Above & Beyond Rcfe, Inc..
Above & Beyond Rcfe, Inc. is Ranked in the bottom 5% of California memory care with 40 CDSS citations on record; last inspected Mar 2026.
6-Bed Memory Care Home in Hayward's Nevada Road Neighborhood, reviewed on public record.
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Compared to 152 California facilities with a similar number of beds.
RCFE memory care · 36-month window. Higher percentile = better performance on inspection record. Source: California Dept. of Social Services · Community Care Licensing.
Rankings based on 36-month CDSS inspection data. Severity and frequency: fewer citations = higher percentile. Repeat rate: lower repeat citation share = higher percentile.
FACILITY WATCH · BETA
Above & Beyond Rcfe, Inc. has 40 citations on record. Know the moment anything changes.
New findings, complaint investigations, or status changes — emailed to you free.
Citation history, plotted month by month.
40 deficiencies on record. Each bar is a month with a citation.
Finding distribution
40 total · 36 monthsScope × Severity (CMS A–L)
The rules that apply to this facility.
State requirements with the exact regulation citation, plain-language explanation, and a question to ask on tour. Rules this facility has been cited for appear first.
Plain language
Because a facility markets dementia or Alzheimer's care, state law mandates higher training standards: 12 hours of initial dementia training (6 hours before a staff member works independently with residents, 6 more within the first 4 weeks), 8 hours of annual dementia in-service every year thereafter, and an administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle. Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.
Ask on tour
“Can you show me each direct-care staffer's most recent dementia training certificate, and tell me when their next refresher is due?”
Questions to ask before you visit.
A short pre-tour checklist tailored to Above & Beyond Rcfe, Inc.'s record and state requirements.
State records show 20 Type A deficiencies (actual harm citations) across 7 inspections — can you walk me through what specific incidents led to these citations and what corrective actions were implemented?
Ask the operator on tour. Take notes and compare answers across facilities you visit.
The facility has been cited twice under §87705 or §87706 for dementia-care requirements — what were the specific deficiencies, and how has the facility changed its dementia care practices in response?
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With 44 total deficiencies documented by CDSS, how has the facility's leadership or ownership changed its oversight, training, or staffing since these citations were issued?
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Every inspection visit, verbatim.
4 inspections in the public record, most recent first. Click any row to expand — cited rows open automatically.
2026-03-26Other VisitType A · 5 findings
Plain-language summary
On March 26, 2026, inspectors conducted an unannounced annual inspection and found multiple safety issues: medications and cleaning supplies stored in unlocked cabinets and drawers where residents could access them, mildew in a shower, and a staff member who had been working since March 8 without required background clearance. The facility also received a civil penalty for the unclearanced staff member and repeat violations related to storage and safety procedures. The inspection was not completed on that day and inspectors indicated they would return to continue.
“Based on observation, the licensee did not comply with the section cited above in unlocked scissors in kitchen drawer, and bleach and Lysol spray in in unlocked cabinet in residents' ensuite bathroom which pose an immediate health, safety and/or personal rights risk to persons in care. This is a repeat violation within 12 month period. POC Due Date: 03/27/2026 Plan of Correction 1 2 3 4 Staff locked the scissors and ensuite bathroom cabinet. In addition, licensee and/or administrator to in-service the staff and submit copy of training topic with attendees signatures by 3/27/26.”
“Based on observation, the licensee did not comply with the section cited above in Cortisone ointments in unlocked staff room which poses an immediate safety and/or personal rights risks to persons in care. This is a repeat violation within 12 month period. POC Due Date: 03/27/2026 Plan of Correction 1 2 3 4 Staff locked the room. In addition, licensee and/or administrator to in-service the staff and submit copy of training topic with attendees signatures by 3/27/26.”
“Based on observation, the licensee did not comply with the section cited above inunlocked central storage for medications which poses an immediate health, safety and/or personal rights risks to persons in care. POC Due Date: 03/27/2026 Plan of Correction 1 2 3 4 Staff locked medication central storage. In addition, licensee and/or administrator to in-service the staff and submit copy of training topic with attendees signatures by 3/27/26.”
