The Vistas at Oxnard Senior Living

87465Incidental Medical and Dental Care. (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications...This requirement is not met as evidenced by: Based on medication review and interview, the licensee did not comply with the section cited above as two (2) out of three (3) residents’ CSMDR which poses a potential health, safety or personal rights risk to persons in care.

87465(a)(4) Incidental Medical&Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review and observations, the licensee did not comply with the section cited above, as the facility staff did not properly assist with R1’s self-administered medications per physician’s order which poses an immediate health and safety risk to residents in care.

§1569.58(a) (2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California. This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above as facility staff consumed alcohol while working, which posed an immediate health, safety and personal rights risk to persons in care.

(a) Except as specified in Section 87611(a)…: (3) Residents with a stage one or two pressure injury... (A) The resident shall receive care for the pressure injury from a physician or an appropriately skilled professional.This requirement was not met as evidenced by: Based on interview and record review, the Licensee did not comply with the above cited section in that unlicensed staff provided wound care to R1 which poses/posed an immediate health, safety, and personal rights risk to persons in care.

87465(a)(4) Incidental Medical&Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility…(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review and observations, the licensee did not comply with the section cited above, as the facility staff did not properly assist with R2’s, R3’s and R4’s self-administered medications per physician’s order which poses an immediate health and safety risk to residents in care.

87468.2 (a)(20) Personal Rights of Residents ... residents in privately operated residential care facilities for ... shall have all of the following personal rights:(20) To be protected from involuntary transfers, discharges, and evictions…This requirement was not met as evidenced by: Based on record review and interviews, the Licensee did not accept Resident #1 back to facility from the hospital which poses a potential health and safety risk to residents in care.

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times... services and procedures for the safety and well-being of residents... This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not comply with the section cited above as the LPA observed several areas throughout the facility not maintained clean and sanitary such as residents’ toilets which poses a potential health and safety or personal rights risk to persons in 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 ...This requirement was not met as evidenced by: Based on observation and record review, the licensee did not comply with the above cited section as a resident had access to medications which posed an immediate health, safety, and personal rights risk to residents in care.

Based on observation, the licensee did not comply with the section cited above. The west side patio door on the memory care patio was not functional and there was a poorly covered hole in the floor in memory care which would cause a potential tripping hazard, 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 was not met as evidenced by: Based on interviews, the licensee did not comply with the above cited section, as witnesses stated S1 left medication on dining room tables unattended by staff and left meds in a drawer, which posed an immediate health and safety risk to persons in care.

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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the above cited section, as witnesses stated S1 spoke in a rude manner to residents, which posed a potential health and safety 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...This requirement was not met as evidenced by: Based on record review, R1's responsible party was not notified of at least one incident, which posed a potential health and safety risk to persons in care.

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 on interviews, the licensee did not comply with the above cited section, as R1 was allowed to leave unnoticed by staff, staff was sleeping in a common area and staff require training on oxygen, which posed a potential health and safety risk to persons in care.

87411 Personnel Requirements General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Ths requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above cited section, as there were no med techs scheduled for Sundays and Thursdays NOC shift, which poses an immediate safety risk to persons in care.

87405 Administrator - Qualifications and Duties. (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. Based on interviews with staff, the licensee did not comply with the above cited section, as there was no qualified administrator running the facility for several days during a time of severe staffing shortage, which posed a potential health and safety risk to persons in care.

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, individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on interviews and record review of alert response times, some responses were not completed in a timely manner and other calls went unanswered, which posed a potential health and safety risk to residents in care.

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not comply with the above cited section, as there were no records showing drills had been conducted, which poses a potential safety risk to persons in care.

87555 General Food Service Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents... All food shall be selected, stored, prepared and served in a safe and healthful manner.This requirement is not met as evidence by: Based on resident and staff interviews, the licensee did not comply with the section cited above, too many starches and not enough fresh produce, running out of food items, hot food served cold, which poses a potential health, safety, and personal risk to persons in care.

87555 General Food Service Requirements (b) The following food service requirements shall apply:(18) Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents.This requirement is not met as evidence by: Based on resident and staff interviews, the licensee did not comply with the section cited above, due to late or no meal service while meals were served in residents' rooms due to COVID outbreaks, which poses a potential health, safety, and personal risk to persons in care.

