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Based on observation, the licensee did not comply with the section cited above in that paint and clearing products were observed in the storage room in the common area and in the sink cabinet next to the storage room which poses a potential health, safety or personal rights risk to persons in care.

Based on observation & record review, the licensee did not comply with the section cited above in that Staff Member S1 was not associated to the facility in the Guardian Background Check System which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in that Room number one (1) was observed with a strong urine odor which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in that the kitchen cabinets were observed to be very dirty with some caked in dried grease or sauces which poses a potential health, safety or personal rights risk to persons in care.

1569.625 Staff training; legislative findings; contents (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training...This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that one (1) of (5) staff members (S2) did not complete their 2025 annual training which poses a potential health, safety or personal rights risk to persons in care.

87468 Personal Rights (b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1...This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that residents R1 & R2 did not have signed personal rights documents in their records which poses a potential health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not...This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that a prescribed medication was left unsecured in the storage room in the common area of the facility which poses an immediate health, safety or personal rights risk to persons in care.

87457 Pre-Admission Appraisal (c) Prior 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...This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that resident R2 did not have a completed and signed pre-placement appraisal in their records which poses a potential health, safety or personal rights risk to persons in care.

87411 Personnel Requirements – General (f) All personnel, including the licensee and administrator, shall be in good health...shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months...This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that staff member S2 did not have a medical assessment or proof of a negative TB test in their personal record which poses a potential health, safety or personal rights risk to persons in care.

1569.655 Increase in fee rates for elderly residents; 60 days’ written notice standing amount of reasons for increase;...(a) If a licensee of a residential care facility for the elderly increases the rates,... the licensee shall provide no less than 60 days’ prior written notice. This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that resident R1 was not given the regulated sixty (60) day advanced notice of the rate increase which poses a potential health, safety or personal rights risk to persons in care.

87506 Resident Records (b)Each resident’s record shall contain at least the following information: (8)Names, address, and telephone numbers of the resident’s representative, as defined in Section 87101(r), to be notified in case of accident, death, or other emergency. This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that 1 of 3 residents records (for R1) did not contain Emergency Contact Information which poses a potential health, safety or personal rights risk to persons in care.

87309 Storage Space and Access(a)Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances...and other similar items which could pose a danger to residents are in locked storage...This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that unsecured toxins and insulin syringes were observed in a storage room which poses an immediate health, safety or personal rights risk to persons in care.

87457 Pre-Admission Appraisal (c) Prior 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...This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that 1 of 3 residents files (for resident R2) did not contain an LIC 603 Preplacement Appraisal Information form which poses a potential health, safety or personal rights risk to persons in care.

87465Incidental Medical and Dental Care (h)The following requirements shall apply to medications which are centrally stored: (2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees...This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that over the counter PRN medication was observed to be unsecured in Room #2 which poses an immediate health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care(c) If the resident's physician has stated in writing..(1)There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication... This requirement is not met as evidenced by: Based on observation & record review, the licensee did not comply with the section cited above in that PRN medication was provided to Resident R3 without a licensed medical professional's order or prescription, which poses an immediate health, safety or personal rights risk to persons in care.

87307 Personal Accommodations and Services (e)The licensee shall supervise residents as needed...when residents are in proximity to or when there is use of the following items:(1)... heaters,...and other heating devices.(A)Heating devices shall have protective mechanisms...in order to reduce the risk of burns or fire. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that in the common area, next to the storage room, a parabolic dish heater was observed to not have a protective screen which poses an immediate health, safety or personal rights risk to persons in care.

87405 Administrator - Qualifications and Duties (a)All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person...This requirement is not met as evidenced by Based on record review, the licensee did not comply with the section cited above in that the facility does not have a currently certified Administrator which poses an immediate health, safety or personal rights risk to persons in care

87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that a medication cabinet in common area, next to the storage room was unlocked, which poses a immediate health, safety or personal rights risk to persons in care.

