Tlc Home Care II

Type of visit: Required - 1 Year

On 2/19/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Cirila Mauricio, Administrator and explained the purpose of the visit. LPA toured the physical plant. This is a 2-story building with 8 bedrooms(6 for residents and 2 for staff), 3 bathrooms, a living room, dining room, kitchen, garage, backyard and sunroom. No accessible bodies of water or hazards were observed. All bedrooms had sufficient lighting and the required items. All bathrooms had anti-skid floor mats and grab bars. The facility's hot water temperature was measured within the required 105-120 degrees Fahrenheit. The facility's fire alarm and carbon monoxide detectors were observed to be in working order. The facility's fire extinguishers were observed to be fully charged and last checked on 10/23/2025 The facility had the required 7 days of non-perishables and 2 days of perishables on hand. No food was expired. All sharp objects, soap, detergents, and poisons were observed to be locked and in-accessible to persons in care. LPA reviewed 5 resident records and 6 staff files. All were observed to be complete. During file review, LPA observed that that the Licensee did not have record of the required 8 hours of Dementia training or 4 hours of training on Hospice care, postural supports, and restricted health conditions. A Type B citation was issued for this deficiency. In addition, during the physical plant tour, LPA observed that the facility does not have an evacuation chair at each stairwell. A Type B citation was issued for this deficiency. A review of Centrally Stored Medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility. LPA requested copies of the following documents by the 6th of March: Current LIC 500 Current Liability Insurance Administrator's Certificate Theft and Loss Policy Transportation Procedures Control of Property(Lease agreement) Deficiencies are cited under the California Code of Regulations. Failure to correct the deficiencies by the POC due date may result in Civil Penalties. An exit interview was conducted. A copy of this report along with Appeal Rights were provided.the state’s words, verbatim · CDSS document, Feb 19, 2026

Type of visit: Required - 1 Year

On 1/15/2025, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Cirila Mauricio and explained the purpose of the visit. LPA toured the facility inside and outside including resident rooms, common areas, and kitchen area. Facility has 2 floors. Downstairs rooms has 2 resident rooms, one of which is a shared room. Upstairs rooms have 4 bedrooms, one of which is also shared. While touring the facility it was observed that the temperature was at 69 deg F. Hot water was also tested in the resident rooms and the temperature was 108 deg F. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. Facility has sprinkler system. All fire extinguishers have been checked and current. Resident bedrooms were observed to be in good repair and adequate lighting. Bathrooms are equipped with grab bars and non-skid floors. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Emergency food supply is updated and stored. Emergency drills are logged and done every quarter. Six resident records and six staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic 20hr requirement. Facility has a certified administrator on site with complete certification and training requirements. Facility accepts hospice residents and are in compliance with the required waiver requirements. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. LPA requested the following documents: Liability Insurance. LPA received a copy of the LIC500, Control of Property and LIC308. No deficiencies are cited at this time. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Jan 15, 2025

Type of visit: Required - 1 Year

On February 13, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 11:54 AM to conduct an unannounced Annual 1-year required inspection. LPA Calandra met with Jason Pineda, Administrator and explained the purpose of his visit. LPA Calandra toured the physical plant. This is a two story building that consists of 6 bedrooms and 3 bathrooms. Water in all bathrooms was measured within the required range of 105-120 degrees Fahrenheit. Bathrooms were observed to have the required grab bars and anti-skid mats. Fire extinguishers in the facility were observed to be fully charged and last checked on October 30, 2023. The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. The kitchen refrigerators and freezers temperature was within the required range. All bedrooms were sufficiently lit and had the required furniture. The backyard was clear from obstructions. No accessible bodies of water or hazards were observed. The facility's first aid was observed to be complete. The facility does not handle any cash resources. The facility was maintained at a comfortable temperature of 70 degrees Fahrenheit. All knives and sharp objects were observed to be locked and in-accessible to persons in care. All medications, soaps, and detergents were observed to be locked and in-accessible to persons in care. A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records kept at the facility. LPA Calandra also reviewed 5 resident and 5 staff files. All were observed to be complete. During today's visit, Type B violations were issued for the facility administrator failing to provide both a Fire Safety Plan (HSC 87212(b)(2)(a)-Emergency Disaster Plan) and Evacuation Procedures, including identification of an assembly point or points that shall be included in the facility sketch.(HSC 1569.695) Deficiencies are cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report was reviewed with Administrator, Jason Pineda and a copy along with appeal rights left at the facility.the state’s words, verbatim · CDSS document, Feb 13, 2024

