Rowena Care Home

Acceptance obligations tied to pre-admission appraisal needs

87464(d) Basic Services(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources.This was not met as evidenced by: During LPA Lee’s visit on 12/12/2025, S1 was observed seated in staff room #4 supervising resident R7. S2 was observed sleeping in resident room #8, as S2 was assigned to the NOC shift. LPA Lee questioned the facility’s ability to provide adequate care and supervision to the remaining residents, as only one awake care staff member was on duty and was observed spending the majority of the visit in staff room #4 with the door closed while supervising R7 which raised concerns regarding who was providing care and supervision to the remaining residents during that time. This is immediate health, safety or personal rights to person in care.

Assist residents with self-administered medication

87465(a)(4) Incidental Medical and Dental Care:(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed.This was not met as evidenced by: Based on record review and interviews, the Licensee did not comply with the section cited above. During 12/12/2025 visit, LPA Lee reviewed 2 out of 7 residents’ medication and it was learned that R7 had two medications that did not have a doctor's order to be administer to R7. R1 had 3 medications that were on hand; however, it was not documented in R1's CSMDR. This posed an immediate health and safety risk to R1.

Protection from punishment and intimidation

87468.1(a)(3) Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.This was not met as evidenced by: The LPA Lee observed a chain and lock on the refrigerator and the pantry, which is an immediate health, safety or personal rights to persons in care.

Freedom to leave and not be locked in

87468.1(a)(6) Personal Rights of Residents in All Facilities Type A(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 does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above. LPA Lee observed resident in bedroom #3 had a gate on their door to prevent the resident from going out of their room to cause disturbances to other residents and from injuring themselves. Moreover, another resident was placed in staff room #4 with a gate installed by the door which poses an immediate health, safety or personal rights risk to persons in care.

Right to personal privacy in daily care

87468.2 (a)(1) 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:(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 was not met as evidenced by: Based on observation and interview residents were not permitted a reasonable level of privacy in their private bedrooms since there was a camera in the resident’s room, which poses an immediate health, safety or personal rights risk to persons in care.

Prohibit false or misleading facility statements

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 was not met as evidenced by: During 12/12/2025 visit, both administrator and caregiver gave false statement in regard to R7 not being a resident but a grandmother or S1 who is babysitting S1’s son since the facility was over capacity by 1. This is immediate health, safety or personal rights to person in care.

87211(a)(1)(D) Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(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…(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.This requirement is not met as evidenced by: Based on interviews and record reviews, 2 residents went to the ER due to a fall and there was no incident report pertaining to the residents ER discharge records. Administrator admitted not completing any incident reports and submitting it to CCLD which poses a potential health, safety or personal rights risk to persons in care.

Conformance with applicable laws and regulations

87405(d)(2) Administrator - Qualifications and Duties(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.This requirement is not met as evidenced by: Based on observation, record review and interviews, the licensee/administrator did not ensure to comply with regulations to ensure that the facility is within compliance and fire clearance are being followed which poses a potential health, safety or personal rights risk to persons in care.

Limit operations to licensed capacity

Based on records review, observation and interview the licensee did not comply with the section cited above. LPA Lee observed resident #7 in the staff room #4. The facility has a total of 7 residents in care which the facility is licensed for 6 non-ambulator residents. This poses/posed a immediate health, safety or personal rights risk to persons in care.

Maintain facilities for fire and panic safety

LPA Lee observed that the emergency gate to the right of the facility was locked with a pad lock and the emergency gate to the left of the facility is missing the string with the handle that is attached to the gate latch. Moreover, fire extinguishers located in the kitchen, dining area, and hallway were last serviced on 09/26/2024. This poses/posed a immediate health, safety or personal rights risk to persons in care.

Use slip-resistant surfaces in bathing areas

Based on observation and interview the licensee did not comply with the section cited above in 2 out of 6 resident bathroom shower floor does not have slip resistant mats, which poses an immediate health, safety or personal rights risk to persons in care.

Store disinfectants separately from food supplies

Based on observations and interviews the licensee did not comply with the section cited. LPA Lee observed the cleaning supplies under the kitchen sink unlock and accessible to residents in care. LPA Lee also observed knives in a kitchen cabinet unlocked as well, which poses an immediate health, safety or personal rights risk to persons in care.

Maintain records of centrally stored medication dosages

Based on observations, interviews and record review, the licensee did not comply with the section cited above. LPA Lee review 2 out 6 resident's medication and observed that R1's medication on had did not match with the resident's CSMDR. R2's had two medications that was not listed on the CSMDR and has no doctor's order. The administrator stated that they do use MAR log; however, it is not at the facility and doesn't know and had to text care staff, which poses an immediate health, safety or personal rights risk to persons in care.

Passageways and stairways kept clear

Based on observation and interview, the licensee did not comply with the section cited above. LPA Lee observed resident in room #6's exit door to the back of the facility's emergency gate is obstructed with a metal frame. This poses an immediate health, safety or personal rights risk to persons in care.

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

Use slip-resistant surfaces in bathing areas

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

Maintain grab bars for toileting and bathing

Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.