“Based on record review, the licensee did not comply with the section cited above in a staff not fingerprint cleared which poses an immediate safety and/or personal rights risks to persons in care. POC Due Date: 03/27/2026 Plan of Correction 1 2 3 4 Staff left the facility while at the facility. Administrator to have the staff fingerprinted and cleared. Proof to be submitted by 3/27/26.”
“Based on observation, the licensee did not comply with the section cited above in shower room in ensuite bathroom with mildew which poses a potential health and/or personal rights risks to persons in care. POC Due Date: 04/09/2026 Plan of Correction 1 2 3 4 Licensee and/or administrator to have the shower room cleaned and submit picture by 4/09/26.”
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On this day, March 26, 2026, at 4:10 pm., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Larry Poblete and LOurdes Deocampo, and informed the reason for visit. LPA called and spoke over the phone with Leticia Velasco, licensee. Licensee and Max 'Mike' Neri, administrator (ADM) arrived at around 4:20 pm. LPA started the inspection with Larry Poblete and continued with Max Neri. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Facility has 2 in 1 smoke and carbon monoxide detector that was tested and observed in operating condition during today's visit. Hot water temperature in the common bathroom was tested an measured at 117 degrees Fahrenheit.. Fire extinguisher was observed fully charge with tag showed serviced March 16, 2026. LPA observed the following: -at 4:16 pm, unlocked central storage for medications. -at 4:19 pm, unlocked scissors in the kitchen drawer. -at 4:25 pm, Cortisone ointments in unlocked staff room. -at 4:27 pm, bleach and Lysol spray in unlocked cabinet in residents' ensuite bathroom. -at 4:28 pm, shower room in ensuite bathroom with mildew. ...continued on 809C (page 2) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 -at 4:35 pm, Calmoseptine ointments in one of the residents' room. -Staff (S1) who started working on March 8, 2026 is not fingerprint cleared. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $500.00 civil penalty is assessed for deficiency section #87355(e)92) for staff who is not fingerprint cleared and will continue for $100.00/day until corrected, and for repeat violations of section #'s 87309(a) and 87309(c) within 12 month period. Failure to submit proof of corrections by plan of correction due dates for other deficiencies cited may also result in civil penalties. Deficiencies, plan and proof of corrections, and civil penalties were discussed with the administrator. Due to time constraint, LPA will come back to continue the inspection. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalties, LIC9098 Proof of Correction form and copy of this report provided.
2025-04-08Annual Compliance VisitType B · 13 findings
Plain-language summary
This was a continuation of the facility's annual inspection on April 8, 2025. Inspectors found that several staff members lacked required health screenings, tuberculosis tests, and training documentation; resident care plans were incomplete or outdated; and some medications were not properly recorded. The facility was required to submit corrected documentation and plans to address these issues.
“Based on record review, the licensee did not comply with the section cited above in S2 does not having LIC501 Personnel Record on file which poses a potential safety and/or personal rights risks to persons in care. POC Due Date: 04/22/2025 Plan of Correction 1 2 3 4 Administrator to have the LIC501 completed and submit proof by 4/22/25.”
“Based on record review, the licensee did not comply with the section cited above in R4 not having Pre-Admission Appraisal which poses a potential health, safety and/or personal rights risks to persons in care. POC Due Date: 04/22/2025 Plan of Correction 1 2 3 4 Administrator to complete the Pre-Admission Appraisal and submit copy by 4/22/25.”
“Based on record review, the licensee did not comply with the section cited above in S4 not associated which poses a potential safety and/or personal rights risks to persons in care. POC Due Date: 04/22/2025 Plan of Correction 1 2 3 4 Administrator provided a copy of LIC9182 transfer request while LPA is at the facility. In addition, administrator to submit the documents via email to the Oakland Regional Office by POC date.”
“Based on record review, the licensee did not comply with the section cited above in R4 not having LIC625 Appraisal/Needs and Services Plan which poses a potential health, safety and/or personal rights risks to persons in care. POC Due Date: 04/22/2025 Plan of Correction 1 2 3 4 Administrator to complete the LIC625 and submit copy by 4/22/25.”