Type of visit: Case Management - Legal/Non-compliance

On 01/25/24, Licensing Program Analyst (LPA), Grace Donato conducted an unannounced case management- legal/non-compliance inspection to monitor the facility operation. LPA met with Administrator, Jason Pineda, and explained the purpose of the visit. A non-compliance conference was held on November 9, 2023. During non-compliance meeting, the following violations were discussed: General Food Service Requirements, Reappraisals, Storage Space, Incidental Medical and Dental Care, Alterations to Existing Building or New Facilities, Postural Supports, Care of Persons with Dementia, Exceptions for Health Conditions, Maintenance and Operations, Emergency Disaster Plan, Emergency Plans, Fire Clearance, Care of Bedridden Residents. During the visit, LPA reviewed four resident records, all have updated and signed appraisals. Chemicals are all in a locked cabinet. Medications are updated and logged in centrally stored medication and are in a locked cabinet. Food supply in the facility is enough and there are no expired food found. Emergency drills are conducted quarterly, latest of which is done on October, 29, 2023. Kitchen sink has a permit issued on 9/26/200 hence it's been there before the facility was licensed in 2019. Room 3 wall has been patched and fixed. Fire clearance was not approved for bedridden residents, but as of now no residents in the facility are bedridden. Facility has an updated LIC610 Emergency Disaster Plan. Door alarms for rooms of dementia residents are in good working condition. LPA observed two residents, R3 & R4, who were previously bedridden are capable of transferring with assistance and when in bed are able to turn and move on their own. LIC602 for both were also updated to be non-ambulatory. No citations issued today. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Jan 25, 2024

Type of visit: Case Management - Annual Continuation

On December 14, 2023, Licensing Program Analyst(LPA) John Calandra and Licensing Program Manager(LPM) Jackie Jin, conducted an unannounced continuation of the Annual 1-year required inspection that was started on October 27, 2023. David and Bernice Orme, Administrators in charge while the Administrator, Jason Pineda is on vacation arrived and met with LPA Calandra and LPM Jin briefly during the visit but did not stay. LPA Calandra and LPM Jin interviewed 3 residents and 3 staff. No deficiencies were cited. A copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 14, 2023

Type of visit: Case Management - Other

On December 14, 2023, Licensing Program Analyst(LPA) John Calandra and Licensing Program Manager(LPM) Jackie Jin arrived at the facility to deliver an amended report for a Case Management visit conducted on October 18, 2023 by LPAs John Calandra and Audrey Jeung. No deficiencies cited during today's visit. A copy of the Amended report was left at the facility with Caretaker, Nieves Sulayao.the state’s words, verbatim · CDSS document, Dec 14, 2023

Type of visit: Office

On November 9, 2023, San Bruno Regional Office conducted a non-compliance conference meeting with Licensee, Lilia Mauricio and Jason Pineda, Administrator at TLC Home Care II. Present in the meeting was Regional Manager, Vivien Helbling, Licensing Program Managers, Cara Smith and April Cowan, Licensing Program Analysts, Audrey Jeung, Grace Donato, and John Calandra . Long Term Care Ombudsman, Bob Lewetzon was also present in this meeting. During non-compliance meeting, the following violations were discussed: General Food Service Requirements, Reappraisals, Storage Space, Incidental Medical and Dental Care, Postural Supports, Care of Persons with Dementia, Exceptions for Health Conditions, Emergency Disaster Plan, Emergency Plans, Fire Clearance, Maintenance and Operations, Care of Bedridden residents. During this meeting, the following citations were amended: -Incidental and Medical Dental from a Case Management visit that was conducted on 11/7/2023 -Postural Support from a Case Management that was conducted on 10/18/2023. The following citations were removed: -Limitations on Capacity/Ambulatory Status which was cited on 10/18/2023 -Alterations to Existing buildings or new facilities which was cited on 10/4/2023 During this meeting, it was discussed, Community Care Licensing will increase frequency monitoring inspection visits to ensure compliance with this compliance plan of Title 22 regulation. Deficiencies are cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was reviewed with Licensee/Administrator, Lilia Mauricio and Jason Pineda and a copy of this report and the Appeal Rights are provided. Licensee was provided the link below for resources and guidance to improve facility operations: https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providersthe state’s words, verbatim · CDSS document, Nov 9, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87205(a) · Plan of correction due date: Nov 13, 2023

Accountability of Licensee Governing Body: The licensee... shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This requirement was not met , as licensee failed to operate facility in conformance with regulations, which poses an immediate health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Nov 9, 2023

