Villa Capri

Regular observation and documentation of resident changes

87466 Observation of the Resident, 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 met as evidenced by: LPA's investigation, R1 was observed to have a change in condition, on 8/18/25, Physician was faxed about R1's changes observed, but there was no follow-up after this date till 8/24/25 at 10:20am, per record reviews. RP was not notified per file reviews, obtained information, and interviews, until 8/27/25 that resident had a change of condition. This is a personal rights risk to resident in care.

Right to sufficient care and qualified staff

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities- 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: 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: Per review of records, interviews with staff, S1 and S2, and interviews with other related parties, it was identified that staff (S4, S5) inappropriately handled (R1) when trying to provide incontinent care to them, and R1 was refusing care from the staff. (R1) reacted by screaming and kicking at staff when they handled R1 inappropriately. Staff didn't use a different approach and/or stepping away and allowing some time to the resident to be agreeable to the incontinent care needed. This is a risk to residents personal rights.

Assist residents with self-administered medication

87465(a)(4) Incidental Medical and Dental Care- The licensee shall assist residents with self-administered medications as needed. This requirement was not as evidenced by: LPAs record reviews, interviews, and observations, Facility policy states that medication refills are to be ordered seven days prior to running out. R1's care plan states that R1's Representative is to be notified a, minimum of two weeks in advance for refills. R1 missed 8 doses of Medication Order #1, and has been provided medication order #2 outside of dosage hours, and given for sleep/insomnia which is not per the Dr's Order. This is a risk to residents rights & health&safety. Civil Penalty assessed at $250 for repeat violation within 12 months, LIC421FC.

Assist residents with self-administered medication

87465(a)(4) Incidental Medical and Dental Care-A plan for incidental medical and dental care shall be developed by each facility. The licensee shall assist residents with self-administered medications as needed. This requirement was not as evidenced by: LPAs record reviews, interviews, and observations, Facility policy states that medication refills are to be ordered seven days prior to running out. R1's care plan states that RP is to be notified when medications need to be filled, minimum of two weeks in advance. R1's last dose of their powdered mix medication was 12/16/24, and today, 12/17, R1 missed the AM dose and will miss the pm dose due to the medication is out, and is just now on order, waiting to be filled, per interviews with staff and other related parties. This is a risk to residents health & safety and personal rights.

87625 (b)(1)(2)(3 Managed Incontinence-)In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervals rather than being diapered. Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. Health & Wellness (H&W) Director Jennifer Haney stated that facility caregivers are to check on the resident every two hours, and change the resident as needed; The resident has a companion with them for part-time hours, and some of the facility caregivers checked a couple times on the resident, to find the companion had already changed R1. Some of the facility caregivers had stopped checking on R1 due to thinking the resident was being provided incontinent care by the resident's private companion. This is a risk to resident's personal rights.

Right to sufficient care and qualified staff

Additional Personal Rights of Residents- In addition to the rights in Section 87468.1, Personal Rights of Residents: 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: Per LPA's review of records, interviews with staff, and other related parties, resident rang call bell/pendant for assistance on 5/20, with no response till 24 minutes later; & 6/27 resident rang call bell/pendant for assistance and no response till 25 minutes later. This is a risk to resident health & safety and/or personal rights. Civil Penalty assessed in the amount of $250.see LIC421FC.

Assist residents with self-administered medication

87465(a)(4) Incidental Medical and Dental Care- The licensee shall assist residents with self- administered medications as needed. This requirement was not met as evidenced by: The LPA's review of records, interviews, investigation revealed that the facility didn't refill resident's medication in a timely manner, Medication was ordered 4/3, and resident's responsible party had to go buy the medication on 4/5/23 for the resident. This is a health and safety risk and/or a personal rights risk to residents in care.

Right to sufficient care and qualified staff

87468.2(a)(4) Additional Personal Rights of Residents- In addition to the rights in Section 87468.1, Personal Rights of Residents: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: Per investigation, Resident waited an hour for assistance after requesting a med-tech, R1 had requested S3/staff to call for a med-tech for them. S3 never called for a med-tech. R1 called on their own for a med-tech to assist them after waiting an hour. This is a risk to residents personal rights and/or a risk to resident's health& safety.

Ensure hazardous items are locked and not unattended

87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients, This requirement wasn't met as evidenced by: LPA observed that the beauty salon in assisted living was unlocked with no staff inside, this left poisons/chemicals, toxins, and other items in the salon accessible to residents in care. This is an immediate health and safety risk to residents in care

Provide resident hot water for personal care

Maintenance and Operation 87303€(2)2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F . This requirement was not met as evidenced by: LPA toured with the Administrator and Maintenace Director, hot water was checked on both florrs and in meory care, 122.F, 121.5F, and 123.4F , this is not within regulation.This is an immediate health and safety risk to residents in care

Food handling safeguards during storage and service

General Food Service Requirements 87555(b)(9) The following food service requirementsshall apply: Procedures which protect the safety, acceptability and nutritive values of foodshall be observed in food storage, preparation and service. This requirement was not met as evidenced by: LPA observed that two large boxes of lentil beans they were opened and were not covered and stored appropriately, a large box of rice was open and was not covered and stored appropriately;These items were not covered appropriately to protect the safety and acceptability necessary to prevent contamination; This is an immediate health and safety risk to residents in care

Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by: LPA reviewed five(5) resident records. Resident three(R3) lacked an updated medical assessment as required by regulation. This is a potential health and safety risk to resident(s) in care.

Assist residents with self-administered medication

(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. LPA reviewed two incident reports of staff not providing correct medication dosage and/or correct medication for the resident which resulted in two incidents of medication errors. This is a health and safety risk and/or personal rights violation to the residents in care.

Provide resident hot water for personal care

87303(e)(2)Maintenance and Operation: Water supplies and plumbing fixtures shall be maintained as follows:Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement was not met as evidenced by review of records, interviews with staff and other related parties. The hot water has had some incidents of running cold for 15 mins or so before getting warm and running hot intermittently. Currently a unit is affected by this, and Professional Plumber identified a part needing to be replaced. Currently, it is on order and will be installed as soon as received. Hot water may continue to run hot intermittently till repaired. Licensee has reported all hot water incidents. his is a risk to health and safety and/or a personal rights violation to residents in care.

Fire approval and staff access to unlock systems

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.

Food handling safeguards during storage and service

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.