“Based on records review, , the licensee did not comply with the section cited above in the following which pose a potential health, safety and/or personal rights risks to persons in care: R1's LIC602A indicated ambulatory but resident has major neurocognitive disorder. R2's LIC602A indicated bedridden but R2 was observed able to ambulate using walker. POC Due Date: 04/22/2025 Plan of Correction 1 2 3 4 Administator to have the LIC602As corrected and submit proof by 4/22/25.”
“Based on records review, the licensee did not comply with the section cited above in the following which pose a potential health, safety and/or personal rights risks to persons in care: R1 and R2's LIC625 over a year old; R3's LIC625 not properly filled-up. POC Due Date: 04/22/2025 Plan of Correction 1 2 3 4 Administrator to do re-appraisal and properly fill-up the LIC625. Self-certification to be submitted by 4/22/25.”
“Based on records review, the licensee did not comply with the section cited above in not having records showing drills were conducted on previous quarters which pose a potential safety and/or personal rights risks to persons in care. POC Due Date: 04/22/2025 Plan of Correction 1 2 3 4 Administrator to read the Regulations and submit self-certification ensuring drills are conducted at least quarterly.”
“Based on record review, the licensee did not comply with the section cited above in S4 and S5 not having first aid certificate on file which pose a potential safety and/or personal rights risks to persons in care. POC Due Date: 04/22/2025 Plan of Correction 1 2 3 4 Administrator to have the staff reqistered for training and submit copies of certificates by 4/22/25.”
“Based on records review, the licensee did not comply with the section cited above in S2, S4 and S5 not having LIC503 on file which pose a potential health and/or personal rights risks to persons in care. POC Due Date: 04/22/2025 Plan of Correction 1 2 3 4 Administrator to have the staff health screened and submit proof by 4/22/25.”
“Based on records review, the licensee did not comply with the section cited above in S2, S4 and S5 not having TB test on file which pose a potential health and/or personal rights risks to persons in care. POC Due Date: 04/22/2025 Plan of Correction 1 2 3 4 Administrator to have the staff TB tested and submit copies of test results by 4/22/25.”
“Based on records review, the licensee did not comply with the section cited above in S2, S4 and S5 not having the 40 hours required training on file which pose a potential health, safety and/or personal rights risk to persons in care. POC Due Date: 04/22/2025 Plan of Correction 1 2 3 4 Administrator to have the staff complete the training and submit proof by 4/22/25.”
“Based on record review, the licensee did not comply with the section cited above in R5’s 2 medications received by the facility not properly recorded on LIC622 which posed a potential personal rights risk to persons in care. POC Due Date: 04/22/2025 Plan of Correction 1 2 3 4 Administrator to correct the LIC622 and submit proof by 4/22/25.”
“Based on records review, the licensee did not comply with the section cited above in R3 and R4’s half bed rails not having doctor's order on file which pose a potential safety and/or personal rights risk to persons in care. POC Due Date: 04/22/2025 Plan of Correction 1 2 3 4 Administrator to obtain doctor's order and submit copies by 4/22/25.”
