California Home for the Aged

In the surveyor’s words

From the most serious findings on record at California Home for the Aged, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 19, 2025

  Based on observation, interview and record review, the facility failed to ensure residents were free from accidents for one of five sampled residents (Resident 1), when Resident 1 was identified as being at risk for falls with a history of seven falls in the facility and the care planned intervention of a 1:1 (continuous observation and support provided by one qualified staff member to one resident) was not implemented and Resident fell on 7/18/25. This failure resulted in Resident 1 experiencing a witnessed fall, from the bed onto the floor on 7/18/25. After the fall Resident 1 experienced pain, discoloration and tenderness to the left shoulder and was sent to the general acute care hospital (GACH) for evaluation. […]

• No harm, potential for more than minimal, widespreadF881Apr 22, 2022

  Based on interview and record review, the facility failed to have an infection prevention and control program that included an antibiotic stewardship program that ensured residents who required antibiotics were prescribed the appropriate antibiotic, when the Infection Preventionist (IP) was unaware one of 21 sampled residents (Resident 67) who tested positive for extended spectrum beta-lactamase (ESBL- enzymes produced by a variety of gram negative bacteria with an increased resistance [not easily killed by] to commonly used antibiotics) and the physician was not notified of the lab results, and the resident was treated with an antibiotic her infection was resistant to. […]

• No harm, potential for more than minimal, patternF584Mar 28, 2024

  Based on observation, interview, and record review the facility failed to provide a comfortable homelike environment for three of 15 sampled residents (Residents 1, 29 and 81) when the air vents (an opening which allows air to pass out of or into a room) in Resident 1, 29, and 81's rooms were covered with black and brown stains and had dust in between the slits of the vent. This failure resulted in Residents 1, 29, and 81 not being provided a comfortable, homelike environment and had the potential to cause the residents to experience illness from breathing in dust from the air vents. […]

• No harm, potential for more than minimal, patternF656Mar 28, 2024

  Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for four of 22 sampled residents (Residents 49, 80, 37 and 4) when: 1. Residents 49 and 80 did not have an individualized care plan developed and implemented for the use of side rails. This failure had the potential for Residents 49 and 80 to be injured while using the side rails. 2. […]

• No harm, potential for more than minimal, patternF658Mar 28, 2024

  Based on observation, interview and record review, the facility failed to meet professional standards of practice for four of 12 sampled residents (Residents 25, 52, 55 and 66) when: 1. Registered Nurse (RN) 1 signed the electronic Medication Administration Record (eMAR- legal record of drug administration to a patient at a facility by a health care professional) prior to administering Resident 25's medications. This failure resulted in inaccurate charting and placed Resident 25 at a risk to not receive the medications ordered. 2. RN 1 did not follow the medication administration direction when she applied a lidocaine patch (medication patch applied on top of the skin for relief of pain) to Resident 25's left upper arm. […]