Cottages at Hemet

87506 Resident Records(e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident.This requirement was not met as evidenced by: Based on interviews conducted, the paper and electronic medication administration records for R1 were not properly retained in the facility after R1 moved out of the facility on 02/14/2026. This poses a potential health/safety/personal rights risk to residents in care.

The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by: Licensee did not call 911 in a timely manner when immediate medical care was needed for R1's injuries.

87211 Reporting Requirements: (a) Each licensee shall furnish...(1) A written report shall be submitted to the licensing agency ...(D) Any incident which threatens the welfare, safety or health of any resident, ...This requirement is not met as evidence by: Based on documents reviewed licensee did not ensure staff were submitting incident reports for incidents sustained while in care for R2 which poses a potential risk to the health, personal rights, and safey of the residents in care.

Resident Records- 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. Removal of records shall be subject to the following requirements: This requirement was not met as evidenced by: R1's resident record was not made available to LPA Ramirez upon demand during normal business hours.

Personnel Records- All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement was not met as evidenced by: S1's peronnel record was made available to LPA Ramirez for review.

Reappraisals: The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented. This was not met by: Based on record review and interviews, the Licensee did not comply with the above regulation with R1. R1 was hospitalized due to a fall, after being discharged from the hospital R1 was not reassessed to determine level of care for R1. This was an immediate safety risk to R1.

Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes...and that appropriate assistance is provided...licensee shall ensure that such changes are documented and brought to the attention of...physician and ... responsible person ...This was not met by: Based on record review and interviews, the Licensee did not comply with the above regulation with R1. R1 exhibited throwing themselves out of their wheelchair on a regular basis. R1 was hospitalized due to a fall. This was an immediate safety risk to R1.

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 and interview, the ceiling in the laundry room of one(1) of the memory care cottage had a hole, 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 2 out of 2 times, 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 6 out of 6 times 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 1 out of 1 time 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 1 out of 1 times which poses a potential health, safety or personal rights risk to persons in care.

80075(b) Health Related Services. Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by:

Based on records reviewed, the Licensee did not ensure that medication was properly administered to a resident in care. This poses a potential health and safety risk to clients in care.

REPORTING REQUIREMENTS:a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to...(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 (D) Any incident which threatens the welfare, safety or health of any resident...This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not being met as evidenced by: During interview with ED on 10/20/2023, ED verbally stated that one resident had a fall and ED failed to report the resident had fall that resulted in bruising on temple and forehead on 09/30/2023. This poses an immediate health and safety risk to residents in care.

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 was not met as evidenced by: Licensee did not ensure hot water was available for all residents. This poses a potential health, safety, and personal rights risk to residents in care.

Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1...(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 was not met as evidenced by: Based on observation, records review and interview,resident's care plan is not being executed as indicated with total assist for toileting, and not enough staff being present to fulfill this need. This resulting in a fall.

Personnel Requirements - General:Facility personnel shall at all times be sufficient in numbers, & 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 as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. This requirement was not met as evidenced by: Kitchen staff did not report, to management, of potentially dangerous mold in the kitchen walk-in refrigerator. This poses a health and safety risk to residents in care.

Night Supervision: (a) The following persons providing night supervision...shall...be available as indicated below to assist in caring for residents... (3) In facilities caring for one hundred one (101)...residents...one employee shall be on call and capable of responding within ten minutes. This was not met by: Based on record review, the Licensee did not comply with the above regulation with at least one shift (NOC). LPA Colvin observed the NOC shift to only have two caregivers to four cottages, and at times, one caregiver to four cottages. Response times show excess of ten minutes. This is a potential personal rights risk.

Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes...and that appropriate assistance is provided...licensee shall ensure that such changes are documented and brought to the attention of...physician and...responsible person...This was not met by: Based on record review and interviews, the Licensee did not comply with the above regulation with R1. R1 had sustained 12 falls in 2019 alone yet no additional protective measures were taken for R1 despite this need being identified. This was an immediate safety risk to R1.

Additional Personal Rights...in Privately Operated Facilities: (a) In addition to the rights listed...residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs... This requirement was not met as evidenced by: Based on record review and interviews, the Licensee did not comply with the above regulation with R1. On 11/23/21, R1 suffered from an unwitnessed fall in the facility, which resulted in bruising on most of R1's extremeties and facial hematoma. This was an immediate health risk to R1.

REPORTING REQUIREMENTS:(a) Each licensee shall furnish to the licensing agency such reports...(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 (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidence by:The facility did not provide CCLD with writen notification of one positive COVID-19 staff. Potential health, safety risk, and personal rights to residents in care.