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On this day, 4/08/25, at 11:45 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the annual required inspection that was started on 3/28/25. LPA met with staff, Larry Poblete, Evangelien Porter and Gerald Cayle Garcia, and informed the reason for visit. LPA called and spoke over the phone with Leticia Velasco, licensee, who arrived at around 12:25 pm. Max Neri, administrator (ADM) arrived at around 1:00 pm. Disaster drill record on file was dated 1/10/25. There's no record as proof drills were conducted on previous quarters. LPA reviewed 5 staff and 5 residents' files. Residents medications were checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources. LPA observed the following: -at 12:20 pm, staff (S2) does have LIC501 Personnel Record, LIC503 Health Screening, TB test and 40 hours required training on file. -at 12:35 pm, staff (S4) is not associated to this facility. Does not have LIC503 Health Screening, TB test, required 40 hours training and first aid certificate on file. -at 12:40 pm, staff (S5) does not have LIC503 Health Screening, TB test, required 40 hours training and first aid certificate on file. .......continued on 809C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 -at 1:05 pm, resident's (R1) LIC602A indicated ambulatory but resident has major neurocognitive disorder. LIC625 on file is over a year old. -at 1:17 pm, resident's (R2) LIC602A on file dated 2023 indicated bedridden but R2 was observed able to ambulate using walker. LIC602A indicated major neurocognitive disorder. LIC625 is over a year old. -at 1:25 pm, resident's (R3) LIC625 Appraisal/Needs Services Plan not properly filled-up - incomplete; page 2 blank; page 3 no care plan. No doctor's order on file for half bed rails. -at 1:40 pm, resident's (R4) LIC602A is over a year old; does not have Pre-Admission Appraisal and LIC625 Appraisal/Needs and Services Plan. Half bed rails does not have doctor's order on file. -at 2:10 pm, resident's (R5) 2 medications received by the facility not properly recorded on LIC622. Administrator to submit current/updated copies of the following documents by April 22, 2025: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610D Emergency Disaster Plan (9 pages). 4. $3M Liability Insurance certificate Deficiencies are cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of corrections by plan of correction due dates and any repeat violation within 12 month period may result in civil penalty. Deficiencies and plan and proof of corrections were discussed with ADM. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
2025-03-28Annual Compliance VisitType A · 6 findings
Plain-language summary
During a routine annual inspection on March 28, 2024, inspectors found multiple safety hazards: medications stored in an unlocked refrigerator and kitchen cabinet, sharp objects like razors and kitchen shears left accessible in resident rooms and unsecured areas, cleaning supplies and disinfectants stored without locks in bathrooms and cabinets, hot water in the common bathroom at 134.1 degrees (a burn risk), and hazardous items like metal pieces and a rake left in the backyard. The facility was also cited for incomplete staffing documentation and not having a current emergency disaster plan on file. The facility must submit proof of corrections by specified deadlines.
“Based on observation, the licensee did not comply with the section cited above in hot water at 134.1 degrees Fahrenheit which poses an immediate health and/or personal rights risks to persons in care. POC Due Date: 03/29/2025 Plan of Correction 1 2 3 4 Administrator to have the temperature adjusted within Regulations range and submit proof by 3/29/25.”
“Based on observation, the licensee did not comply with the section cited above in the following which pose an immediate health, safety and/or personal rights risks to persons in care: medications in unlocked garage; unlocked kitchen shears and medication (Aspirin) in the kitchen cabinet; kitchen cabinets where sharps and cleaning supplies are kept do not have an appropriate lock; unlocked Vitamins and perineal skin protector; shaving cream, Isopropyl alcohol, UTI pain reliever and razor in residents' rooms; disinfectant and sanitizing sprays in the common bathroom POC Due Date: 03/29/2025 Plan of Correction 1 2 3 4 Staff put the items in the garage then locked the garage. In additon, administrator to do the following and submit proof by 3/29/25: 1. Install lock in the cabinets. 2. In-service the staff and submit copy of training topic with attendees signatures.”
“Based on observation, the licensee did not comply with the section cited above in a rake outside the storage in the backyard which poses an immediate safety and/or personal rights risks to persons in care. POC Due Date: 03/29/2025 Plan of Correction 1 2 3 4 Staff temporarily locked the rake in the garage. Administrator to do the following and submit proof by 3/29/25: 1. Put the rake in the storage. 2 In-service the staff and submit copy of training topic with attendees signatures.”
“Based on observation, the licensee did not comply with the section cited above in rotten broccoli which poses an immediate health and/or personal rights risks to persons in care. POC Due Date: 03/29/2025 Plan of Correction 1 2 3 4 Staff discarded the item. Administrator to in-service the staff and submit copy of training topic with attendees signatures by 3/29/25.”
