Aasta Assisted Living

87309 (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions...and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storageThis requirement is not met as evidenced by: Based on observation, a drawer in the memory care unit's common area was left open and contained items such as wound cleanser and personal care items, and housekeeping cart was in the hallway and unlocked, which poses a potential safety risk to persons in care.

87303 (e) (2) Faucets used by residents for personal care such as shaving and grooming shall deliver 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 is not met as evidenced by: Based on observation, hot water was measured in 6 resident rooms and measured above 120 degrees in 5 rooms, measuring up to 131 degrees and was under 105 degrees in 1 room measuring at 83.4 degrees, which poses an immediate safety risk to persons in care.

87503 (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.This requirement is not met as evidenced by: Based on record review, files were incomplete for all 5 residents reviewed. 3 did not contan proof of annual medical visit or updated medical assessment, 3 did not have proof of TB test, and 2 did not have updated reappraisals, which poses a potential health, safety or personal rights risk.

87411 (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 1569.69This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the above cited secton, as staff files did not contain proof of initial training for 1 staff, or annual training for 3 staff, and 3 staff did not have proof of first aid training, which poses a potential health, safety and personal rights risk to persons in care.

87405 (a) All facilities shall have a qualified and currently certified administrator...shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility...by written documentation.This requirement is not met as evidenced by: Based on observation and interview, the Administrator has not been present in the facility on their scheduled days for 1-2 months and LPAs have never met the Administrator either by telephone or in person, which poses a potential health and safety risk to persons in care.

87203 Fire SafetyAll 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 and interview, the fire pull station in the 200s hallway is non-functional, as it was pulled about a week ago and has not been repaired, which poses an immediate safety risk to persons in care.

Safeguards for Resident Cash, Personal Property, and Valuables (a) A licensee shall not be required to handle residents' cash resources. However, if a resident incapable of handling his own cash resources... This requirement is not met as evidenced by… Based on interviews and record review the Licensee did not comply with the regulation above by allowing R1 to manage their cash resources which poses a immediate health, safety and personal rights risk to residents in care.

87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above by not not following shower schedules which posed a immediate personal to residents in care.

(f) No licensee or employee of a facility shall make expenditures from residents' cash resources for any basic service specified in this Chapter, or for any basic services identified in a contract... This requirement is not met as evidenced by… Based on interviews and record review the Licensee did not comply with the regulation allowing staff/caregivers to make expenditures from residents' case resources which poses a immediate health, safety and personal rights risk to residents in care.

87411(a) Personnel Requirements General (a) Facility personnel shall at all times be sufficient in numbers... In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure...This requirement is not met as evidenced by… Based on interviews and record review the Licensee did not comply with the regulation above by not having sufficient staff during the NOC shift to perform essential duties for residents in care which poses a immediate health, safety and personal rights risk to residents in care.

(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.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the above cited section, as feces was observed in the courtyard of the Meadows accessible to residents in care, additionally gutter was broken which poses an immediate health and personal rights risk to persons in care.

87465(a)(4) (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 observation and record review, the licensee did not comply with the above cited section, as R1's medication was marked administered but was still in the bubble pack, R2's medication could not be located, and MAR did not reflect medications administered, which poses an immediate health and safety risk to persons in care.

In addition to the rights listed in Section 87468.1…residents have shall have the following: care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above as R1 was continuously calling for help and staff did not respond or assist R1, which poses a potential health, safety and personal rights risk to residents in care.

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above as R1’s MAR was inaccurate due to staff signing off on medication administration prior to administering it, which poses a potential health, safety and personal rights risk to residents in care.

The following requirements shall apply to medications which are centrally stored: Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.This requirement was not met as evidenced by: Based on interviews and observation, the licensee did not comply with the section cited above as facility staff are pre-filling residents’ medications in separate containers several days in advance, which poses a potential health, safety and personal rights risk to persons in care.

87411(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 observation, the licensee did not comply in the section cited above as facility staff were unable to answer and transfer telephone calls for R1, which poses a potential health and safety risk to residents in care.