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities... To care, individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by: Based on resident and staff interviews and record review of alert response times, some responses were not completed in a timely manner and other calls went unanswered, which poses a potential health, safety, and personal risk to persons in care.

87468.1(a)(2) Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement was not met as evidenced by: Based on LPAs' observations, the licensee did not comply with the section cited above, as staff were not properly wearing face masks in the facility, which poses a potential health, safety, and personal risk to persons in care.

87411 Personnel Requirements General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requirement is not met as evidenced by: Based on resident and staff interviews, the licensee did not comply with the section cited above, late/no meal service when served in room, late/no response to call buttons due to lack of staff, which poses a potential health, safety, and personal risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in one out of one medication carts, which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in four out of five delayed egress doors located in the memory care unit; the delayed egress on these doors did not operate and one door on the patio was wired shut, which poses an immediate health, safety or personal rights risk to persons in care.

87411 Personnel Requirements General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Based on interview and record review, the licensee did not comply with the above cited section, as there were no med techs scheduled for Sundays and Thursdays NOC shift, which poses an immediate safety risk to persons in care.

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (5)Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.This requirement is not met as evidenced by: The facility did not comply with the section cited above as staff must perform all activities of daily living for R1, which poses an immediate health and safety risk to person in care.

87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (2) Ensuring that oxygen administration is provided by an appropriately skilled professional should the resident require assistance. This requirement was not met as evidenced by: Based on interviews, the licensee did not comply with the sectioncited above as the facility failed to ensure staff were trained to assist resident with oxygen administration, which posed a potential health & safety risk to residents in care.

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department orThis requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as Staff #1 does not have criminal record clearance and has been employed in the facility since 03/10/2023, which poses an immediate safety risk to persons in care.

87468.1(a)(2) Personal Rights of Residents in All Facilities ...To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement was not met as evidenced by: Based on observations, the licensee did not comply with the section cited above, as staff were not properly wearing face masks in the facility, which posed a potential personal rights risk to residents in care.

§1569.695 Emergency Plans (d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. This requirement is not met as evidenced by: The facility did not comply with the section cited above as the facility staff and their emergency contact numbers have not been updated which poses a potential health and safety risk to person in care.

§1569.695 Emergency Plans (b) A 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 evidenced by: The facility did not comply with the section cited above as the facility staff have not been trained on how to use the evacuation chair in the stairwell which poses a potential health and safety risk to person in care.

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:(9) To have communications to the licensee from their representatives answered promptly and appropriately. This requirement is not met as evidence by:Based on interviews and documentation the licensee did not comply with the section cited above as ED Spitznogle did not communicate with R1's family member promptly with poses a potential health, safety and personal rigths violation to person in care.

87705 Care of Persons with Dementia (f)The following shall be stored inaccessible to residents with dementia (1) (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).This requiement is not met as evidenced by: Based on LPA observation the licensee did not comply with the section cited above as kitchen knifes were in an unlocked staff lounge accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.

87705 Care of Persons with Dementia (f) 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 requiement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as unknown chemicals and disinfectant spray was observed in a kitchen and staff lounge accessible to residents which poses/posed an immediate health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care (a)(4)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 is not met as evidenced by: Based on a medication audit, the licensee did not comply with the section cited above as R1 and R2 did not have their PRN blood pressure medication at the facility which staff cannot assist residents with self-adminsitration of medication which poses an immidiate health and safetey risk to resident in care.

1569.312(a) Basic service requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above as the licensee did not provide adequate care and supervision or seek higher level of care to R1 which attributed to R1 sustaining multiple falls within 1 day which poses an immediate health, safety and personal rights risk to residents 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: (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 report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.

87464 Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources.This requirement is not met as evidenced by:Based on interviews and record review, the licensee did not comply with the section cited above, as staff were aware R1 was not to leave the facility unassisted but failed to ensure R1 had assistance when they

87468.1 Personal Rights of Residents in All Facilities (a)(2) 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 requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above the staff did not respond to R1’s calls for assistance in a timely manner and R1's diapering needs were not met, which poses a potential health, safety and personal risk to persons in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities. (a)(4) Residents … shall have ... the following ... rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency ...This requirement is not met as evidenced by: Based on interviews and evidence gathered throughout the investigation, the licensee did not comply with the section cited above as various residents stated that food service is inadequate which poses a potential health, safety and personal rights risk to residents on care.