87555 General Food Service Requirements (b)The following food service requirements shall apply: (25)Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in In the cabinet immediately outside of the kitchen area, across from a bathroom, food products and cleaning products were observed to be stored together. which poses a potential health, safety or personal rights risk to persons in care.

87555:General Food Service Requirements(b)The following ...requirements shall apply: (23) All readily perishable foods... capable of supporting...progressive growth of micro-organisms which can cause food infections..shall be stored...at appropriate temperatures. This requirement is not met as evidenced by:Based on observation, the licensee did not comply with the section cited above in that that two (2) condiments that were required to be refrigerated after opening, were left unrefrigerated in a kitchen cabinet. which poses a potential health, safety or personal rights risk to persons in care.

87211Reporting Requirements (a)Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...for the resident within seven days...This report shall include the resident's name, age....(A) Death of any resident... This requirement is not met as evidenced by:Based on observation and record review, the licensee did not comply with the section cited above in that an LIC 624 Unusual Incident report for R4 and an LIC 9186 Client Death Report for R5 was not sent to CCL which poses a potential health, safety or personal rights risk to persons in care.

87309 Storage Space and Access(a)Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances...and other similar items which could pose a danger to residents are in locked storage...This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that unsecured toxins were observed in a residents bathroom, the laundry room and the storage room which poses an immediate health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement not met by licensee as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that the magnetic key for a medication cabinet in common area, next to the storage room was unsecured next to the cabinet, which poses a potential health, safety or personal rights risk to persons in care.

87405 Administrator - Qualifications and Duties (a)All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person...This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in that the facility does not have a currently certified Administrator which poses an immediate health, safety or personal rights risk to persons in care

87405 Administrator - Qualifications and Duties (a)All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person...This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in that the facility does not have a currently certified Administrator which poses an immediate health, safety or personal rights risk to persons in care.

87411 Personnel Requirements – General(C)(1)Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.This requirement is not met as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that staff members S2 and S4 did not have current First Aid training certification in their files which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in that that six (6) various dressings and sauces that were required to be refrigerated after opening, were left unrefrigerated in a kitchen cabinet. which poses a potential health, safety or personal rights risk to persons in care.

§1569.625 Staff training; legislative findings; contents (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that S1, S2, S3 and S4 did not have required hours of training on file, which poses an immediate health, safety or personal rights risk to persons in care.

87463 Reappraisals (a) The pre-admission appraisal...shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first...For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement not met by licensee as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that R2, R3 and R5 all did not have current appraisals on file, which poses a potential health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement not met by licensee as evidenced by: Based on LPA observation, the licensee did not comply with the section cited above in that a medication cabinet in common area, next to the storage room was unlocked, which poses a potential health, safety or personal rights risk to persons in care.

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency ...(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... This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that licensee did not submit to CCL an Incident Report for R3 or R4 after they experienced incidents that required one be submitted, which poses a potential health, safety or personal rights risk to persons in care.

87303 Maintenance and Operation(a)The facility shall be clean, safe, sanitary and in good repair at all times...This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPAs observed intake vent in front hallway covered in dust/dirt and a grease like substance, which poses an immeidate health, safety or personal rights risk to persons in care.

87303 Maintenance and Operation (e)Water supplies and plumbing fixtures shall be maintained...(2)Faucets used by residents...shall deliver hot water...of not less than 105 degree F and not more than 120 degree F. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in thatwhich poses an immeidate health, safety or personal rights risk to persons 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 requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPAs observed unsealed/ tied trash bags full of soiled incontinence briefs in laundry room with eggs, which poses an potential health, safety or personal rights risk to persons in care.

87309 Storage Space and Access(a)Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that door to laundry room from facility unlocked; LPAs observed unsecured cleaning products in metal cabinet found unlocked in laundry room, which poses an immediate health, safety or personal rights risk to persons in care.

87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health...Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test...This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that S3, S4, and S5 did not have Health Screens on file, which poses a potential health, safety or personal rights risk to persons in care.