87618 Oxygen Administration - Gas and Liquid (b)... (E)Oxygen tanks that are not portable shall be secured in a stand or to the wall and (5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment. This requirement was not met as evidenced by: Based on observation and interviews, the licensee did not comply with the section cited above per tour of the facility, it was observed oxygen tanks not being properly stored and staff are not up-to-date on how to handle and store oxygen tanks

87411(a) Personnel Requirements General (a) Facility personnel shall at all times be sufficient in numbers... In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure...This requirement is not met as evidenced by… Based on interviews and record review the Executive Director did not comply with the regulation above by not having sufficient support staff to perform essential duties for residents in care which poses a potential health, safety and personal rights risk to residents in care.

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c)This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as R1 had numerous falls at the facility and was on 15-minute checks which were not provided, resulting in another fall and fracture, which posed an immediate health and safety risk to residents in care.

87555 (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...safe and healthful manner.This requirement is not met as evidenced by: Based on interview and observation, the licensee did not comply with the above cited section, as portions for residents do not contain the recommended daily amounts of dairy, fruit, or vegetables, which posed an immediate health and personal rights risk to persons in care.

87613 General Requirements for Restricted Health Conditions (a) Prior to admission of a resident with a restricted health condition, the licensee shall:This requirement is not met as evidenced by: Based on record review and interviews, R1 had a stage II pressure injury identified on 03/31/2025, but no outside care provider caring for the wound or staff training provided until 05/04/2025, which posed an immediate health and safety risk to residents in care.

87219 Planned Activities (f) Planned Activities. In facilities licensed for fifty persons or more, one staff member shall have full-time responsibility to organize, and shall be given such staff assistance as… This requirement is not met as evidenced by… Based on interviews, the licensee did not comply with the section cited above as the facility lacks of sufficient personnel to conduct activities for all residents in care which posed a potential personal rights risk to persons in care.

87625(b)(3) Managed Incontinence...the licensee shall be responsible for the following: Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.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 they did not ensure residents’ incontinence was properly managed, which poses an immediate health and safety risk to residents in care.

87303(i)(1)(C)Facilities shall have signal systems which shall meet the following criteria:(1)All facilities licensed for 16 ...shall have a signal system which shall:(A)-(C). This requirement was not met by Based on observation and interviews the licensee did not comply by having a signal system malfunction. Which poses a potential risk to resident in care

87202(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal…district providing fire protection services, or the State Fire Marshal.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the above cited section, as both delayed egress exits from the memory care yard were observed to be locked and/or tied shut, which poses an immediate safety risk to residents in care.

87464 (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement is not met as evidenced by: Based on interview and observation, the licensee did not comply with the above cited section, as R3 was allowed continued unsupervised access to R4, although R3 displayed aggressive behaviors towards others, resulting in R4 sustaining injury, which poses an immediate safety risk.

87463 (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first...appraisal shall be referred to as the reappraisal.This requirement is not met as evidenced by: Based on record review and observation, the licensee did not comply with the above cited section, as 2 of 7 files reviewed did not have a reappraisal within a 12-month period and 1 of 7 had a change of condition with no reappraisal, which poses a potential health and safety risk to persons in care.

A plan for incidental medical and dental care shall be developed by each facility. The plan shall...provide for assistance in obtaining such care...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication review, the Licensee did not comply with the section cited above as medication audit revealed discrepancies for R1 which poses an immediate health, safety or personal rights risk to persons in care.

A plan for incidental medical and dental care shall be developed by each facility. The plan shall...provide for assistance in obtaining such care...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication review, the Licensee did not comply with the section cited above as medication audit revealed discrepancies for R1 which poses an immediate health, safety or personal rights risk to persons in care.

87628 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to... medication administered orally or through injection, or has it administered by an appropriately skilled professional.This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as R1 has injectable medication prescribed on a sliding scale and a diagnosis of dementia and unable to check their own blood sugar and determine the amount, which poses an immediate health risk.

87203 Fire SafetyAll 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 and interview, the licensee did not comply with the above cited section, as the exhaust fan has been broken for 2 weeks, is not repaired and staff have continued to cook with an inoperable fan, which poses an immediate health and safety risk to persons in care.