87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents … shall have ... the following ... rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency ... This requirement is not met as evidenced by:Based on observation and interview, the licensee did not comply with the section cited above, as staff did not provide meals to residents in a timely manner as determined by the posted meal times, which poses a potential personal rights risk to residents in care.

87468.1(a)(6) Personal Rights of Residents in All Facilities (a) Residents ... shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as the doors to the courtyard in the dementia unit are locked from the inside, thus prohibiting a resident from going into the facility if they're in the courtyard, which poses an immediate personal rights risk to residents in care.

87705(f)(2) Care of Persons with Dementia. The following shall be stored inaccessible ... : Over-the-counter medication ... or, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement is not met as evidenced by: Based on observations, the licensee did not comply with the section cited above as alcohol and cleaning supplies were accessible to residents, which poses an immediate health and safety risk to persons in care.

Based on interviews, the licensee did not comply with the section cited above, as the exterior doors to the courtyard in the memory care unit are locked from the inside, this inhibiting a resident from going back into the facility if they are in the courtyard, which poses an immediate personal rights risk to residents in care.

87468.1 Personal Rights of Residents in All Facilities (a)(2) 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 requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above the staff did not respond to R1’s calls for assistance in a timely manner and R1's diapering needs were not met, which poses a potential health, safety and personal risk to persons in care.

87468.1(a)(6) Personal Rights of Residents in All Facilities (a) Residents ... shall have all of the following personal rights:(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above, as the exterior doors to the courtyard in the memory care unit are locked from the inside, which poses an immediate personal rights risk to residents in care.

87555(b)(27) General Food Service Requirements. All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.This requirement is not met as evidenced by: Based on interviews and observations, the licensee did not comply with the section cited above, as there were rodent droppings observed in the kitchen and staff admitted that the facility had an issue with rodents in the kitchen, which poses and immediate health and safety risk to persons in care.

87303(c) Maintenance and Operation. All window screens shall be clean and maintained in good repair.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as the window screen in the theater room was missing, which poses an immediate health and safety risk to residents in care.

87309(a) Storage Space. 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 is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above, as a knife was accessible in the staff room and accessible gardening supplies and tools in the courtyard, which poses an immediate health and safety risk to residents in care.

87307(e) Personal Accommodations and Services. Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools, or similar bodies of water...through fencing, covering or other means. This requirement is not met as evidenced by:Based on observation, the licensee did not comply with the section cited above as the facility had water fountains in the courtyard and in front of the building filled with standing water, which poses an immediate health and safety risk to persons in care.

87555 General Food Service Requirements (b) (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.This requirement is not met as evidence by: Based on interviews, the licensee did not comply with the section cited above as modified diets prescribed by resident physicians have not been followed which poses a potential health, safety and personal rights risk to resident in care.

87468.2(a)(6) Additional Personal Rights of Residents in Privately Operated Facilities. Residents …. shall have all of the following personal rights: To make choices concerning their daily lives in the facility. This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the section cited above, as the facility has not allowed residents whom are not on isolation or quarantine precautions to participate in communal dining or activities, which poses an immediate personal rights risk to residents in care.

87211(a)(2) Reporting Requirements. Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety...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 is not met as evidenced by:Based on interview, the licensee did not comply with the section cited above as the facility did not report an outbreak to the appropriate agencies in a timely manner, which poses an immediate health, safety and personal rights risk to persons in care.

87468.1 Personal Rights of Residents in all Facilities (a) Residents in all residential care facilities for the elderly shall have all of thefollowing personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as on 10/13/2022 and 10/25/2022,two (2) housekeepers and 2 kitchen staff were observed without a face mask upon arrival which poses an immediate health and safety risk to persons in care.

87555 General Food Service Requirments (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by:Based on interviews, record review and observation, the licensee did not comply with the section cited above as the facility has not been meeting the needs of the residents in quality and quantity which poses a potentail health, safety and personal rights risk to person in care.

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.This requirement is not met as evidenced by Based on observation, the Licensee did not comply with the section cited above as LPA observed 2 fire exit door at the stairwell being propped open with a door wedge which poses an immidiate health, safety and personal rights risk to persons in care.