87463 Reappraisals (a) The pre-admission appraisal...shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first...For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that R1, R2, R3, R4, and R5 all did not have current appraisals on file,which poses a potential health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that prescription and PRN medications were accessible to residents in rooms 10, 8, 9, and in dining and laundry room, which poses a potential health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored:(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 not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that R3's prescription medication had it's label partially removed, which poses a potential health, safety or personal rights risk to persons in care.

87555 General Food Service Requirements(b) The following food service requirements shall apply:(23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation large container of eggs left on a shelf unrefrigerated in laundry room, which poses a potential health, safety or personal rights risk to persons in care.

87618 Oxygen Administration ...the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation oxygen tank in storage closet not secured to wall or in cradle, which poses a potential health, safety or personal rights risk to persons in care.

87625 Managed Incontinence(b)...the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPAs observed an extremely strong urine odor in room five (5) and odor in room two [2B], which poses a potential health, safety or personal rights risk to persons in care.

§1569.625 Staff training; legislative findings; contents (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that S1, S2 and S3 did not required hours of training on file, which poses an immediate health, safety or personal rights risk to persons in care.

87303 Maintenance and Operation(e) Water supplies and plumbing fixtures shall be... (2) Faucets used by residents ...shall deliver hot water. Hot water temperature controls shall be maintained ... 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 by licensee as evidenced by: water temperature over 120 degrees F in two [2] out of five [5] sinks measured, which poses an immediate health, safety, and/or personal rights risk to resident in care.

1569.625(b)(2)...training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training...four hours of which shall be specific to postural supports, restricted health conditions, and hospice care.. This requirement was not met by licensee as evidenced by: failure to satifsy plan of correction for this regulation deficeincy issued on 10/30/2024, which poses an immediate health, safety, and/or personal rights risk to resident in care.

87355(e) All individuals subject to a criminal record review...shall prior to working...in a licensed facility:(2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met by licensee as evidenced by: failure to satifsy plan of correction for this regulation deficeincy issued on 6/19/2024, which poses a potential health, safety, and/or personal rights risk to resident in care.

(a) All facilities shall have a qualified and currently certified administrator.... The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. 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... This requirement is not met by licensee as evidenced by: failure to clear deficiencies timely and deficeinces pertaining to: staff training, staff records, and resident's care needs and personal rights, which poses a potential health, safety, and/or personal rights risk to resident in care.

87465(h)(5) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met by licensee as evidenced by: failure to satifsy plan of correction for this regulation deficeincy issued on 6/19/2024, which poses a potential health, safety, and/or personal rights risk to resident in care.

87705(f)(2) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement was not met by licensee as evidenced by: failure to satifsy plan of correction for this regulation deficeincy issued on 6/19/2024, which poses an immediate health, safety, and/or personal rights risk to resident in care.

87465(h)(4) The following requirements shall apply to medications which are centrally stored: (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 by licensee as evidenced by: failure to satifsy plan of correction for this regulation deficeincy issued on 6/19/2024, which poses a potential health, safety, and/or personal rights risk to resident in care.

87303 Maintenance and Operation(e) Water supplies and plumbing fixtures shall be maintained as follows: (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 (41 degree C) and not more than 120 degree F (49 degree C).. Based on observations made, the Licensee did not comply with the section cited above. 7 of 13 facility sinks were found to be out of Title 22 regulations of 105F to 120F measuring between 120.5F and 126.8F. This poses a potential health, safety or personal rights risk to residents in care.

1569.625(b)(2)...training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training...four hours of which shall be specific to postural supports, restricted health conditions, and hospice care... This requirement was not met by licensee as evidenced by: failure to satifsy plan of correction for this regulation deficeincy issued on 6/19/2024, which poses an immediate health, safety, and/or personal rights risk to resident in care.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include... procedures for the safety and well-being of residents, employees and visitors. This requirement was not met by license as evidenced by: Facility on-going issue of bed bugs present at facility is known by licensee and LPA obtained photographic evidence, which poses an potential health, safety, and personal rights risk to resident in care.

