San Dimas Adventist Home Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Caregiver Mark Santiago and explained the purpose for today’s visit, shortly after administrator Jasaiel De Leon arrived to assist with the visit. The facility is licensed to serve 6 Non-Ambulatory Residents ages 60+. There is a hospice waiver on file for (1) and approved Dementia Program. The facility is a single story home located in San Dimas Ca, and includes the following: kitchen, dining area, living room, 4 resident bedrooms, 2 bathrooms, laundry room, detached garage, front yard and backyard.LPA observed the following during todays inspection: Infection Control: The facility maintains a copy of the required Infection Control Plan. Operational Requirements: The facility has an approved fire clearance and facility maintains the required liability insurance that is valid until 8/3/27. Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms were checked and closet/drawer space to accommodate each resident comfortably was available. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees F. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. LPA observed rat poison, bleach, all purpose glue, and cleaning chemicals in the unlocked resident patio area, and also observed cleaning chemicals, disinfectants and roach spray in an unlocked kitchen cabinet under the sink, LPA also observed that all exit doors including 1 resident room with exit door to back yard, did not have the required auditory device or alert feature to monitor exits that were operable, all residents in facility have dementia or alzheimer's, (citations issued). (continued on LIC809-C) Staffing & Personnel Records-Training: There appears to be sufficient staffing at all times in the facility. Staff has criminal record clearance, training along with training in postural supports, medication assistance, hospice, dementia and other ongoing training are documented in personnel files. Administrator Jasaiel De Leon certificate expires on 4/3/27. During file review LPA observed that both S1 and S2, first-aid certificates are expired since 8/11/26, citation issued. Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 4 Resident Files and observed that 3 out of 4 resident files missing their required yearly updated reappraisals, citation issued. Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Planned Activities: There is an outdoor activity area available for the residents. Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Incidental Medical & Dental: During tour LPA observed medication to be in an unlocked kitchen cabinet, citation issued.Medication review was not completed as updated medication list was not available during visit, LPA reminded Licensee/Administrator that all records must be up to date for proper review. Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites. Last fire/disaster/earthquake drill was conducted on 8/1/26. Residents with Special Health Needs: There is currently 1 resident using hospice services at the facility, hospice file was reviewed with no issues observed. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit will be documented on the LIC809-D pages Exit interview held, a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 11, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Sep 12, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) 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 was not met as evidence by: During facility tour LPA observed medication to be in an unlocked kitchen cabinet, there was an ambulatory resident eating breakfast on the dining table that was right next to the unlocked cabinet making medications accessible to persons in care, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 11, 2026

Plan of correction: Administrator / Licensee to conduct a training on how to properly store and lock medications to ensure that they are not accessible to persons other than employees responsible for the supervision of the centrally stored medication. Copy of training materials and training log to be emailed to LPA by 9/25/26. (tena.herrera@dss.ca.gov)

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(b) · Plan of correction due date: Sep 12, 2026

87309 Storage Space and Access (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidence by: During facility tour LPA observed rat poison, bleach, all purpose glue, and cleaning chemicals in the unlocked resident patio area, and also observed cleaning chemicals, disinfectants and roach spray in an unlocked kitchen cabinet under the sink, making all these items which could pose a danger to residents if left unlocked/unattended accessible to the residents in care, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 11, 2026

Plan of correction: Administrator / Licensee to conduct a training on how to properly store and lock disinfectants, cleaning solutions, poisonous substances and other similar items which could pose a danger to residents to ensure that they are not accessible to residents if left unlocked/unattended. Copy of training materials and training log to be emailed to LPA by 9/25/26. (tena.herrera@dss.ca.gov)

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87643(a) · Plan of correction due date: Sep 25, 2026

87463 Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement was not met as evidence by: During file review LPA observed 3 out of 4 resident files missing their updated reappraisals. The Appraisals in file for residents had the following dates on them R1 11/15/22, R2 8/10/25, R3 1/13/26, R4 11/3/24 which is outside the 12 month requirement, this poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 11, 2026

Plan of correction: Licensee/Administrator to updated the 3 resident reappraisals using the LIC 625 form and follow all requirements for reappraisals. These are to be updated, signed and emailed to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c)(1) · Plan of correction due date: Sep 25, 2026