Plan of correction: Plan of correction to be submitted to CCLD BY DUE DATE, in which licensee shall ensure that facility operates in conformance with these regulations

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(h) · Plan of correction due date: Nov 13, 2023

ADMINISTRATOR--QUALIFICATIONS/ DUTIES The administrator shall have the responsibility to administer the facility in accordance with these regulations and established policy, program, and budget. This requirement is not met, as administrator failed to adhere to local ordinances on building construction, fire safety, and licensing requirements when facility retained bedridden residents. This posed an immediate health, safety, or personal rights risk to residents in care. Furthermore, in interviews with the administrator, they acknowledged a lack of knowledge regarding their infection control plan and practices.the state’s words, verbatim · CDSS document, Nov 9, 2023

Plan of correction: Licensee shall develop a plan of action and submit to CCLD BY , which will include how the administrator shall perform the duties and requirements according to regulations.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87606(f) · Plan of correction due date: Nov 13, 2023

Care of Bedridden Residents: To accept or retain a bedridden person, a facility shall ensure the following: The facility's plan of operations shall include a statement of how the facility intends to meet the overall health, safety and care needs of bedridden persons. Based on observation and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to residents. The facility currently has 2 bedridden residents in their care.the state’s words, verbatim · CDSS document, Nov 9, 2023

Plan of correction: Licensee and/or Administrator to provide written proof of correction to the department by 11/13/2023.

Type of visit: POC

On November 7, 2023, Licensing Program Analysts (LPA) John Calandra and Audrey Jeung conducted an unannounced plan of correction (POC) visit to clear deficiencies cited during an Annual inspection made on October 27, 2023. LPAs Calandra and Jeung met with Nieves Sulayao, caregiver, and explained the purpose of their visit. LPAs Calandra and Jeung toured bedroom 5 on the first floor, downstairs and observed Nieves Sulayao, caregiver open the door to the outside and heard an audible alarm. LPAs Calandra and Jeung observed all medications to be locked up and inaccessible to persons in care in the kitchen. The facility submitted a copy of the 610e-Emergency and Disaster Plan on November 4, 2023, and a letter stating that all staff had completed a emergency drill on October 30, 2023. Deficiency 87616(b)(1)-Exceptions for Health Conditions and still exist, as plan/proof of correction has not been received by the department. On 11/7/2023, LPA Calandra and LPA Jeung observed proof of correction. Acknowledgement of corrections is given to caregiver--1 page. Civil Penalty of $1000($100 per day x10 days) is hereby assessed for the period of October 28,2023 to November 6, 2023 for failure to correct deficiency 87204-Fire Safety. Administrator submitted Plan of Correction on November 7, 2023. See LIC421FC and POC letter. Report is reviewed with Administrator and copies are provided.the state’s words, verbatim · CDSS document, Nov 7, 2023

Type of visit: POC

On October 20, 2023, Licensing Program Analysts, John Calandra and Audrey Jeung arrived at the licensed facility for an unannounced POC visit to follow up on deficiencies cited on 10/18/23 during a case management visit. The LPAs met with Nieves Sulayao and Alicia Lapuz and explained the purpose of their visit. Acknowledgement of corrections is given to Caretaker, Nieves Sulayao- 2 pages. The following deficiencies still exist, as plan/proof of corrections has not yet been received by due date of 10/19/23. Licensee is granted an extension, as requested, and must submit corrections by 10/24/23. Section: 87204(a) LIMITATIONS--CAPACITY/AMBULATORY STATUS: Bedridden client resides in non-ambulatory room. Section 87608(a)(5)(B): Postural Supports: Client in room 5 has full bed rail and is not on hospice. Jason Pineda, the Administrator informed LPA, John Calandra via email that he had contacted family and they had reached out to the resident's family regarding the bed rails.the state’s words, verbatim · CDSS document, Oct 20, 2023

Type of visit: Case Management - Deficiencies

On October 20, 2023, Licensing Program Analysts, John Calandra and Audrey Jeung arrived at the facility to cite for a deficiency observed on 10/18/2023. The LPAs were greeted by Angie Lapuz and Nieves Sulayao, both Caretakers. The LPAs toured all rooms including but not limited to bedrooms, bathrooms, a kitchen, living room, etc. LPAs Calandra and Jeung observed half bed rails in all resident bedrooms and a full bed rail in bedroom 5. Review of all client files is done. There is another resident who is bedridden in room 2 on 2nd floor. See separate Facility Evaluation Report dated 10/20/23 for additional deficiencies observed. Deficiencies are cited under California Code of Regulations, Title 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Nieves Sulayao, Caretaker. A copy of this report and the Appeal Rights were provided.the state’s words, verbatim · CDSS document, Oct 20, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Oct 24, 2023

Fire Safety: 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. This requirement is not met, as there is a bedridden client in room 2 upstairs and 5 downstairs. Licensee failed to comply with conditions and limitations of fire clearance approved for 9 non-ambulatory clients, and no bedridden, which poses an immediate health, safety, and personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Oct 20, 2023

Plan of correction: Licensee shall submit plan/proof of correction to CCLD by due date.

