Sonnet Hill

Record centrally stored prescriptions and refill data

Based on records reviewed, the licensee did not comply with the section cited above. Based on a medication audit, resident R1 had a medication that was not listed on his/her centrally stored medication record. Resident R2 also had a medication that was not listed on their centrally stored medication record. This poses/posed a potential health, safety or personal rights risk to persons in care.

87705 Care of Persons with Dementia (e) (5) Facility staff shall ensure the continued safety of residents if they wander away from the facility ... Personal Rights of Residents in Privately Operated Facilities.This requirement was not met as evidenced by; Based on investigation, on January 11, 2026 R1, who has a neurocognitive disorder, left the facility unassisted and was found by law enforcement unattended. This poses an immediate Health, Safety, or Personal Rights risk to persons in care.

Facility personnel sufficiency and competence

87411 Personnel Requirements - General(a) Facility personnel shall at all times be...competent to provide the services necessary to meet resident needsThis requirement was not met as evidenced by Based on interviews conducted, on January 2, 2026, resident R1 was administered residents R2’s M1 medication. This poses a potential health, safety and personal rights risk to persons in care.

Record centrally stored prescriptions and refill data

87465 Incidental Medical and Dental Care(h)(6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year...This requirement was not met as evidenced by: Based on record review, interview and observation, Licensee did not ensure 4 out of 4 resident records of centrally stoed prescription medications were maintained which poses/posed a potential health, safety or personal rights risk to persons in care.

Assist residents with self-administered medication

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 observation, record review and interview, the facility staff did not assist R1 with medications as needed when LIC 602A states R1 is not able to administer or store own medication which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

Ensure hazardous items are locked and not unattended

87309(a)... the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances...which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.This requirement is not met as evidenced by: Based on observation and record review, laundry/cleaning solution was observed in R2's room left unattended outside of locked storage which poses/posed an immediate 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)(2) Centrally stored medicines 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 is not met as evidenced by: Based on observation and record review, R2 medications were accessible to R2 who is not able to store own medication which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

Label and preserve medicine compliance standards

87465 Incidential Medical and Dental Care (h)(4) All 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 was not met as evidenced by: Based on observation, and record review, the facility staff did not discard R2's medication after expiration date and was still present in R1's room which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.

Right to confidential records and approved disclosure

87468.2 (a)(2) To have their records and personal information remain confidential and to approve their release, except as authorized by law.This requirement was not met as evidenced by: Based on record review and interview, Licensee did not make available the requested records when resident’s designated representative made a written consent which poses/posed a potential health, safety or personal rights risk to persons in care.

Safe, healthful, comfortable accommodations

87468.1 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: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was not met as evidenced by, based in interviews & records review, R1 was left outside the balcony of the facility for a long period of time exposing R1 to high temperatures, which poses an immediate health, safety, or personal rights risk to clients in care.

Admit resident care meeting requirements

87467 Resident Participation in Decisionmaking (a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility. This was not met as evidenced by: Based on records review, 7 out of 7 resident files reviewed does not have a needs and services plan, which poses an immediate health, safety, or personal rights risk to clients in care.

Right to sufficient care and qualified staff

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(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 interviews conducted & evidence reviewed, R1 care plan states R1 requires status checks every 2 hours at night. R1 was last seen on 08/12/24 at 11:21pm and was check on again on 08/13/24 at 3:47am the following day. This poses/posed a potential health, safety or personal rights risk to persons in care.

Maintain records of centrally stored medication dosages

Based on record review, the licensee did not comply with the section cited above in that staff were unable to provide 5 out 5 resident central stored medications forms in the resident files poses/posed a potential health, safety risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in that 2 out 3 caregivers were observed without valid first aid certificate which poses/posed a potential health, safety risk to persons in care.

Regular observation and documentation of resident changes

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not being met as evidenced by:Based on interview and record review, there was no documentation that facility brought to the attention of R1’s physician prior to stopping R1’s medications when R1 was not eating. Facility also did not inform R1’s responsible person when R1 was not eating for 48 hours. This poses an immediate threat to the health and safety of the resident in care.

87468.2(a)(12) 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: (12) To receive in the admission agreement a comprehensive description of the method for evaluating residents’ service needs and the fee schedule for the items and services, and to receive written notice of any rate increases according to Health and Safety Code sections 1569.655 and 1569.884. This requirement is not being met as evidenced by:Based on interview and record review, R1 was not given a copy of admission agreement that listed the fee schedule but a reservation agreement which did not list the fee for incontinent care. This poses a potential risk to the health and welfare of the resident in care.

87507 Admission Agreements (g)(3)(B)(2): (g) Admission agreements shall specify the following: (3) Payment provisions, including the following: (B) Rate for additional items and services, including: 2. A separate charge for an item or service may be assessed only if that charge is included in and authorized by the admission agreement This requirement is not being met as evidenced by:Based on interview and record review, facility failed to complete the admission agreement for R1 during the entire time of admission. Without the admission agreement, the separate charge for incontinent care was not authorized due to lack of admission agreement. This poses a potential risk to the health and safety of the resident in care.

Give PRN medication by physician order

87465(c)(2) Incidental Medical and Dental Care: (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not being met as evidenced by: Based on record review, facility stopped giving R1’s medication without a doctor’s order to stop when R1 was not eating for 48 hours. This poses an immediate risk to the health and safety of resident in care.

87224(d)(1) Eviction Procedures: (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. (1) The notice to quit shall include the following information: (B) to (D)This requirement is not being met as evidenced by: Based on record review, the eviction notice dated 2/10/22 did not have information on resources, the right to file a complaint, and unlawful detainer language.

Eviction report must be filed within five days

87224(f) Eviction Procedures: (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement was not met as evidenced by: Based on record review, CCL did not receive a copy of R1’s eviction notice in February.

Must complete individual written admission agreements

87507(a) Admission Agreements: (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement is not being met as evidenced by:Based on interview and record review, the licensee did not complete a written admission agreement with R1’s representative which poses a potential risk to the health of the resident in care.

Conformance with applicable laws and regulations

87405 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 was not being met as evidenced by: Based on interview and record review, Admin failed to have knowledge of and ability to conform to Title 22 on eviction procedures, personal rights and admission agreement as R1 was not given the proper eviction notice, the eviction notice was not sent to licensing agency, admission agreement was not completed, involuntary discharge and unprofessionalism in dealing with a family member. This poses an immediate risk to the health and safety of residents in care.

87468.2 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: (20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents for reasons other than those permitted by state law or regulations and shall comply with all eviction and relocation protections for residents. For purposes of this paragraph, "involuntary" means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident. This requirement is not being met as evidenced by:Based on interview and record review, facility initiated the involuntary discharge of R1 by refusing to take R1 back from the hospital without a proper eviction notice and without discussion with all parties involved. This poses a potential risk to the personal right of the resident in care.

Report serious outbreaks and major accidents

Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidenced by: Licensee did not report 4 COVID positive cases at the facility, which posed a potential safety risk to residents in care.