(6) The licensee shall maintain documentation pertaining to staff training in the personnel records...For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by not providing adecuate training to staff and not verifiying training for agency staff, which poses/posed a potential health, safety or personal rights risk to persons in care.

§1569.191 Sale of licensed facility; resulting issuance of new license; procedure (b) Except as...the property and business shall not be transferred until the buyer qualifies for a license or provisional license within the appropriate provisions of this chapter.This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the above cited section, as interim management service agreement is in effect 07/07/25 and no application was submitted to CCLD to reflect the addition of a management company, which poses a potential risk to residents.

87355 (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c)This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as an individual began working at the facility on 07/07/25 and background clearance was not transferred until 07/10/25, which posed a potential 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 interview, the licensee did not comply with the above cited section, as on 07/07/2025, an excluded individual was present at the facility, which posed an immediate health and safety risk to persons in care.

Incidental Medical and Dental Care (a) (4) The licensee shall assist residents with self-administered medications as needed.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the above cited section, as 3 loose pills were observed in the memory care courtyard and therefore the resident did not take them as prescribed, which poses an immediate health and safety risk to persons in care.

§1569.312(a) Basic services requirements.Basic services shall at a minimum include: (a) Care and supervision as defined in Section 1569.2.This requirement is not met as evidenced by: Based on interviews and records review, the Licensee did not comply with the section cited above. As a result of facility staff neglect R2 sexually assaulted R1, which posed an immediate health and safety risk to residents in care.

87307(a)(3)(A) Personal Accommodations and Services.(a) Living accommodations...The facility shall...provide comfortable living accommodations...The following provisions shall apply:(3) ...the licensee shall assure provision of:(A)A bed for each resident...Each bed shall...good springs, a clean and comfortable mattress...This requirement is not met as evidenced by… Based on observation, the licensee did not comply with the section cited above by not providing a comfortable mattress to residents in care, which poses a potential health, safety or personal rights risk to persons in care.

87202(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal…district providing fire protection services, or the State Fire Marshal.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the above cited section, as both delayed egress exits from the memory care yard were observed to be locked and/or tied shut, which poses an immediate safety risk to residents in care.

87303 (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.This requirement is not met as evidenced by: Based on LPA observations, the licensee did not comply with the section cited above as feces was observed in the courtyard of the Meadows accessible to residents in care, which poses an immediate health and personal rights risk to persons in care.

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the above cited section, as LPAs have observed multiple repeat citations and non-compliance with regulation while Administrator has been designated at the facility, which poses an immediate health, safety, and personal rights risk to residents.

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in two out of five staff files. LPA reviewed Guardian roster and found 2 staff had fingerprint/background clearance but were not associated to this facility, which poses an immediate health, safety or personal rights risk to persons in care.

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 in two out of ten rooms inspected they did not have smoke detectors, which poses an immediate health, safety or personal rights risk to persons in care.

a) The department may prohibit any person from being a licensee...,any employee, prospective employee, or person who is not a client and who has done any of the following: This requirement was not met as evidenced by: Based on interviews conducted and evidece received the three caregivers and one Med Tech were drinking during their scheduled work shift which poses an immediate personal rights risk to residents in care.

87411(a) Personnel Requirements General (a) Facility personnel shall at all times be sufficient in numbers... In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure...This requirement is not met as evidenced by… Based on interviews and record review the Executive Director did not comply with the regulation above by not having sufficient support staff and supervision to perform essential duties for residents in care which poses a potential health, safety and personal rights risk to residents in care.

A plan for incidental medical and dental care shall be developed by each facility. The plan shall...provide for assistance in obtaining such care...The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication review, the Licensee did not comply with the section cited above as medication for R1 was not available as of today and staff was unable to provide documentation that medication was reordered, which poses an immediate health, safety or personal rights risk to persons in care.

87202(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal…district providing fire protection services, or the State Fire Marshal.This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the above cited section, as both delayed egress exits from the memory care yard were observed to be locked and/or wired shut, which poses an immediate safety risk to residents in care.

(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.This requirement is not met as evidenced by: Based on LPA observations, the licensee did not comply with the section cited above as feces was observed in the courtyard of the Meadows accessible to residents in care, which poses an immediate health and personal rights risk to persons in care.