Type of visit: Case Management - Deficiencies

LPAs Calandra and Jeung observed deficiencies of the California Code of Regulations, Title 22, during PoC visit. Citations appear on a following page.the state’s words, verbatim · CDSS document, Oct 18, 2023

From the deficiency page

**This report was amended to remove a previous deficiency related to limitations and capacity. **the state’s words, verbatim · CDSS document, Oct 18, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR87608(a)(5)(B) · Plan of correction due date: Oct 18, 2023

POSTURAL SUPPORTS Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met, as client in room 5 on ground level uses full bed rail. Client is not receiving hospice services. Licensee failed to ensure that full bed rails are only used for hospice residents, which poses an immedialte health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Oct 18, 2023

Plan of correction: Full bed rail will be removed or shortened by DUE DATE, and plan/proof of correction to be sent to CCLD BY DUE DATE. Half bed rail may be utilized only if there is an MD order maintained for half bed rail.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(2) · Plan of correction due date: Oct 19, 2023

POSTURAL SUPPORTS Postural supports shall be fastened or tied in a manner that permits quick release by the resident. This requirement is not met, as client in room 5 is observed seated in wheelchair in living room, with beige gait belt around her waist and wheelchair, with buckle in back. Licensee failed to ensure that postural support is fastened in front, so client can easily unfasten it. This poses an immediate health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Oct 18, 2023

Plan of correction: Plan/proof of correction to be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(2)(C) · Plan of correction due date: Oct 25, 2023

PERSONAL ACCOMMODATIONS/SVCS No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement is not met, as administrator "office" is accessed from room #4 on upper level. This "office" appears to be a large closet. Licensee failed to ensure that bedrooms are not passageways to another room, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Oct 18, 2023

Plan of correction: Desk, chair and other facility operations materials will be removed from closet of room #4 and will not be used by staff. Plan/proof of correction will be sent to CCLD BY DUE DATE.

Type of visit: POC

On October 18, 2023, Licensing Program Analysts (LPA) John Calandra and Audrey Jeung conducted an unannounced plan of correction (POC) visit to follow up on a Case Management visit made on October 4, 2023. LPAs Calandra and Jeung met with Administrator, Jason Pineda, Esther, and Nieves, caregivers, and explained the purpose of their visit. On 10/4/2023, the facility was cited for California Code of Regulation (CCR), 87303(a): Maintenance and Operation, 87608(a)(3)(Postural Supports), 8755(b)(8)(general food service requirements), 87463(c)(appraisals), 87309(a)(1)(Storage Space, and 87465(h)(2)(internal medication and dental care). The plan of correction for these citations was submitted to CCLD on 10/8/2023. Deficiency 87305(a) Alterations to Existing Buildings still exists, as plan/proof of correction has not been received. A copy of approved building permit and revised facility sketch showing the wet bar are requested to be submitted to CCLD by 10/25/2023. On 10/18/2023, LPA Calandra and LPA Jeung observed proof of correction. Outstanding deficiencies are now verified as corrected and cleared. Acknowledgement of corrections is given to administrator--6 pages. Report is reviewed with Administrator and copies are provided with appeal rights.the state’s words, verbatim · CDSS document, Oct 18, 2023

