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13 | At approximately 8:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct an investigation into the above allegations. LPA met with Executive Director Zenia Shah, interviewed staff and reviewed records. Based on interviews and records reviewed, facility has not had adequate staffing on a regular basis to meet residents needs. Records reviewed showed at least two individuals requiring 2 person assistance in the building. Staffing records show only one staff assigned to the memory care area. When staff are called from the assisted living portion of the building to assist in memory care, resident wait times are extended in the rest of the building. Based on observation, care staff are serving meals, which takes them off the floor to assist residents that did not come to the dining room. The activities program advertises weekly outings that are routinly cancelled due to staffing concerns. LPA reviewed the activity calendar designed for memory care and observed the activities do not occur on a regular basis. During this visit, 2 of the listed activities for the memory care area did not occur.
Based on the Departments investigation, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.
Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
This report was reviewed with Zenia Shah and Appeal rights were given. |
| Substantiated | Estimated Days of Completion: |
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
05/16/2025
Section Cited
CCR
87411(a) | 1
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7 | 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 records reviewed and interviews conducted, Licensee did not | 1
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7 | Licensee shall ensure staff are present in the building to meet resident needs. Licensee shall submit a written plan showing how scheduling of staff will meet resident needs. Written plan shall be submitted to CCL by 05/16/2025. |
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14 | ensure there was adequate staff to meet resident needs. This poses a potential Health, Safety or Personal Rights risk to persons in care. | 8
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Type B
05/16/2025
Section Cited
CCR
87219(f) | 1
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7 | 87219 Planned Activities:(f) In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities, and shall be given such staff assistance as necessary in order for all residents to partiacipate in accordance | 1
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7 | Licensee shall submit a written plan describing how activities will be conducted as scheduled and how the activities will be of interest to the residents and within their abilities. Plan shall be submitted to CCL by 05/16/2025. |
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14 | with their interests and abilities. This requirement is not met as evidenced by: Based on observation and records reviewed, Activities are cancelled or not conducted on a regular basis, which poses a potential Health, Safety or personal rights risk to persons in care. | 8
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