87411(a) Personnel Requirements General (a) Facility personnel shall at all times be sufficient in numbers... In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure...This requirement is not met as evidenced by… Based on interviews and record review the Executive Director did not comply with the regulation above by not having sufficient support staff to perform essential duties for residents in care which poses a potential health, safety and personal rights risk to residents in care.

87219 Planned Activities (f) Planned Activities. In facilities licensed for fifty persons or more, one staff member shall have full-time responsibility to organize, and shall be given such staff assistance as… This requirement is not met as evidenced by… Based on interviews, the licensee did not comply with the section cited above as the facility temporarily reassigned the Activities Director to perform transportation duties, resulting in the cancellation of daily activities, which posed a potential personal rights risk to persons in care.

87465 (a)(4) Incidental Medical and Dental Care. (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above by not ensuring medications are giving on a regular basis to residents in care which poses a immediate health, safety and personal rights risk to residents in care.

1569.655 (a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents...the licensee shall provide no less than 90 days' prior written notice...the amount of the increase...This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above when they issued a general rate increase with less than 60 days’ notice, which posed a potential personal rights risk to residents in care.

Based on record review, the licensee did not comply with the section cited above as 8 out od 8 appraisals were incomplete and not filled out properly, which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as 4 out of 8 staff files reviewed did not have required training filed and were not accesible during the inspection, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA observation, the licensee did not comply with the section cited above as 1 out of 5 bathrooms did not have toilet paper and 5 out of 5 bathrooms did not have paper towels accesible to residents and visitors, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPAs observation, the licensee did not comply with the section cited above as six out of 15 bathrooms checked measured above 120 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPAs observation, the licensee did not comply with the section cited above as gloves and incontinence bed pads were observed disposed of in a regular trash can without a tight-fitting lid, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA observations, the licensee did not comply with the section cited above as feces was observed in the courtyard of the Meadows accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.

Based on medication review, the licensee did not comply with the section cited above as medication quantity did not match that of the CSMDR and no refusals were noted, which poses an immediate health, safety or personal rights risk to persons in care.

Based on record review, the licensee did not comply with the section cited above as 1 out of 8 files reviewed indicate resident has no capacity for self-care and is not on hospice, or have approved exception on file with the department, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPAs observations, the licensee did not comply with the section cited above as 3 out of 5 emergency exit door were not functioning properly when tested at the time of the visit, which poses an immediate health, safety or personal rights risk to persons in care.

87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement is not met as evidenced by: Based on interview, the facility did not comply with the above cited section, as residents reported having to wait on average 45-60 minutes for staff assistance when residents use their call buttons, which poses an immediate health, safety, and personal rights risk to residents in care.

87468.1 Personal Rights of Residents in all Facilities (a) (3) to be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature...or eliminationThis requirement is not met as evidenced by: Based on interview, the licensee did not comply with the above cited section, as multiple staff and witnesses reported staff being disrespectful and rude to R1 and making fun of R1, which posed an immediate personal rights risk to persons in care.

87468.1(a)(1) Personal Rights. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above when residents were not treated with dignity, which posed a immediate personal rights risk to residents in care.

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… All persons who supervise employees or who supervise or care for residents shall be at least eighteen (18) years of age. This requirement was not met as evidenced by: Based on record review and interviews, the Licensee did not comply with the section cited above as S1 was assisting residents with ADLs but was not eighteen (18) years of age, which posed an immediate health and safety risk to persons in care.

A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage... and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review, the Licensee did not comply with the section cited above as R1’s MAR indicates medication is being administered but medication was not found and R2 has missing PRN as staff has not reordered yet, which posed an immediate 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...adequate services.This requirement is not met as evidenced by: The licensee did not comply with the above cited section, as staff were aware of R1's care needs and that R1 was a fall risk, however did not provide supervision as required, which posed an immediate health and safety risk to persons in care.

87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days...(B) Any serious injury...under facility supervision.This requirement is not met as evidenced by: The facility did not comply with the above cited section, as no written report was provided to R1's responsible party, which posed a potential health, safety and personal rights risk to persons in care.

