Sacramento Senior Living Iii

Central store medicines that create safety hazards

(h) The following requirements shall apply to medications which are centrally stored:(1) Medications shall be centrally stored under the following circumstances:(C) Because of potential dangers related to the medication itself...in the facility and the condition or the habits of other persons in the facility... Department to be a safety hazard to others. This requirement was not met as evidenced by:During a facility inspection, LPA observed an open sharps disposal container on the kitchen table. The container was unlocked and accessible in a resident common area, which poses a potential health and safety risk to residents in care.

Licensee must supervise facility operations

Based on observation, interview, and record review, the licensee did not comply with the section cited above in which there is only one staff scheduled which is not enough to ensure all care needs are being met timely. LPA observed inconsistent meal times and/or missed meals for 1 out of 1 residents during multiple visits poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain separate complete record for each resident

Based on (record review)], the licensee did not comply with the section cited above in which records including incident reports, discharge paper work, complete LIC 601, and the most updated LIC 602 is avialble for review which poses/posed a potential health, safety or personal rights risk to persons in care.

Modified diets for medical necessity

Based on observation, interview, record review, the licensee did not comply with the section cited above in ensuring there are diabetic and or vegetarian options available at each meal time. LPA observed only turkey sandwitches were prepared for residents and 1 of 1 resident ate their own snacks/food due to not having an option available to them which poses/posed a potential health, safety or personal rights risk to persons in care.

Provide resident hot water for personal care

Based on observation) (interview) (record review, the licensee did not comply with the section cited above in due to water being under 105 degrees which poses/posed a potential health, safety or personal rights risk to persons in care.

Store centrally held medications in locked secure place

87465 Incidental Medical and Dental Care (h) ... to medications which are centrally stored: (2)... shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication ... this requirement was not met as evidence by the facility continuing to not ensure medications/insulin is stored properly and with a locking mechanisms and is locked/inaccessible to residents, this poses a potential/immediate health risk to residents in care.

Certified administrator requirements and substitute coverage

87405 Administrator - Qualifications and Duties(a) ... qualified ... administrator shall have sufficient freedom from other responsibilities... on the premises a sufficient number of hours ... a designated substitute ... qualifications adequate ... this requirement was not met as evidenced by licensee not updating the assigned facility administrator with community care licensing by previous POC due date 12/3/25, this poses a health and safety risk to residents in care.

Report specified resident events within seven days

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency (1) A written report ... 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)... this requirement was not met as evidence by the facility not submitting an incident report for a hospital visit for R4 on 11/4/25 this poses a potential/immediate health risk to residents in care.

Update reappraisal at required intervals

87463 Reappraisals (a) ... as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary ... to note significant changes in conditon...referred to as the reappraisal. This requirement was not met as evidence by the facility not submitting an incident report for a hospital visit for R4 on 11/4/25 this poses a potential/immediate health risk to residents in care.

Store centrally held medications in locked secure place

87465 Incidental Medical and Dental Care (h) ... to medications which are centrally stored: (2)... shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication ... this requirement was not met as evidence by the facility not submitting an incident report for a hospital visit for R4 on 11/4/25 this poses a potential/immediate health risk to residents in care.

Safe, healthful, comfortable accommodations

87468.1 Personal Rights of Residents in All Facilities (a) Residents... shall have all of the following personal rights ... (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipmentthis requirement was not met as evidence by: Care staff did not accord residents, including residents with blindness, timely notification that the toilet was removed for maintenance on 11/7/25 resulting in an incident in which R1 going to use the bathroom as usual without knowing the toilet had been removed. Additionally, the two resident interviews in which it was learned that care staff using work hours for personal social gathering on 11/6/25, this shows failure to perform required duties and introduced uncleared individuals to the environment. This poses an immediate health risk to residents in care.

87303 Maintenance and Operation (f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents... This was not met as evidence by: Based on interviews with staff and residents confirming there is a mouse infestation. This posed a potential health and safety risk to residents in care.

Facility personnel sufficiency and competence

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 interview and observations in which it was learned one care staff is not enough to meet the needs of five residents in care. Additionally, there should be wake staff at night time due to the facility having an exit seeking resident with a diagnosis of dementia; this poses a potential health and safety risk to residents in care.

On-the-job training requirements

87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (1) Principles of good nutrition, good food preparation and storage, and menu planning. This was not met as evidence by: Based on interviews and observations, it was learned staff is still not adequately trained on providing modified diets as prescribed by a resident's physician, dietary restrictions, and resident preferences are provided to residents.

87628 Diabetes(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(4) Providing modified diets as prescribed by a resident's physician as specified in Section 87555(b)(7). This requirement is not met as evidenced by interviews that reveal diabetic resident, R1, has missed meals and is not being offered meals that are appropriate for their diabetic and dietary needs. On 11/7/25, R1 did not have breakfast nor medication until 2:28PM. On 8/27/25, R1 was hospitalized after a keto acidosis episode. The facility designated representative stated that an updated plan of care will be implemented to address the care needs, specifically for special diet needed for residents with diabetes.

Arrange appropriate medical and dental care

87465 Incidental Medical and Dental Care (a ) A plan for incidental medical and dental care ... routine medical and dental care and provide for assistance in obtaining such care.. (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 evidence by record review and interviews in which it was learned that 4 out of 5 residents not having dental care verification in over a year as well as routine medical doctors visit. Additionally, resident 1 (R1) has missed medical appointments due to not having assistance with transportation arranged. this poses a potential health an safety risk for residents in care.

Certified administrator requirements and substitute coverage

87405 Administrator - Qualifications and Duties(a) ... qualified ... administrator shall have sufficient freedom from other responsibilities... on the premises a sufficient number of hours... attention to the management and administration ... a designated substitute ... qualifications adequate to be responsible and accountable for management and administration 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. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.

7219 Planned Activities (a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:(1) Socialization to promote or enhance personal relationships. Activities may include, but are not limited, to... This requirement was not met as evidenced by interview observations and interviews in which it was leaned no activities are being offered to residents in care. This poses a potential health and safety risk to residents in care.

Allowing diabetic residents based on self-management ability

87628 Diabetes (a) ... resident who has diabetes ... able to perform his/her own glucose testing .... able to administer his/her own medication .... or has it administered by an appropriately skilled professional. This was not met as evidence by: Based on interviews and observation, in which it was observed that Staff 1 (S1) did not ensure to safe administration of insulin was done by not using gloves nor use sterilizing pad when assisting resident 1 (R1) with their medications and that timely administration of medications is taking place. This posed an immediate or potential health and safety risk to residents.

Auditory exit monitoring for elopement risk

87705 Care of Persons with Dementia (d) ... shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents ... risk for elopement ... This requirement was not met as evidenced by: Based on observation and interview, Licensee did not ensure adequate alert and monitoring devices on all exterior doors and gates despite knowledge of elopement risk for R1. This poses an immediate health and safety risk to residents in care.

87628 Diabetes(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(4) Providing modified diets as prescribed by a resident's physician as specified in Section 87555(b)(7). This requirement is not met as evidenced by:The facility designated representative stated that an updated plan of care will be implemented to address the care needs, specifically for special diet needed for residents with diabetes.

Facility personnel sufficiency and competence

87411Personnel Requirements (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs ... shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds... licensing ... may require... to provide additional staff... This requirement was not met as evidenced by Reported elopement of resident who has been determined by their physician that they cannot leave the facility unassisted which poses an immediate health, safety and personal rights risk to residents in care.