On of 7/31/2024 licensee agreed to be on a Non-Compliance plan. The areas of concern were identified as:

· Administrator Duties and Plan of Operation

· Staff Training

· Resident and staff records

· Resident Care and Personal Rights

· Insufficient Staffing

· Failure to clear deficiencies timely

· Medication Management

· Failure to follow through with TSP

Continued on 809C...

• Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

• Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

· Follow through with responding to and participating with the Technical Support Program

· Ensure compliance with areas including, but not limited to, staff training records, maintaining staff and resident records and pre-pouring of medication.

· Ensuring personal rights of residents in care and ensuring resident needs are met.

On 2/11/26 LPA conducted a non-compliance (NCC) visit simultaneously with the facility’s annual inspection. Deficiencies were cited for identified NCC areas of concern. As of today, 4/23/26, the plans of correction to clear those deficiencies are still outstanding. So, as pertains to the failure to clear deficiencies timely, the licensee has failed to clear deficiencies. LPA discussed failure with licensee.

As pertains to resident and staff records, deficiency of regulation 87458(c)(1)(A) was cited on 2/11/26 because resident (R1) did not have TB clearance on file. As of 3/4/26, R1 moved out of facility. Therefore the citation is being cleared today and will not be re-cited.

As pertains to medication management, deficiency of regulation 87465(h)(6)(c) was cited on 2/11/26 because LPA and caregiver observed errors present on Centrally Stored Medication log (CSML) and current physician's orders for R1. The plan of correction required staff to complete one hour of medication management training by no later than 2/18/26. As of today, the plan of correction was not submitted to CCL. However, while present at facility staff provided LPA with completed medication training certificate issued 2/23/26. Therefore the citation is being cleared today and will not be re-cited.

Also pertaining to medication management, deficiency of regulation 87465(h)(5) was cited on 2/11/26 because LPA and caregiver observed pre-poured medications in kitchen drawer. As of today, CCL has not received the plan of correction which required licensee/administrator to submit a LIC9098 self-certifying that facility will stop pre-pouring medications. Therefore, deficiency of regulation 87465(h)(5) is being re-cited today, see 809D.

Facility’s physical plant was not identified as a NCC area of concern. However, a deficiency of regulation 87303(a) was cited at the annual inspection. As of today, the plan of correction to clear that citation has not

Continued on 809C(2)...

As pertains to inadequate staffing: on 2/11/26 Administrator advised LPA that only himself or S1 have been on shift for about 2 or 3 weeks while licensee has been on of the country. However, per the NCC compliance plan all shifts must be covered by at least two [2] staff. LPA spoke to licensee over telephone while out of the country. Licensee indicated to LPA that the requirement for two [2] staff per shift is no longer needed as resident care needs have changed. However, during inspection LPA did not observe any paperwork indicating any change in resident care needs so the deficiency was cited. Today, LPA reviewed R2's most recent hospice care plan dated 4/06/26, per care plan R2 no longer requires a two person assist. So, facility is not required to staff for a two person assist. Therefore, the citation is being cleared today and will not be re-cited. However, LPA discussed with licensee and S1 the need for R2 to be repositioned every 2 hours and discussed documenting the repositioning so as to have an accounting of the times at which they were repositioned.

During today’s visit, LPA and S1 did a spot check of medication. No deficiencies were observed. LPA reviewed resident documentation. No deficiencies observed. LPA did not observe or identify deficiencies pertaining to the other areas of concern identified in the NCC plan, such as Administrator Duties and Plan of Operation, Resident Care and Personal Rights, and failure to follow through with TSP. Facility has a certified Administrator, followed through with TSP, and observing personal rights.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with designee and a copy of this report was given.