87464 Basic Services (f) (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking...Postural SupportsThis requirement is not met as evidenced by: The licensee did not comply with the above cited section, as R1 was not provided full assist with ADL care as required in care assessment, which resulted in R1 falling and sustaining multiple fractures and R1 passing away as a result of injuries sustained, which posed an immediate health and safety risk.

87705 Care of Persons with Dementia(c) (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.This requirement is not met as evidenced by: The licensee did not comply with the above cited section, as R1 did not have a reappraisal reviewed with with R1 or their responsible party, which posed a potential health and personal rights risk to persons in care.

87464 Basic Services (f) (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living...Postural Supports.This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the above cited section, as R1 either refused (not documented) or was not offered hygiene care, incontinence care, and home health services for restricted health conditions, which posed an immediate health risk to R1.

87506 Resident Records(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.This requirement is not met as evidenced by: Based on record review and observation, the licensee did not comply with the above cited section, as R1's file did not contain a completed Admission Agreement or pre-placement appraisal, and other incomplete documents, which posed a potential health and personal rights risk to persons in care.

1569.312 Basic services 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 1569.2. Based on record review and interview Facility staff did not ensure to provide the necessary care and supervision to Resident #1 which allowed Resident #1 to elope from the facility unassisted, which poses an immediate health and safety risk to residents in care.

87456 Evaluation of Suitability for Admission (a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8:This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the above cited section, as R1 did not have proof of a pre-admission appraisal nor interview prior to admission and R1 was identified to require an Intermediate Care Facility, but was accepted to care at this RCFE, which posed an immediate health and safety risk to R1.

87466The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional...When changes such as unusual...physical health condition...responsible person, if any. This requirement was not met as evidenced by: Based on interviews, and records reviewLicensee/Administrator did not obtain timely medical attention for R1 which posed an immediate health and safety concern to persons in care.

87465 (a)(4) Incidental Medical and Dental Care. (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with the section cited above as medications are not being given to R1 which posed an immediate health and safety concern to persons in care.

87468.2(a)(21)To consent to have their relatives and other individuals of their choosing visit during reasonable hours, privately, and without prior notice.This requirement is not met as evidenced by: Based on interviews and record review, the Administrator did not comply with the section cited above when staff did not allow visiitors during reasonalble hours, which posed a potential personal rights risk to residents in care.

87468.1(a)(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... to protect residents, or barring windows against intruders, with permission from the Department. This requirement is not met as evidenced by: Based on interviews and record review, the Administrator did not comply with the section cited above when staff was told not to allow R1 to leave the community with one specific family member, which posed a potential personal rights risk to residents in care.

Additional Personal Rights of Residents in Privately Operated Facilities. 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 evidence by: Based on interview, and record review, the licensee did not comply with the section above, as facility staff failed to regularly monitor R1’s oxygen and oxygen tank level, which posed an immediate health and safety risk to resident in care.

Incidental Medical and 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 interview and record review, the licensee did not comply with the above cited section, as facility staff did not assist R1 in obtaining their medications, so no prescribed medications were available to administer for the month of December 2022, which posed an immediate health risk to residents in care.

87464(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as facility staff did not assist R1 in rectifying the payment issue with the facility-contracted pharmacy nor assist R1 in obtaining medical care which poses an immediate health risk to residents in care.

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the above cited section, as R1 was on 15-minute status checks, yet on 01/15/2024, R1 left the facility unassisted and was found a mile away before staff were aware R1 left, which poses an immediate safety risk to residents in care.

87411 (a) Facility personnel shall at all times be sufficient in numbers....the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.This requirement is not met as evidenced by: Based on interview, the licensee did not comply with the above cited section, as during the overnight shift on 01/14-01/15/2024, there were 2 staff present to care for all residents in AL and MC, which poses an immediate health and safety risk to residents in care.

1569.683 Eviction notices; reasons for eviction contents; service (a) In addition to complying with other applicable regulations...shall set forth in the notice to quit the reasons relied upon for the eviction...quit shall include all of the following:This requirement is not met as evidenced by: Based on interview and record review, the Licensee did not comply with the above cited section, as an eviction notice was issued for R1, which did not contain reasons for the eviction, nor the required language contained in the above section, which poses a potential personal rights risk to resident in care.

