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25 | Licensing Program Analyst (LPA) Manuel Monter arrived unannounced visit to open a complaint investigation. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Staff (S1) Cleofe Lucas. Staff S1 informed LPA that the Administrator was on vacation. LPA contacted the facility's designee (FD) (based on a review of the facility's LIC309). FD stated he/she was preoccupied due to an emergency. FD stated staff S1 could sign on his/her behalf.
While investigating the complaint 26-AS-20250128124742, LPA toured the facility. While touring the backyard, LPA observed 12 pieces of bread, with mold in the backyard, directly across from exit #2, in the dinning room. (Photographs were taken.) LPA spoke with FD via phone call, who stated, the staff put the bread there to feed the birds. Staff S1 disposed of the molded bread during visit.
While touring resident bedroom #3, LPA observed the doorway to the private bath did not have a door. LPA observed it only contained a brown curtain. LPA took photographs of the bathroom, from the inside of bedroom #3. (Photos with light on and off.) Based on observation, the curtains do not obscure the inside of the bathroom, resulting in a violation of a residents personal rights to privacy and dignity when using the restroom.
Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Staff S1 Cleofe Lucas and a copy of the report and appeal rights were provided. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type A
02/01/2025
Section Cited
CCR
87468.1(a)(1)
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7 | 87468.1 Personal Rights of Residents in All Facilities (a)(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement was not met as evidenced by; | 1
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7 | ADM stated she will send a written plan of action on how she will ensure residents who use the private bathroom, in bedroom #3 are accorded privacy and dignity.
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14 | Based on observation, resident bedroom #3 private bath does not have a door. Based on observation, the curtains do not obscure the inside of the bathroom when in use. This poses an immideate health, safety or personal rights risk to persons in care. | 8
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14 | ADM stated she will send this written plan of action to LPA by POC date February 1, 2025. |
Type B
02/07/2025
Section Cited
CCR87303(a)
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7 | 87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by; | 1
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7 | Staff S1 disposed of the molded bread during visit. ADM stated she will send a letter of understanding regarding the regulation, and the importance of ensuring the facility remains clean, safe, sanitary and in good repair at all times. |
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14 | Based on observation and interview, LPA observed 12 pieces of bread, with mold in the backyard, directly across from exit #2. FD stated the staff put the bread there to feed the birds. This poses a potential health, safety or personal rights risk to persons in care. | 8
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14 | ADM stated she will send this written plan of action to LPA by POC date February 7, 2025. |