Type of visit: Case Management - Incident

On October 4, 2023, Licensing Program Analyst John Calandra and Licensing Program Manager Cara Smith conducted an unannounced case management visit to the facility in regards to an incident report submitted. LPA Calandra and LPM Smith were greeted at the door by the Administrator, Jason Pineda and explained the purpose of today's visit. LPA Calandra and LPM Smith toured the facility with Administrator, Jason Pineda and observed expired food, unsecured sharp objects, accessible medications, unsupervised residents, no call buttons in downstairs bedroom, unsecured medication, and lid free trash cans. The tour consisted of 3 bedrooms, the kitchen, dining room, living room, staff bedrooms, bathrooms, etc. In Bedroom 3, the LPA and LPM observed a wall where the bed used to be, in disrepair. In the Kitchen, eggs were observed to be sitting on a counter, a slice of Carrot cake on a table, and perishable food items that needed to be refrigerated upon opening. Medications for both staff and residents were observed to be accessible to persons in care and expired food inside of the refrigerator. The LPA observed the administrator remove the items from the fridge and dispose of. The tour continued downstairs where laundry detergent was observed on the floor of the staff room that was unsecured. Administrator, Jason removed the detergent. In R4's bedroom, a kitchenette was observed that is not displayed on the facility map. In the fridge, LPA Calandra and LPM Smith found expired foods. Next to the refrigerator, in an unsecured drawer were sharp knives. In the bathroom, a trash can with no lid and a air vent was covered with duct tape. In bedroom 2 downstairs, it was observed that bedrails on both beds were out of compliance. The tour concluded in the staff bathroom on the first floor where medication was observed in a cabinet on the wall accessible to persons in care. Records were reviewed for residents: R1, R2, and R3. Documents were requested during the visit from the administrator including the LIC500, LIC 308, LIC 501, Administrator Certificate and LIC 508: Criminal Record Statement. Deficiencies are cited under California Code of Regulations, Title 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator. A copy of this report and the Appeal Rights were provided.the state’s words, verbatim · CDSS document, Oct 4, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Nov 1, 2023

(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Based on observation, this requirement is not met by a wall in bedroom 3 where the bed used to be, in disrepair and trash cans in all rooms have no lids.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: Administrator to have bedroom 3's wall to be patched and trash cans with no lids. Administrator to provide proof of correction to LPA after the work is completed and trash cans replaced.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(3) · Plan of correction due date: Nov 1, 2023

Postural Supports (a) Based on the individual's preadmission appraisal, Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support. This requirement is not met as evidence by: R2 has half bed rails up by the head of the bed and there was no written order from their physician which poses a potential health risks to residents in care.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: The administrator will review the regulation pertaining to Postural Supports and provide in-services to facility staff. The administrator and/or designee will obtain a written physician's order for R2's half bed rails. The administrator and/or designee will conduct an evaluation of all the resident's beds for postural supports and if one is being used, the facility will obtain a physician's order indicating the need for the device that is being used.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(8) · Plan of correction due date: Oct 5, 2023

General Food Service Requirements: All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by interview of administrator and observation of a slice of Carrot cake on a table and multiple expired food/food products inside of refrigerators upstairs and downstairs.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: Administrator removed all expired food and dispose of it in addition to placing all food that needs to be refrigerated in refrigerator. Administrator and/or designee shall review the regulation and provide-in services to facility staff. The administrator and/or designee shall obtain put in place a procedure to ensure food will be of good quality. .

From the deficiency page — Deficiency type: Type A · Section cited: CCR87555(b)(23) · Plan of correction due date: Oct 5, 2023

General Food Service Requirements:All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by observation of food that needs to be refrigerated after opening not refrigerated.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: Administrator disposed of all perishable food that has not been refrigerated. Administrator to schedule regular checks of refrigerators in facility to ensure all readily persihable foods or beverages be stored in covered containers at appropriate temperatures.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Oct 5, 2023

Maintenance and Operation: (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 an interview with the administrator and observation of bedroom 3 which has a wall that needs to be patched and/or painted.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: Administrator to have wall painted and/or patched and submit photo to LPA.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87463(c) · Plan of correction due date: Oct 5, 2023

Appraisals (c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months. This requirement is not met as evidence by record reviews of R1, R2, and R3. R1’s needs and services plan (LIC625) was dated 01/05/2022 and unsigned. R2 and R3 does not have a copy of the needs and services plan.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a)(1) · Plan of correction due date: Oct 5, 2023

Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. This requirement is not evidenced by interview with administrator and observation of chemicals on the floor and accessible to persons in care. This poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 4, 2023

Plan of correction: Administrator removed liquid detergent from staff room. Administrator to schedule in-service with all staff to ensure that all liquid detergent is kept locked up and inaccessible to persons in care.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Oct 5, 2023

Incident Medication and Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by observation of staff and resident medication in areas throughout facility that are accessible to persons in care which poses an immediate health and safety risk to residents.the state’s words, verbatim · CDSS document, Oct 4, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87305(a) · Plan of correction due date: Oct 5, 2023

This is an Amended Report The report was generated in error This is an Amended Report The report was generated in errorthe state’s words, verbatim · CDSS document, Oct 4, 2023