“Based on observation, the licensee did not comply with the section cited above in the following pose a potential safety and/or personal rights risks to persons in care: piece of metal, mattress, bed frame and bed rail in the backyard. POC Due Date: 04/11/2025 Plan of Correction 1 2 3 4 Administrator to have the yard cleaned and submit pictures by 4/11/25.”
“Based on interview and review of facility roster in Guardian, the licensee did not comply with the section cited above in S1 not associated which poses a potential safety and/or personal rights risks to persons in care. POC Due Date: 04/11/2025 Plan of Correction 1 2 3 4 Administrator to have the staff associated and submit proof by 4/11/25.”
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On this day, March 28, 2024, at 4:10 pm., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Virginia Rulete and Blesilda Yamat, and informed the reason for visit. LPA called and spoke over the phone with Leticia Velasco, licensee, and Max 'Mike' Neri, administrator (ADM). The licensee authorized to have the staff to be with LPA in touring the facility. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Facility has smoke and carbon monoxide detectors that were observed in operating condition. Hot water temperature in the common bathroom was tested. Fire extinguisher was observed fully charge with tag showed serviced 3/06/25. LPA observed the following: -at 4:25 pm, medications in the refrigerator in unlocked garage. -at 4:27 pm, unlocked kitchen shears and medication (Aspirin) in the kitchen cabinet. -at 4:28 pm, kitchen cabinets where sharps and cleaning supplies are kept do not have an appropriate lock. -at 4:30 pm, Vitamins and perineal skin protector in cabinet without lock in the area adjacent to the dining area. ...continued on 809C (page 2) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 2 -at 4:42 pm, shaving cream in one of the residents' rooms. -at 4:43 pm, razor in food tray in another resident's room. -at 4:44 pm, disinfectant and sanitizing sprays in the common bathroom. -at 4:50 pm, hot water in the common bathroom was at 134.1 degrees Fahrenheit. -at 5:02 pm, Isopropyl alcohol and urinary tract infection (UTI) pain reliever in the drawer in another residents' room. -at 5:04 pm, piece of metal, mattress, bed frame and bed rail in the backyard. -at 5:05 pm, rake outside the storage in the backyard. -staff (S1) is fingerprint cleared, however, not associated to this facility. Administrator to submit copies of the following updated/current documents by April 11, 2025: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in additional civil penalties. Deficiencies and plan and proof of corrections were discussed with licensee and ADM over the phone. Licensee authorized Virginia Rulete to sign and receive this report. Due to time constraint, LPA to come back to continue the inspection. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
2024-03-23Annual Compliance VisitType A · 16 findings
Plain-language summary
During a routine annual inspection on March 23, 2024, inspectors found multiple safety and medication management problems: medication cabinets and storage areas were left unlocked, allowing residents access to medications and hazardous items like cleaning supplies and sharp objects; hot water exceeded safe temperature; and one staff member lacked required health clearance and fingerprint background clearance. Additional violations included missing or outdated physician reports for some residents, incorrect medication records, medications that did not match doctor's orders, and disaster drills not conducted as required. The facility was assessed a $500 civil penalty.
“Based on observation, the licensee did not comply with the section cited above in cabinets with residents' medications unlocked which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 03/24/2024 Plan of Correction 1 2 3 4 Staff locked the cabinets. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 3/24/24.”
“Based on observation, the licensee did not comply with the section cited above in hot water at 125.1 degrees Fahrenheit.which poses an immediate health, safety and/or personal rights risks to persons in care. POC Due Date: 03/24/2024 Plan of Correction 1 2 3 4 Corrected. Administrator adjusted the water temperature to 110 degrees Fahrenheit.”
“Based on observation, the licensee did not comply with the section cited above which pose an immediate health, safety and/or personal rights risk to persons in care. LPA observed the following: knives in unlocked kitchen cabinet; scissors and pizza cutter in drawers without lock; Lysol, Windex, Barbasol in cabinet without lock in the ensuite bathroom; peritoneal cleansers and ointments, lighter, scissors in one of the residents rooms; peritnoeal cleaner in the common bathroom POC Due Date: 03/24/2024 Plan of Correction 1 2 3 4 Administrator and staff lock the items. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 3/24/24.”