87465 Incidental Medical and Dental Care Services (a) (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 licensee did not comply with the above cited section, as 3 medications for R1, based on start date and assumed daily administration did not contain the appropriate amount of doses and MAR was inaccurate, which poses an immediate health risk to residents in care.

87208 Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation...changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval...This requirement is not met as evidenced by: Based on observation and record review, the Licensee did not comply with the above cited section, as the Licensee made changes to the facility's Admission Agreement and did not submit the changes to the Department for approval, which poses a potential personal rights risk to residents in care.

87628 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication...skilled professional.This requirement is not met as evidenced by: Based on interview and record review, the Licensee did not comply with the above cited section, as R1's physician ordered blood glucose testing on 10/05/2022 and the facility staff was unaware of the orders and R1's need for medical assistance, which posed an immediate health risk to residents in care.

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health...except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).This 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 fell on 07/04/2021, resulting in a fractured femur and the facility did not call 9-1-1 until 11:50AM on 07/05/2021, which posed an immediate health and safety risk to residents in care.

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (18) To select their own...hospice agency, and health care providers in a manner that is consistent with the resident’s admission agreement...to these personal rights.This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above as the facility Admistrator sent a letter urging residents to use the facility's preferred providers or an additional monthly charge will apply, which poses a potential personal rights risk to residents in care.

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).This requirement is not met as evidenced by: Based on interview, the facility did not comply with the above cited section, as residents reported having to wait on average 15-20 minutes for staff assistance when residents use their call buttons, which poses 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 as one vacant room and 2 facility hallways were observed to be malodorous which poses a potential personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as during facility tour, there was only one caregiving staff working in the Memory Care unit to supervise 18 residents, one of which was wandering and attempting to exit which poses an immediate health, safety, and personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as the bottom drawer in the Memory Care kitchen containing items such as lotions, incontinence care products, and nail polish remover was observed open and unable to be locked, which poses an immediate health and safety risk to persons in care

Based on observation and record review, the licensee did not comply with the section cited above as 4 of 5 resident medications reviewed contained inconsistencies with their medication amounts remaining and amounts documented as administered on the MAR which poses an immediate health and safety risk to persons in care.

Based on observation and record review, the licensee did not comply with the section cited above as 2 of 5 residents observed had medications stored in their rooms, however physician's report indicated residents are not able to store their own medications which poses an immediate health and safety risk to persons in care.

Based on observation, the licensee did not comply with the section cited above as LPA observed multiple canned items which were expired, as well as tofu in the refrigerator was expired, which poses a potential health risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in 2 out of 10 resident rooms observed had a water temperature reading at 124.1 degrees Fahrenheit and 126.7 degrees Fahrenheit 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...shall be on the premises a sufficient number of hours to permit adequate attention... documentation.This requirement is not met as evidenced by: Based on interview and record review, the facility does not have an active Administrator, as the Administrator left before 09/30/2022 and a qualified replacement has not been designated, which poses a potential health, safety and personal rights risk to persons 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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)This requirement is not met as evidenced by: Based on interview and record review, the facility did not comply with the above cited section, as S1 has been employed and working at the facility since 09/30/2022 and is not associated to the facility, which poses an immediate safety risk to residents in care.

87705 (f) The following shall be stored inaccessible to residents with dementia:(1) 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 observation, during facility tour, scissors were observed in both the beauty salon at 10:19AM and in the memory care unit activity room at 10:36AM accessible to residents with dementia, which poses an immediate health and safety risk to residents in care.

87705 (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication...and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement is not met as evidenced by: Based on observation, during facility tour, Barbicide liquid was observed at10:19AM, crushed medications were observed at 10:22AM, Febreze was observed at 10:34AM and Calmoseptine cream was observed at 10:34AM and 10:36AM accessible to residents with dementia which poses an immediate health and safety risk to residents in care.

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication...and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement is not met as evidenced by: During facility tour, LPA observed Febreze Air Freshener spray and Snuggle air freshener in a resident room in the Memory Care unit, which poses an immediate safety risk to residents in care.