87468.2 Additional Personal Rights of Residents... (a) ... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (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 by licensee as evidenced by: Based on LPA interview with licensee and photographic evidence obtained,This requirement was not met by license as evidenced by: LPA interview with licensee indicating R1 fell on to the floor but licesee could not pick R1 up unasssited. R1 waited at least 30 minutes before receiving assistance, which poses a immediate health, safety, and personal rights risk to resident in care.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include... procedures for the safety and well-being of residents, employees and visitors. This requirement was not met by license as evidenced by: Facility on-going issue of bed bugs present at facility is known by licensee, which poses an immediate health, safety, and personal rights risk to resident in care.

Based on records reviewed, the Licensee did not comply with the section cited above. 1 of 4 staff members were missing proof of their health screening report and proof of negative TB. This poses an immediate health, safety or personal rights risk to residents in care.

Based on records reviewed, the Licensee did not comply with the section cited above. 3 of 4 staff members were missing proof of their annual 2023 training. This poses an immediate health, safety or personal rights risk to residents in care.

Based on observations made, the Licensee did not comply with the section cited above. 7 of 13 facility sinks were found to be out of Title 22 regulations of 105F to 120F measuring between 120.5F and 126.8F. This poses a potential health, safety or personal rights risk to residents in care.

Based on observations made, the Licensee did not comply with the section cited above. 2 of 2 staff members were found to be background cleared but not associated to the facility as required. This poses a potential health, safety or personal rights risk to residents in care.

Based on observations made, the Licensee did not comply with the section cited above. LPA observed the following toxins, hazards, and medications to be accessible: unlocked knife drawer, Disinfectant cleaner, bed bug repellent, blood sugar monitors and sharps, 3 bottles of cough syrup, 1 bottle of Pepto Bismol and 1 bottle of Tums. This poses an immediate health, safety or personal rights risk to residents in care.

Based on observations made, the Licensee did not comply with the section cited above. 2 of 9 residents did not have an updated Physician's Report as required. These two residents had a dementia diagnosis. This poses a potential health, safety or personal rights risk to residents in care.

Based on record review, the Licensee did not comply with the section cited above. 9 of 9 resident files did not have a needs and services plan. This poses a potential health, safety or personal rights risk to residents in care.

Based on observations made, the Licensee did not comply with the section cited above. LPA observed pre-poured medications located in a locked cabinet. This poses a potential health, safety or personal rights risk to residents in care.

Based on observations made, the Licensee did not comply with the section cited above. 1 of 9 residents did not have a completed Pre-Appraisal as required. This poses a potential health, safety or personal rights risk to residents in care.

Based on observations made, the Licensee did not comply with the section cited above. 4 of 9 resident medications reviewed were not centrally stored as required. LPA observed that some medications were not logged or incorrectly documented. This poses a potential health, safety or personal rights risk to residents in care.

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met based on record reviews showing that staff was not trained per regulation. This is an immediate risk to the Health and Safety of residents in care.

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not med based on interview and observation showing that facility has insects inside the facility. This is an immediate risk to the health and safety of residents in care.

87465 Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:based on observation and interview facility is pre-pouring medication.

87465 Incidental Medical and Dental Care (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident... includes:(A)The name of the resident for whom prescribed. (B) The name of the prescribing physician., (C) The drug name, strength and quantity., (D) The date filled., (E) The prescription number and the name of the issuing pharmacy., (F) Instructions, if any, regarding control and custody of the medication.

Based on record review, the licensee did not comply with the section cited above in two out of two staff not having documented annual training which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above in two out of two staff not having documented annual training which poses/posed a potential health, safety or personal rights risk to persons in care.

87211 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: (2) 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. Requirement was not met based on interviews confirming that 2 residents were diagnosed with Covid-19 and facility did not report to CCL or local public health. This is a potential risk to the health and safety of residents in care.