California Care Center

In the surveyor’s words

From the most serious findings on record at California Care Center, in the surveyor’s own words.

• Actual harm, isolatedF580May 3, 2024

  Based on interview and record review, facility staff failed to notify one resident's (Resident #1's) out of one sampled residents' physician when the resident was given another residents medication which resulted in a hospital stay. The facility census was 29. 1. Review of the facility Medications, Errors and Drug Reactions policy, undated, showed the facility shall report all medication errors and adverse drug reactions immediately to the attending physician, Director of Nursing (DON), and the Administrator. 2. […]

• Actual harm, isolatedF760May 3, 2024

  Based on interview and record review, facility staff failed to ensure residents remained free of significant medication errors when staff administered Resident #2's medication to Resident #1 which resulted in Resident #1 being transported to the hospital after an adverse reaction. The facility census was 29. 1. Review of the facility Medications, Administration guidelines, undated, showed it is the purpose of this facility residents receive their medicationson timely and in accordance with established policies. Drug administration shall be defined as an act in which an authorized person, in accordance with all laws and regulations governing such acts, gives a single dose of a prescribed drug or biological to a resident. […]

• No harm, potential for more than minimal, patternF657May 7, 2026

  Based on observation, interview, and record review, facility staff failed to review and revise the plan of care for three residents (Resident #3, #13, and #21) out of 14 sampled residents. The facility census was 32. 1. Review of the facility's Care Plan Comprehensive policy, undated, showed an assessment of each resident is an ongoing process and the care plan's revised as changes occur in the resident's condition. The interdisciplinary care plan team is responsible to review and update care plans when a significant change in the resident's condition occurs. 2. […]

• No harm, potential for more than minimal, patternF584Jun 14, 2023

  Based on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment, when staff failed to ensure resident areas were in good repair. The facility census was 28. 1. Review of the facility's policy titled, Deep Cleaning a Resident Room, undated, showed staff were directed to do the following: -Deep cleaning is the segment of housekeeping that ensures total cleanliness of the resident room. The deep cleaning guarantees that all areas of the resident room and bathroom are cleaned and disinfected. Deep cleaning includes polishing, scrubbing, scrapping, dusting, and disinfecting everything in the resident room; -Spot wipe all walls using approved disinfectant; -Clean all corners, edges, and baseboards. […]

• No harm, potential for more than minimal, patternF657Apr 20, 2022

  Based on observation, interview, and record review, facility staff failed to revise care plans for five residents (Resident #6, #11, #12 #21, and #66) with interventions to prevent falls. The facility census was 30. 1. Review of the facility's, Care Plan Comprehensive Policy, dated March 2015, showed the policy directed staff as follows: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental and psychosocial well-being; -Assessment of each resident is an ongoing process and the care plan will be revised as changes occur in the resident's condition; -A well developed care plan will be oriented to: -Preventing avoidable declines in functioning or functional levels or otherwise… […]