boxes of cereal stored in the kitchen that have expired. This poses an immediate health and safety risk to residents in care.

In facilities required to have a signal system, specified in Section 87303, Maintenance Operation, at least one night staff person shall be located to enable immediate response to the signal system. If the signal system is visual only, that person shall be awake. This requirement is not being met as evidenced by record review and interviews verified the facility does not have a staff person monitoring the signal system to provide immediate response. This poses an immediate health, safety and personal rights risk to residents in care.

(e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility(2)Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement was not met as evidenced by, through record review LPA observed Staff 1 has a background clearance but is not associated to the facility. This poses an immediate health and safety and personal rights risk to residents in care.

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not being met as evidenced by: LPA observed Resident 1's room, 233 did not have a smoke detector. This poses an immediate Health and safety risk to residents in care.

Per CCR Section 87303(a): "The facility shall be clean, safe, sanitary and in good repair at all times." This requirement is not met as evidenced by: Based on observation, the presence of a makeshift table balanced on refrigerator, with a broken glass cover constitutes an immediate risk to the health, safety and personal rights of individuals in care.

Per CCR Section 87705(f)(2) on the Care of Persons with Dementia: "The following shall be stored inaccessible to residents with dementia: (...) toxic substances such as (...) cleaning supplies and disinfectants". This requirement is not met as evidenced by: Based on observation conducted during the visit, cleaning supplies and potential toxic substances were left unattended in the memory care unit. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department… This requirement was not met as evidenced by: Based on observation, documents, and admission, the licensee was not following its approved fire clearance because 2 out of 3 delayed egress doors were not functioning as required and the facility has been keeping the west delayed egress door open, which poses an immediate safety risk to persons in care.

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department… This requirement was not met as evidenced by: Based on observation, documents, and admission, the licensee was not following its approved fire clearance because 2 out of 3 delayed egress doors were not functioning as required and the facility has been keeping the west delayed egress door open, which poses an immediate safety risk to persons in care. CIVIL PENALTY ASSESSED.

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. This requirement was not met as evidenced by: Based on documents, the licensee did not ensure an administrator with an active administrator’s certificate was properly designated, which poses a potential safety risk to persons in care. CIVIL PENALTY ASSESSED.

§ 1569.69(a) … (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training... This requirement was not met as evidenced by: Based on documents, the licensee did not ensure S1 and S2 had documented medication technician training, which poses a potential health risk to persons in care.

Based on documents, R1 moved in on 01/13/24 but the facility still does not have a Physician's Report for R1, which poses a potential health risk to persons in care.

Based on documents and Administrator's admission, the facility has not been conducting emergency disaster drills, which poses a potential safety risk to persons in care.

Based on documents, the licensee did not ensure their licensing fees were paid and has a past-due balance, which poses a potential risk to persons in care.

87464(f)(1) Basic Services. Basic services shall at a minimum include: Care and supervision…This requirement was not met as evidence by: Licensee failed to ensure R1 was receiving care and supervision which resulted in R1 sustaining a burn from an unknown cause while in the care of the facility as evidence by interviews conducted and hospital records reviewed. This poses an immediate health and safety risk to residents in care.

Administrator Qualifications and Duties. …When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section… This regulation was not met as evidenced by: Licensee failed to have a qualified designated substitute when Administrator was not in the facility on 8/24/23 as evidenced by Department staff observations and comments made by Administrator. This poses a potential risk to residents health and safety while in care.

Inspection Authority of the Licensing Agency. The licensee shall ensure that provisions are made for private interviews with any resident or any staff member... This regulation was not met as evidenced by: Licensee failed to ensure provisions were made for private interviews with staff on 8/24/23 as evidenced by Administrator’s statements. This poses a potential risk to residents’ personal rights and safety while in care.

Advanced Directives and Requests Regarding Resuscitative Measures. Immediately telephone 9-1-1, present the advance directive and/or request regarding resuscitative measures form to the responding emergency medical personnel… This regulation was not met as evidenced by: Licensee failed to ensure records were made available to emergency personnel as evidenced by records being locked inaccessible to staff. This poses a potential risk to resident’s health and safety while 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 regulation was not met as evidence by: Based on interviews conducted and records reviewed the Licensee provided false statements to the Department by stating they had not received R1’s paperwork prior to being admitted and was dropped off at the facility blindly without Licensee consent. Statements were proven to be false. This poses an immediate risk to resident’s safety.

Resident Records. The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility…This regulation was not met as evidence by: Based on interviews conducted and records reviewed the Licensee did not maintain a complete record for R1 as evidenced by incomplete appraisal and unsigned physician report. This poses a potential risk to resident’s health and safety.

(a) Evaluation of Suitability for Admission. Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8:..conduct an interview…perform a pre-admission appraisal…obtain and evaluate a recent medical assessment…This regulation was not met as evidenced by: Based on interviews conducted and records reviewed the Licensee did not evaluate R1 for suitability prior to accepting them. This poses an immediate risk to resident’s health and safety.

Administrator- Qualifications and Duties. The administrator shall have the responsibility to: Administer the facility in accordance with these regulations and established policy… This regulation was not met as evidenced by: Based on interviews conducted and records reviewed the Licensee did not ensure the facility was following regulatory and policy regarding acceptance and retention due to failure to evaluate R1 for suitability prior to accepting them and providing required supervision. This poses an immediate risk to resident’s health and safety.

Basic Services (f)Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This regulation was not met as evidence by: Based on interviews conducted and records reviewed the Licensee did not provide care and supervision to R1 resulting in R1 eloping from the facility and dying. Prior to being admitted the facility was made aware of R1’s exit seeking behaviors and still chose to admit R1 to the facility. This poses an immediate risk to health risk to residents in care. An immediate civil penalty of $500 is being assessed.

