The Californian

In the surveyor’s words

From the most serious findings on record at The Californian, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF801Aug 20, 2026

  Based on interview and record review, the facility failed to employ either a dietitian (a licensed health expert on food and nutrition), a qualified nutritional professional (a certified expert who completes specific college degrees, supervised clinical hours, and board exams to provide safe, science-based dietary care and medical nutrition therapy), or a director of food and nutrition services (a senior leader who manages meal programs and kitchen operations such as planning healthy menus, handling budgets, following safety laws, and managing kitchen staff) on a full-time basis (35 hours or more a week). This had the potential to result in the facility's inability to meet the nutritional needs of the residents.During an interview on 8/18/26 at 3:09 p.m. […]

• No harm, potential for more than minimal, isolatedF578Aug 20, 2026

  Based on interview and record review, the facility failed to ensure documentation establishing the legal authority of individuals identified as the Responsible Party (RP) (the person listed by the facility as the resident's representative or contact person who may assist with decisions, paperwork, or communication) and/or legally recognized decision-maker was maintained in the medical record for two of four residents reviewed for advance directives (a legal document in which a person states their healthcare wishes and/or identifies someone to make healthcare decisions for them if they become unable to do so) (Residents #3 and #38), when:Resident #3's medical record did not contain a Durable Power of Attorney (DPOA) (a legal document that names another person to make healthcare decisions… […]

• No harm, potential for more than minimal, isolatedF644Aug 20, 2026

  Based on interview and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASSR - a federally required screening of all individuals for Intellectual Disability (ID) or Related Condition and a Serious Mental Illness (SMI) prior to admission) Level 1 was accurate in 1 of 13 sampled residents (Resident 65).This failure had the potential to place Resident 65 at risk for unidentified health care needs, lack of services and diminished quality of life.During review of Resident 65's electronic medical record (EMR), the admission Record (AR), dated 8/13/26, indicated Resident #65 was admitted with a diagnosis of unspecified psychosis (loss of touch with reality-such as hallucinations or delusions). […]

• No harm, potential for more than minimal, isolatedF812Aug 20, 2026

  Based on observation, interview, and review, facility staff failed to ensure food temperatures for alternate food items were taken, recorded, and at an acceptable temperature prior to meal service. This failure had the potential to spread foodborne illness to the entire resident population at the facility that receives meals prepared in the kitchen.During a concurrent observation, interview, and record review on 8/17/26 at 11:45 a.m. with Dietary Aide (DA), observed DA getting a chicken breast from the oven (not from the steam table) and placing it on a resident's tray during tray line. DA stated that Resident 52 did not eat pork or beef and the chicken breast was served as an alternative protein. […]

• No harm, potential for more than minimal, isolatedF880Aug 20, 2026

  Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program when:Resident meal trays were placed on a Personal Protective Equipment (PPE) carts while staff put on PPE creating a direct pathway of cross contamination by exposing the resident's food to pathogens, body fluids, and/or contaminated surfaces. 2. Deep cleaning of a room was not completed following discontinuation of residents Contact Isolation for one of two sampled residents (Resident 62) These deficient practices had the potential to spread infection to residents in the facility. 1.During lunch tray pass observation on 8/17/26 at 12:12 p.m. […]