“Based on record review, the licensee did not comply with the section cited above in S4 not fingerprint cleared and associated to the facility which poses an immediate safety and/or personal rights risk to persons in care. A $500.00 civil penalty is assessed. POC Due Date: 03/24/2024 Plan of Correction 1 2 3 4 Administrator to have the staff fingerprinted, and will not allow to work until cleared and associated. Proof to be submitted by 3/24/24.”
“Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: Plan of Correction 1 2 3 4”
“Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: Plan of Correction 1 2 3 4”
“Based on record review, the licensee did not comply with the section cited above in staff administering R2's multi vitamins twice daily when doctor's order is once daily; Doctor's order for R3's calcium carbonate-Vit D3 (600 mg-12.5 mcg(500 unit) but the medication on facility's hand os 600 mg-10 mg (400 unit).which poses an immediate health and/or personal rights risk to persons in care. POC Due Date: 03/24/2024 Plan of Correction 1 2 3 4 Administrator to have the medication for R2 administered as ordered and obtain correct medication for R3, and submit proof by 3/24/24.”
“Based on observation and record review)], the licensee did not comply with the section cited above in having 21 medications on hand for R2 but order on file is only for 18.count which poses an immediate health and/or personal rights risk to persons in care. POC Due Date: 03/24/2024 Plan of Correction 1 2 3 4 Administrator to check with the doctor if the 3 medications are still needed by R2 and obtain doctor's order. Proof to be submitted by 3/24/24.”
“Based on observation, he licensee did not comply with the section cited above in Aleve, Glucosamine. Bengay in one of the resident's rooms which poses an immediate health, safety or personal rights risk to persons in care. POC Due Date: 03/25/2024 Plan of Correction 1 2 3 4 Administrator and staff locked the items. In addition, administrator to in-service the staff and submit copy of training topic with attendees signatures by 3/24/24.”
“Based on observation, the licensee did not comply with the section cited above in trash can without lid which poses a potential health and/or personal rights risk to persons in care. POC Due Date: 04/06/2024 Plan of Correction 1 2 3 4 Administrator to purchase trash can with foot pedal operated lid, and submit proof of purchase by 4/06/24.”
“Based on record review, the licensee did not comply with the section cited above in S3 has not having LIC503 Health Screening & TB test on file which pose a potential health and/or personal rights risk to persons in care. POC Due Date: 04/06/2024 Plan of Correction 1 2 3 4 Administrator to have the staff health screened and TB tested, Proof to be submitted by 4/06/24,”
“Based on record review, the licensee did not comply with the section cited above in S3 only having total of 22 hours training ofn file which poses a potential health, safety and/or personal rights risk to persons in care. POC Due Date: 04/06/2024 Plan of Correction 1 2 3 4 Administrator to have the staff complete the training, and submit self-certification by 4/06/24.”
“Based on record review, the licensee did not comply with the section cited above in for not conducting drills at least every quater which poses a potential safety risk to persons in care. POC Due Date: 04/06/2024 Plan of Correction 1 2 3 4 Administrator to have drill conducted, and submit proof by 4/06/24.”
“Based on record review, the licensee did not comply with the section cited above for not having doctor's orders for R1,R2, R3 and R4's half bed rails which poses a potential health, safety and/or personal rights risk to persons in care. POC Due Date: 04/06/2024 Plan of Correction 1 2 3 4 Administrator to obtain doctor's order, and submit copies by 4/06/24.”
“Based on record review, the licensee did not comply with the section cited above in R1's LIC602A over a year old & no LIC625 on file which pose a potential health and/or personal rights risk to persons in care. POC Due Date: 04/06/2024 Plan of Correction 1 2 3 4 Administrator to obtain an updated LIC602A and complete LIC625 for R1, and submit self-certification.”