87464(f)(1) Basic Services(f) Basic services shall... include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement is not met as evidence by: Based on the documents obtained and interviews conducted, the facility did not obtain a proper medical evaluation for the resident, therefore was unaware of the care and supervision the resident needed, resulting into the resident wandering out of the facility and sustaining injuries. This poses an immediate health and safety risk to residents in care.

87207 False ClaimsNo 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 is not met as evidence by: Based on LPA’s observation, records obtained and interviews, it was revealed that the doctor indicated on R1, R2, R3, R4, R5, and R6 physician's report denied of evaluating the residents and stated that the physician signature was falsified. This poses an immediate health and safety risk to residents in care.

87458 Medical Assessment(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician...This requirement is not met as evidence by: Based on the reviewed documents obtained, interviews conducted, and direct admission from the indicated physician on the reports, facility did not obtain a physician report and medical evaluation for R1, R2, R3, R4, R5, and R6.This poses an immediate health and safety risk to residents in care.

87464 Basic Services (f) 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 is not met as evidence by: Three of three UIIRs reviewed by LPA indicate that the residents left the facility unassisted. Therefore, the facility neglected the residents’ care and supervision as it was unsafe for all three residents to leave the facility unassisted.

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. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care...This requirement is not met as evidence by: Per Unusual Incident/Injury Report (UIIR) dated 05/02/22 on 05/01/22 at 11:49 AM R1 left the facility unassisted. Per Physician Report (LIC602A) R1 is not Able to Leave Facility Unassisted.

Care of Persons with Dementia. Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. This regulation was not met as evidence by: Based on LPA’s observations, Licensee failed to ensure that facility gate which led to back lot had a functioning self-closing latch. This poses an immediate risk to the safety of residents in care.

Maintenance and Operation. 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 regulation was not met as evidence by: Based on LPA’s observations, Licensee failed to keep the facility safe and sanitary as evidence by Broken glass observed unattended on the ground in Memory Care Unit and feces smeared on the wall. Both were observed accessible to dementia residents. This poses an immediate risk to the health and safety of residents in care.

all residential care facilities for the elderly … shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee health and safety. The requirement was not met as evidence by Licensee did not provide requested full liability insurance policy. This poses a potential threat.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to... Section 87468.1...residents...shall have all of the following personal rights:(1) To have reasonable level of personal privacy...communications, telephone conversations...This requirement is not met as evidence by: Based on LPA's tour, interviews, observations and records reviews, facility took possession of a total of 6 resident's cellphones and placed it in a plastic container located in the staff office.This poses a potential health and safety risk to residents in care.

87458 Medical Assessment(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician...This requirement is not met as evidence by: Based on LPA's interviews, observations and record reviews, facility failed to obtain physician reports for R1, R2, R3, and R4,This poses an immediate health and safety risk to residents in care.

c) All information and records obtained from or regarding residents shall be confidential.(1) ... 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 was not met as evidence by facility has not provided requestor with documents and has not shown proof to LPA.

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. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care...This requirement is not met as evidence by: Per Unusual Incident/Injury Report (UIIR) dated 05/02/22 on 05/01/22 at 11:49 AM R1 left the facility unassisted. Per Physician Report (LIC602A) R1 is not Able to Leave Facility Unassisted.

(c) All information and records obtained from or regarding residents shall be confidential.(1) ... 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 was not met as evidence by the facility has not provided requested documents or contacted requestor for an extension. This poses a risk to persons in care.

The California Code of Regulations Section 87506(e) on Resident Records states that "Original records (...) shall be retained for a minimum of three (3) years following termination of service to the resident." This requirement is not met as evidenced by: The records requested by LPA Saborit-Guasch were unsuccessfully searched by facility staff who was eventually unable to provide them altogether. This poses a potential risk to the health, safety and personal rights of individuals in care.

Health and Safety Code section 1569.312 provides that every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety. Based on interviews conducted, this requirement is not being met as evidenced by the fact that resident R1 was able to leave the facility unattended in spite of being admitted to the secure memory care unit.

California Code of Regulations Section 87303(a) on Maintenance and Operation states that: "The facility shall be clean, safe, sanitary and in good repair at all times." Based on observation conducted at the facility, this requirement is not met as evidenced by: Floor material in the memory care unit bunches up in places and creases up, thus creating a fall hazard.

The California Code of Regulations Section 87211(a)(1)(B) on Reporting Requirements states that: "A written report shall be submitted (...) within seven days (...) [for] Any serious injury (...) occurring while the resident is under facility supervision." This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, it was determined that licensee failed to submit an incident report prior to the facility inspection on 01/28/2023. This constitutes a potential risk to the health, safety and personal rights of individuals in care.

The California Code of Regulations Section 87608(a)(3) states that: "A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record." This requirement is not met as evidenced by: Based on records reviewed, observation conducted and interviews, it was determined that half bed rails were in place without a physician report at the time of the fall incident on 01/18/2023. This constitutes a potential risk to the health, safety and personal rights of individuals in care.

(c) All information and records obtained from or regarding residents shall be confidential.(1) ... 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 was not met as evidenced by the facility not providing documents after a formal request was made. This poses a potential risk to persons in care.

87468.2 Additional Personal Rights … (a) In addition to the … (8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure R1 was free from neglect, punishment, and physical abuse when a staff member tied R1 to their wheelchair, which poses an immediate personal rights and safety risk to residents in care.

Fire Safety- All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement was not met as evidenced by: LPA and Licensee observed a wheelchair laying on its side blocking an exit gate door on the outside of the first floor by Memory Care. Gate door was also tied with a cloth at the top. This posed an immediate health and safety risk to residents in care.