Correction check·March 20, 2025

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a POC visit and was greeted by caregiver, LVN. Facility Administrator Gloria Tadrun arrived later. On 2/20/25 LPA conducted the facility annual inspection and issued citations for deficiencies of the following regulations: HSC 1569.618(c)(3), HSC 1569.625(b)(2), CCR 87625(b)(3), CCR 87355(e)(3), CCR 87555(b)(27), CCR 87463(i), CCR 87412(g) and CCR 87202(a). As of today 3/20/25, the plans of corrections for these deficiencies have not been submitted to CCL. Therefore, deficiencies for regulations: HSC 1569.618(c)(3), HSC 1569.625(b)(2, CCR 87625(b)(3), CCR 87355(e)(3), CCR 87555(b)(27), CCR 87463(i), and CCR 87412(g) are being re-cited today. The plan of correction was due on 2/21/25 for HSC 1569.618(c)(3). The plan of correction required facility to submit plan to have S4 and S2 complete First Aid/CPR training. Training to be completed no later than 3/6/25. Proof of First Aid/CPR certificate/card to be submitted to CCL no later than 3/6/25. Deficiency is being re-cited today, see 809D. Failure to correct the deficiency by the plan of correction due of 3/21/25 and/or repeat deficiencies within a 12 month period may result in civil penalties. The plan of correction was due on 2/21/25 for HSC 1569.625(b)(2). The plan of correction required facility to submit plan to have all staff complete required number of hours (as identified by their start date) of training by plan of correction due date. Admin agrees to use Senior Community Learning for all staff training. Training certificates in the required number of hours for each respective staff: S1, S2. S3, S4, S5, S6, and S7 to be completed and sent to CCL by no later than 3/13/25. Deficiency is being re-cited today, see 809D. Failure to correct the deficiency by the plan of correction due of 3/21/25 and/or repeat deficiencies within a 12 month period may result in civil penalties. The plan of correction was due on 2/24/25 for CCR 87625(b)(3). The plan of correction required facility to Continued on 809C... Continued from 809... submit LIC9098 self-certifying they will ensure that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence by plan of correction due date. Deficiency is being re-cited today, see 809D. Failure to correct the deficiency by the plan of correction due of 3/21/25 and/or repeat deficiencies within a 12 month period may result in civil penalties. The plan of correction was due on 2/24/25 for CCR 87355(e)(3). The plan of correction required facility to submit to CCL facility Guardian roster print out showing S6 as being associated to the facility by plan of correction due date. Deficiency is being re-cited today, see 809D. Failure to correct the deficiency by the plan of correction due of 3/21/25 and/or repeat deficiencies within a 12 month period may result in civil penalties. The plan of correction was due on 2/27/25 for CCR 87555(b)(27). The plan of correction required facility to submit to CCL pictures of grout around kitchen sink free of black substances and film by plan of correction due date. Deficiency is being re-cited today, see 809D. Failure to correct the deficiency by the plan of correction due of 3/21/25 and/or repeat deficiencies within a 12 month period may result in civil penalties. The plan of correction was due on 2/27/25 for CCR 87463(i). The plan of correction required facility to submit current and complete Appraisal for R1, R2, and R3 by plan of correction due date, including resident or resident's responsible party's signature and date of receipt by plan of correction due date. Deficiency is being re-cited today, see 809D. Failure to correct the deficiency by the plan of correction due of 3/21/25 and/or repeat deficiencies within a 12 month period may result in civil penalties. Continued on 809C(2)... Continued from 809C... The plan of correction was due on 2/27/25 for CCR 87412(g). The plan of correction required facility to submit Health Screen with TB clearance or LIC503, LIC501, and copy of First Aid/CPR for S6 and S7 to CCL by plan of correction due date. Deficiency is being re-cited today, see 809D. Failure to correct the deficiency by the plan of correction due of 3/21/25 and/or repeat deficiencies within a 12 month period may result in civil penalties. Upon arrival today 3/20/25, LPA observed deficiency of regulation CCR 87202(a) has been corrected. LPA observed broken hospital bed has been removed and is no longer partially obstructing the emergency fire exit path. LPA asked caregiver, LVN why facility did not submit pictures of cleared path in order to clear deficiency. Caregiver, LVN explained they did send the picture to the Administrator on 3/5/25. LPA reviewed metadata of picture shown to LPA of removal and it did show the picture was taken 3/5/25. LPA advised next time, be sure to send the picture to CCL to clear the deficiency. LPA advised Administrator of the same. Deficiency is cleared. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given .