“Based on records review, the licensee did not comply with the section cited above for the following which poses a potential personal rights risk to persons in care: R1's 3 medications not recorded & other medications not proeprly recorded on LIC622; R2's medications not properly recorded on LIC622. POC Due Date: 04/06/2024 Plan of Correction 1 2 3 4 Administrator to correct the record, and submit self-certification by 4/06/24,”
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.On this day, March 23, 2024, at 11:05 a.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with staff, Marlyn Joaquin and Raul Pangilinan, and informed the reason for visit. LPA called and spoke over the phone with Leticia Velasco, licensee, who authorized Marilyn Joaquin to be with LPA to start inspection. Licensee and Max 'Mike' Neri, administrator, arrived at 11:35 a.m. and 11:40 a.m.. respectively. Facility submitted the LIC9282 Infection Control Plan on June 29, 2022. LPA started the inspection with Marlyn Joaquin, and continued with the licensee and administrator. LPA inspected the kitchen, dining area, living room, bedrooms, bathrooms, front, side and backyards. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Facility has smoke and carbon monoxide detectors that were observed functional. Hot water temperature in the ensuite bathroom was tested. Fire extinguisher was observed fully charge with tag showed serviced February 13, 2024. Facility disaster drill records checked. LPA reviewed 5 residents and 4 staff files, and interviewed 2 staff and 2 residents. Medications were checked, and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources. LPA observed the following: -at 11:19 a.m., unlocked medication cabinets. -at 11:20 a.m., residents medications in the refrigerator in the kitchen. ...continued on 809C (page 2) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 2 -at 11:24 a.m., knives in unlocked kitchen cabinet, and scissors and pizza cutter in kitchen drawers without lock. -at 11:32 a.m., scissors in drawer without lock in the living room. -at 11:34 a.m., medication in unlocked staff room. -at 11:41 a.m., Aleve, Glucosamine. Bengay in one of residents rooms. -at 11:52 a.m., Lysol, Windex, Barbasol in cabinet without lock in the ensuite bathroom. -at 11:55 a.m., hot water at 125.1 degrees Fahrenheit. -at 11:59 a.m., peritoneal cleansers and ointments in the common bathroom.. -at 12:01 p.m., trash cans without lid in one of the residents' rooms and living room. -at 12:06 p.m., Oxygen tanks, pails of paint in unlocked storage in the backyard. -at 12:30 p.m., disaster drills not conducted quarterly; records showed conducted on 1/11/22 and 1/11/24. -at 2:00 p.m., staff (S3) has no LIC503 Health Screening & TB test result on file, Total hours of training on file is only 22 hours. -at 2:30 p.m., staff (S4) not fingerprint cleared and associated. -at 3:15 p.m., resident (R1) LIC602A Physician's Report is over a year old. No LIC625 Appraisal/Needs and Services Plan & doctor's order for half bed rails. -at 3:50 p.m., R2's half bed rails no doctor's order on file,, -at 4:05 p.m., no doctor's order on file for R3's half bed rails. -at 5:00 p.m., R1's 3 medications not recorded on LIC622 Centrally Stored Medication and Destruction Record, Dates filled of other medications incorrectly recorded. -at 5:35 p.m., R2 has 21 medications on facility's hand but there's only 18 on doctor's order, Facility is only giving only 11 medications of which one (muti vitamins) is given twice daily when order is only once daily. Medications received were not properly recorded on LIC622. -at 7:00 p.m., R3 has no LIC622 on file. Doctor's order for calcium carbonate-Vit D3 (600 mg-12.5 mcg(500 unit) but the medication on facility's hand os 600 mg-10 mg (400 unit).No doctor's order for half bedrails. -at 7:05 p.m., no doctor's for R4's half bed rails. ....continued on 809C (pge 3) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Page 3 Administrator submitted on this day the following updated/current documents: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) 4. $3M Liability Insurance certificate Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $500.00 civil penalty is assessed for staff not fingerprint cleared. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in additional civil penalties. Deficiencies and plan and proof of corrections were discussed with the administrator and licensee. Exit interview conducted. Appeal Rights, LIC421BG Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.
3 older inspections from 2022 are not shown in the free view.
3 older inspections from 2022 are not shown in the free view.
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