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25 | Unannounced Plan of Correction visit made out to this facility on 12/02/2024 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility staff person Nordia Heywood. A brief interview was conducted with the facility staff person at this time. This LPA requested that the facility staff person go ahead and contact the facility designated Administrator, Monica Plowden, to inform her that CCL was present at this time.
The facility designated Administrator, Monica Plowden, arrived later to this facility while this LPA was conducting this visit. A brief interview was conducted with the facility designated Administrator after her arrival.
Current census was 5 residents.
The purpose of this visit was to follow up on the deficiencies that were cited from prior complaint and case management visits conducted on 11/14/2024. This visit was to follow up on the Plans of Correction that were due.
The following deficiencies were observed and cited on 11/14/2024:
- Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or:
- 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. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (2) Bedridden persons
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- Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
- 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. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, 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.
- 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.
- Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds.
- A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed.
It was learned that all of the citations have not been addressed nor brought back into compliance at this time. The plan of corrections have not been completed and submitted into CCL, for review by this LPA, as requested on the LIC 9099-D and LIC 809-D documents dated on 11/14/2024.
All of the above deficiencies will be re-cited and given a new due date for completion, and submission, of the plan of corrections on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.
Exit Interview |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
12/03/2024
Section Cited
CCR
87411(g)
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7 | Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or:
This facility was found to be deficient as | 1
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7 | This facility representative stated that all facility staff will always be fingerprint cleared and properly associated prior to employment. A statement of correction, along with updated LIC 500, will be completed and submitted into CCL by the due date. |
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14 | evidenced by the allowance of an individual to be present and employed at this facility prior to obtaining the required criminal clearance. This posed an immediate threat to the Health, Safety, and Personal Rights of residents in care. | 8
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Type A
12/03/2024
Section Cited
CCR87202(a)(2)
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7 | 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. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the | 1
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7 | This facility representative stated that this facility will notify the local fire department about the number of Bedridden residents present in care at this time. In addition, this facility will submit all of the required forms and documents related to care and supervision being provided to residents |
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14 | licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.
(2) Bedridden persons
This facility was found to be deficient as evidenced by the allowance of facility residents deemed to be Bedridden to be present receiving care and supervision without the proper issuance of a bedridden fire clearance. This posed an immediate threat to the Health, Safety, and Personal Rights of residents in care. | 8
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14 | deemed as Bedridden.
A statement of correction, along with all required forms and documents for Bedridden Care, will be completed and submitted into CCL by the due date. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
12/03/2024
Section Cited
CCR
87705(c)(5)
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7 | Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
This facility was found to be deficient as | 1
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7 | This facility representative stated that all residents diagnosed with dementia will be reviewed to make sure that all medical assessments have been updated to address any changes in care and supervisory needs. A statement of correction, along with a copy of the updated medical assessment, will be |
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14 | based on a records review conducted, 1 out of 6 residents, was found to be diagnosed with dementia and did not have an updated medical assessment on file. This posed an immediate threat to the Health, Safety, and Personal Rights of residents in care. | 8
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14 | completed and submitted into CCL by the due date. |
Type A
12/03/2024
Section Cited
CCR87466
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7 | 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. When changes such as unusual weight gains or losses or deterioration of mental ability or | 1
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7 | The facility designated representative stated that all facility staff will be trained, for no less than (1) hour in duration, from a third party vendor on the topic of maintaining professionalism to make sure that facility residents' personal rights were always upheld. |
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14 | a physical health condition are observed, 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 facility was found to be deficient as evidenced by information concluding that the sole facility staff member left the premises so that facility residents were unsupervised for an unknown amount of time. In addition, facility staff did not regularly change and check on the residents to prevent the emergence of pressure injuries and other physical issues. This presented an immediate threat to the Health, Safety, and Personal Rights of residents in care. | 8
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14 | A statement of correction, along with documented proof of vendorized staff training, will be completed and submitted into CCL by the due date. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
12/03/2024
Section Cited
CCR
87468.1(a)(1)
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7 | 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 facility was found to be deficient as | 1
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7 | The facility designated representative stated that all facility staff will be trained, for no less than (1) hour in duration, from a third party vendor on the topic of maintaining professionalism to make sure that facility residents' personal rights were always upheld. |
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14 | evidenced by information concluding that facility staff members were arguing and engaing in disputes in front of the residents which presented an immediate threat to the Health, Safety, and Personal Rights of residents in care. | 8
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14 | A statement of correction, along with documented proof of vendorized staff training, will be completed and submitted into CCL by the due date. |
Type A
12/03/2024
Section Cited
CCR87411(a)
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7 | Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment | 1
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7 | The facility designated representative stated that this facility was currently seeking additional staff persons for hire at this time. In addition, all facility staff will be trained, for no less than (1) hour in duration, from a third party vendor on the topic of proper care and supervision at all times 24 hours/7 days a |
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14 | and grounds.
This facility was found to be deficient as evidenced by information concluding that the sole facility staff member left the premises so that facility residents were unsupervised for an unknown amount of time. This presented an immediate threat to the Health, Safety, and Personal Rights of residents in care. | 8
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14 | week.
A statement of correction, along with documented proof of vendorized staff training, will be completed and submitted into CCL by the due date. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
12/03/2024
Section Cited
CCR
87465(a)(4)
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7 | A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
The licensee shall assist residents with self-
administered medications as needed. | 1
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7 | The facility designated representative stated that all facility staff will be trained, for no less than (1) hour in duration, from a third party vendor on the topic of proper handling, dispensing, and documentation of the resident medications. |
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14 | This facility was found to be deficient as evidenced by a review of all (6) resident medication administration records revealing that medications were not properly handled, dispensed, or notated which presented an immediate threat to the Health, Safety, and Personal Rights of residents in care. | 8
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14 | A statement of correction, along with documented proof of vendorized medication training, will be completed and submitted into CCL by the due date. |
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