Correction check·August 27, 2025

Citations

14 citations recorded^*CCLD

• 1569.626(a)Type B

  HEALTH AND SAFETY CODERCFEs shall meet...training requirements, as described in Section 1569.625, for all direct care staff...12 hours of dementia care training, 6 of which...completed before...working independently with residents, and the remaining 6 hours of which shall be completed within the first 4 weeks of employment. This requirement is not met, as training records are not available for review. Licensee failed to maintain documentation that staff have received dementia training, which poses a potential health, safety or personall rights risk. This was cited on 9/3/24 and 8/5/25.

• 1569.69(a)Type B

  HEALTH AND SAFETY CODE...employee shall complete 10 hours of initial training...consist of 6 hours of hands-on shadowing training...prior to assisting with the self-administration of medications, & 4 hours of other training or instruction, as described in subdivision (f)...be completed within the first 2 weeks of employment. This requirement is not met, as training records are not available for review. Licensee failed to maintain documentation that staff have received medication training, which poses a potential health, safety or personal rights risk. This was cited on 9/3/24 & 8/5/25.

• 1569.695(b)Type B

  HEALTH & SAFETY CODEA facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement is not met, as there is no documentation that staff received training on responding to emergencies, which poses a potential health, safety or personal rights risk to clients in care.This deficiency was cited on 9/3/24 and 7/31/25, and proof of correction was not submitted.

• 1569.696(a)Type B

  HEALTH AND SAFETY CODEAll RCFEs shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. This requirement is not met, as training records are not available for review. Licensee failed to maintain documentation that staff have received this training, which poses a potential health, safety or personall rights risk. This was cited on 9/3/24 and 8/5/25 and not corrected.

• 87207Type A

  Prohibit false or misleading facility statements

  FALSE CLAIMSNo licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility...This requirement was not met, as facility staff obtained personal and confidential information by falsely stating that the information was required by state licensing. Licensee failed to prevent staff from making false claims, which poses an immediate health, safety or personal rights risk to clients in care.This was cited on 8/14/25 and not addressed in plan of correction submitted on 8/18/25.

• 87411(f)Type B

  Health screening and fitness requirements

  PERSONNEL REQUIREMENTS... verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than 6 months prior to or 7 days after employment or licensure. A report shall be made of each screening, signed by the examining physician. This requirement is not met, as 6 out of 6 staff files were missing health screenings and TB test results. Licensee failed to ensure that health screenings are maintained for all staff, which poses a potential health, safety or personal rights risk. This was cited on 9/3/24 and not corrected.

• 87457(c)Type B

  Complete admission suitability appraisal

  PRE-ADMISSION APPRAISALPrior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance/Retention LimitS. This requirement is not met, as there is no signed appraisal on file for client #5, who was admitted 3 years ago. This poses a potential health, safety or personal rights risk to clients. This was cited on 9/3/24 and 7/31/25.

• 87463(a)Type B

  Update reappraisal at required intervals

  REAPPRAISALSThe pre-admission appraisal... shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition... and to keep the appraisal accurate. This requirement is not met as reappraisals for ALL clients are missing or dated more than 12 months ago. Licensee failed to ensure that annual reappraisals are done, which poses a potential health, safety or personal rights risk to clients.This deficiency was observed on 9/3/24 & 7/31/25, & proof of correction was not submitted.

• 87465(e)(1Type B

  INCIDENTAL MEDICAL CAREFor every Rx and non Rx medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the MD order & the label shall contain ...specific information. This requirement is not met, as MD orders are not maintained for C3 OTC Senna and C6 Senna Plus. Licensee failed to ensure that MD orders are maintained for OTC meds, which poses a potential health, safety or personal rights risk. This was cited 8/5/25.

• 87465(h)(1)(4)Type B

  INCIDENTAL MEDICAL CAREAll centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met, as staff write on RX labels. Licensee failed to ensure that staff do not write on Rx labels, which poses a potential health, safety or personal rights risk to clients in care.This was cited on 8/5/25 and not corrected.

• 87465(i)(1Type B

  INCIDENTAL MEDICAL CARERx medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician & documented in the resident’s record nor disposed of... shall be destroyed in the facility by the facility administrator & another adult who is not a resident. Both shall sign a record, to be retained for at least 3 years, which lists... specific information. This requirement is not met, as Rx meds for former client observed in kitchen cabinet, which poses a potential health, safety or personal rights risk. This was cited 8/5/25.

• 87468.1(a)(1)Type A

  Dignity in personal relationships

  PERSONAL RIGHTSResidents in all RCFEs shall have... the ... personal right to be accorded safe, healthful &comfortable accommodations, furnishings & equipment. This requirement is not met, as client in room #5 is observed in bed with recliner chair & wheelchair placed next to bed, preventing her from getting out of bed. Licensee failed to ensure that clients are accorded safe & healthful accommodations, which poses an immediate health, safety or personal rights risk to clients in care.This was cited on 8/5/25, and "explanation" was submitted on 8/6/25, not correction.

• 87468.1(a)(13)Type B

  PERSONAL RIGHTSResidents in all RCFEs shall have the personal right to have access to individual storage space for private use. This requirement is not met, as facility records are stored in client room #4. Licensee failed to ensure that client's room is for client's personal use and not used by staff. This poses a potential health, safety or personal rights risk to clients in care.This was cited on 8/5/25 and not corrected

• 87611(b)(1Type B

  GENL REQUIREMNTS HEALTH COND.The licensee shall complete & maintain a current, written record of care... that includes, but is not limited to... Documentation from the physician of... Stability of the medical condition, Medical condition which requires incidental medical services, Method of intervention...skilled professional...who will perform the procedure if the resident needs assistance; names...phone number of...skilled professionals providing services, Emergency contacts. Client #4 has gall bladder stoma & there is no info about care or condition. This was cited on 7/31/25.