87468.1 Personal Rights of Residents in All Facilities (a)(2) 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 requirement is not met as evidenced by: Based on record review and interviews, the licensee did not comly with the section cited above the staff did not respond to resident's calls for assistance which poses a potential health, safety and personal risk to persons in care.

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Based on interviews and observation, the licensee did not comply with teh section cited above as R1's toilet has not been working for 1 week which poses a potential health, safety and personal rights risk to persons in care.

87555 General Food Service Requirements (b)(27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. Based on interviews, the Licensee did not comply with the section cited above as the ED stated they did find rodents in the kitchen which poses and immediate health, safety and personal rights risk to persons in care.

87211 Reporting Requirements (a)(2) Occurrences, such as epidemic outbreaks, ...or major accidents which threaten the welfare, safety or health of residents...shall be reported within 24 hours either by telephone or facsimile to the licensing agencyThis requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above, as R1 was diagnosed with scabies, yet CCL was not notified, which poses a potential personal rights risk to residents in care.

87625(b)(3)Managed Incontinence (b)General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry... This requirement is not met as evidenced by: Based on interview and record review, licensee failed to ensure/meet R1’s incontinence needs which led to R1 being found not clean and dry, which poses an immediate health and safety risk to residents in care.

87411(a)Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requirement is not met as evidenced by: Based on interviews and record review, licensee failed to ensure that the facility had an adequate number of staff to meet the residents needs, which poses an immediate health and safety risk to residents in care.

87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).This requirement is not met as evidenced by: Based on LPA's observations, the licensee did not comply with the section cited above as a lighter, shovels and a paper cutter were observed accessible to residents which poses an immediate safety risk to persons in care.

87464 Basic services (f)(1)(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above as R1 left the facility unassisted which poses an immediate health and safety risk to persons in care.

87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: 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 is not met as evidenced by: Based on LPA's observations, the licensee did not comply with the section cited above as toxic items were accessible to residents which poses an immediate health and safety risk to persons in care.

87211(a)(1)(A) Reporting Requirements. A written report shall be submitted to the licensing agency ... within seven days of the occurrence: (A)Death of any resident from any cause regardless of where the death occurred… This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the sectioncited above as the facility failed to notify the person responsible for R1 of R1’s death which poses a potential health & safety risk to residents in care.

1569.312(a) Basic service requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above as the licensee did not provide adequate care and supervision or seek higher level of care to R1 which attributed to R1 sustaining pressure injuries which posed an immediate health and safety risk to residents in care.

87217(b) Safeguards for Resident Cash, Personal Property, and Valuables. Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff.... This requirement is not met as evidenced by: Based on interviews with witnesses, R1 was missing personal care items that was need as part of their care which posed a potential health and safety risk to residents in care.

87303 Maintenance and Operation.(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services....for the safety and well-being of residents,This requirement is not met as evidenced by: Based on interview and record review, the Licensee did not assure that the facility remins free of ants, as 5 of 7 residents interviewed indicated the facility has an "ant problem" and Resident Care Director corroborated the facility has ants, which poses a potential health risk to residents in care.

87555 General Food Service Requirements(b) The following food service requirements shall apply: (18) Sufficient food service personnel shall be employed, trained and their working hours scheduled to meet the needs of residents.This requirement is not met as evidenced by: Based on interview, during COVID, the facility did not have any kitchen staff nor cooks and the Administrator and other untrained staff were cooking the food for the facility, which poses a potential health risk to residents in care.

87466 Observation of the ResidentThe licensee shall ensure that residents are regularly observed for changes...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 is not met as evidenced by: Based on interview and record review, the licensee did not notify R1's responsible party nor physician of a change in condition, which poses a potential health and safety risk to residents in care.

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs....the facility require such additional staff for the provision of adequate services.This requirement is not met as evidenced by: Based on interview and record review, the facility only had only one caregiver working on 3 different dates, which poses an immediate health and safety risk to residents in care.

8755(a) General Food Service Requirements. (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by: Based on interviews, while tray service was being provided to all residents due to COVID-19, some residents were receiving cold food which should have been served hot, which posed a potential health and safety risk to residents in care.