87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidence by: During file review LPA observed that both S1 and S2, first-aid certificates are expired since 8/11/26, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 11, 2026

Plan of correction: S1 & S2 completed the required first-aid training during todays visit and provided LPA with proof of valid cetificates that expire 9/11/28. POC cleared during todays visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(d) · Plan of correction due date: Sep 25, 2026

87705 Care of Persons with Dementia (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. This requirement was not met as evidence by: During facility tour LPA observed that all exit doors including 1 resident room with exit door to back yard, did not have the required auditory device or alert feature to monitor exits that were operable, all residents in facility have dementia or alzheimer's, this poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 11, 2026

Plan of correction: Administrator installed the required auditory devices to each exit during todays visit, each device was tested and observed to be operable, therefore, no POC is needed and will be cleared during todays visit.

Type of visit: Required - 1 Year

LPA Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual inspection visit and was greeted by Administrator Jasaiel De Leon. LPA Gonzalez explained the purpose of the visit. The facility is located on a main street in the city of San Dimas and is licensed to serve the elderly 60 and above, fire clearance for six (6) non- ambulatory, facility main retain one (1) hospice resident and has a dementia program. The facility is a single story home consisting of a kitchen, dining area, living room, four (4) resident bedrooms and two (2) bathrooms, laundry room, a front yard and a backyard. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents, secured in the locked laundry room. LPA observed carbon monoxide detector in the hallway, was tested and is operable. Smoke detectors observed in the hallway and resident bedrooms, were tested and are operable. LPA inspected four (4) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA observed grab bars near toilets and inside showers. LPA observed no-slip flooring in showers. Showers were observed to be wheelchair accessible. continued on LIC 809C Food Service: LPA observed sufficient supply of nonperishables for one (1) week and perishable foods for a minimum of two (2) days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean Residents Rights-Information: LPA observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA observed facility land line was operable. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Fire drills are conducted monthly, last drill 10/01/25. LPA observed facility sketches with exits and emergency exits routes throughout various locations of the facility. Residents with Special Needs: No large bodies of water were observed. LPA observed signs posted indicating “No smoking - Oxygen in Use.” LPA observed an oxygen tank in resident room secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Health Related Services/Incidental Medical Services: The medications are centrally stored, secured in ta kitchen cabinet inaccessible to residents in care. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. Staffing: Administrator Certificate for Jasaiel De Leon expires 04/03/2026. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA observed required annual training, CPR and First Aid for two (2) personnel records reviewed. LPA observed TB testing results, Health screening, fingerprint clearance and job application for personnel records reviewed. Resident Records/Incident Reports: LPA reviewed files for four (4) residents in care. Resident files are maintained at the facility and contain the required documents. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were cited during today’s visit. Exit interview held and a copy of this report was provided to Administrator Jasaiel De Leon.the state’s words, verbatim · CDSS document, Oct 27, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit and was greeted by Administrator Jasaiel De Leon. LPA Ramirez explained the purpose of the visit. The facility is located on a main street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. Showers were observed to be wheelchair accessible. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). Planned Activities: LPA Ramirez observed board games and activities for residents. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. No proof of documented fire drill was observed during records review. LPA Ramirez will issue deficiency based on this record review. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply. See 809-C Residents with Special Needs: No large bodies of water were observed LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory device in resident bedroom#1 was in disrepair. LPA Ramirez will issue Type B deficiency based on this observation. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. Staffing: Administrator Certificate for Jasaiel De Leon expires 04/03/2025. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for two (2) out of the three (3) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel records reviewed. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for six (6) non-ambulatory. This facility may retain no more than one (1) hospice resident. Resident Records/Incident Reports: LPA reviewed Resident files for four (4) residents in care. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment were observed. LPA Ramirez did not observe Resident Rights form signed for R1, R2, and R3. R1 was missing complete Identification and Emergency form. LPA Ramirez will issue Type B deficiency. Four (4) deficiencies were observed today. A copy of this report, 809-D and appeals rights were provided.the state’s words, verbatim · CDSS document, Aug 11, 2024