87211 Reporting Requirements (a)(2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety...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 is not met as evidenced by:The facility did not comply with the sectioncited above as the facility did not report an outbreak to the appropriate agencies in a timely manner which posses and immediate health, safety and personnal rights risk to person in care.

87303 Maintenance and Operation. (i)Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more...floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit.This requirement is not met as evidenced by: Based on interviews and record review, R1's call button was not working on 8/24/2020. In addition, other call button alerts went unresponded for other residents during the period of August 2020 - September 2020, which poses a potential health and safety risk to residents in care.

87217 Safeguards for Resident Cash, Personal Property, and Valuables (b)Every facility shall take appropriate measures to safeguard residents'...personal property... which have been entrusted to the licensee or facility staff...articles or cash resources.This requirement is not met as evidenced by: Based on interviews with witnesses, R1 was missing personal care items that had been left by a skilled nursing professional, as well as a remote left by family, which posed a potential health and safety risk to residents in care.

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on medication review, the facility did not assist R1 with their medications as prescribed, as medications were waiting for refill and unable to be administered, as well as discontinued medication was marked as administered, which poses an immediate health and safety risk for residents in care.

87466 Observation of the resident. The licensee shall ensure that residents are regularly observed for changes...appropriate supervision is provided when such observation reveals unmet needs…the licensee shall ensure that such changes are documented...This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. The facility failed to observe, document and communicate R1's pressure injuries/wounds which contributed to R1 sustaining pressure injuries not reported and not cared for, which posed an immediate health and safety risk to residents in care.

1569.312(a) Basic service requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above, as the licensee failed to provide adequate care and supervision to R1 which contributed to R1 sustaining pressure injuries and R1's clothing observed with dried fecal matter, which posed an immediate health and safety risk to residents in care.

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine...PRN medication and is unable to communicate his/her symptoms clearly...shall be permitted to assist the resident with self-administration provided (1) Facilty staff...dose of medication.This requirement is not met as evidenced by: Based on interviews and records review, R1 was in obvious pain, however staff failed to contact hospice or a physician for authorization to administer any PRN pain medication 8/21/20-8/23/20, which posed an immediate health and safety risk to residents in care.

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…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 is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. The facility failed to observe, document and communicate R1's pressure injuries/wounds which attributed to

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 is not met as evidenced by: Based on interviews and record review of alert response times, some responses were not completed in a timely manner and otehr calls went unanswered, which posed a potential

8755(a) General Food Service Requirements. (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement was not met as evidenced by: Based on interviews, while tray service was being provided to all residents due to COVID-19, some residents were receiving cold food which should have been served hot, which posed a potential health and safety risk to residents in care.

87465(d)(1) Incidental Medical and Dental Care. If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to 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:Facility staff shall contact the resident's physician prior to each dose, describe the resident's symptoms, and receive direction to assist the resident in self-administration of that dose of medication. This requirement is not met as evidenced by: Based on interviews and records review

87217(b) Safeguards for Resident Cash, Personal Property, and Valuables. Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources.This requirement is not met as evidenced by: Based on interviews with witnesses, R1 was missing personal care items that had been left by a skilled nursing professional, as well as a remote left by family, which posed a potential health and safety risk to residents in care.

87303(i)(1)(A) Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: Operate from each resident's living unit. This requirement was not met as evidenced by: Based on interviews and record review, R1's call button was not working on 8/24/2020. In addition, other call button alerts went unresponded for other residents during the period of June 2020 - September 2020, which poses a potential health and safety risk to residents in care.

1569.312(a) Basic service requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Licensee failed to provide adequate care and supervision to R1 which attributed to R1 sustaining pressure injuries not reported and not cared for, which posed an immediate health and safety risk to residents in care.

87463(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Based on interviews, observation and record review, the licensee did not comply with the section cited above as there was no updated Needs and Service plan for R1 after returning from the hospital which poses a potential health, safety and personal rights violation to persons in care.

87468.1 Personal Rights of Residents in All Facilities (a)(2) 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. Based on record review, interviewsand observations the licensee did not comly with teh section cited above as the facility did not not responding to residents calls for assistance in a timely manor.

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:(15) To send and receive unopened correspondence in a prompt manner.This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above, as the interview with the administrator and interviews with two out of eight residents revealed, resident packages were opened and not given to the residents they were intended for, which poses a personal rights risk to residents in care.