Chateau Le Petite III

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct the required annual visit today. Upon arrival, the LPA was greeted by the House Manager (HM), Dexter Olavario and the reason for the visit was explained. Entrance interview conducted. Beginning at 10:30 a.m., the LPA along with the HM toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The following was observed: Common Areas: This includes the living room and dining room areas. Furniture in the common areas was observed to be in good condition at the time of the visit. The facility maintained a comfortable temperature. The LPA observed a fireplace in the living room; adequately covered. The LPA observed activity supplies in the common areas accessible to residents in care. There is a physical therapy room/area with exercise equipment for resident use. The LPA observed a fire extinguisher to be fully charged with a date of 06/15/2026. Required postings were observed throughout the common space. There is a working telephone on premises. Cameras were observed in the common areas. First aid kit was observed complete at the time of the visit. No hazards/obstructions observed inside or out. Report Continued on LIC 809C... Report Continued from LIC 809... Restrooms: There are five (6) restrooms for resident use. Bathrooms were clean and fixtures were in operating condition. Showers had non-skid surfaces and grab bars. The bathrooms were sufficiently stocked with all necessary supplies. Starting at 10:43 a.m., the hot water temperature was measured in resident bathrooms, and they measured between 105 – 120 degrees Fahrenheit which is within the required range. The LPA observed night lights present in the bathrooms. Bedrooms: There are six (6) bedrooms for resident use. Bedrooms are designated single occupancy. Bedrooms were observed to be furnished appropriately and had sufficient lighting. Additional clean linens and towels were observed in a closet by the hallway. The LPA observed a staff bedroom on premises, locked and inaccessible to residents at the time of the visit. Kitchen: The LPA inspected the kitchen/food service. Knives and sharps were observed in a locked drawer at the time of the visit. Cleaning supplies were observed locked and inaccessible under the kitchen sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The LPA observed an adequate amount of emergency food and water. Garage: The garage is attached to the house and was locked at the time of the visit. There is a second refrigerator with additional food in good condition. The LPA observed an adequate amount of Personal Protection Equipment (PPE). Laundry Room: Washer and dryer were observed inside the laundry room. Detergents and cleaning supplies were observed locked and inaccessible to residents in care at the time of the visit. Backyard: The backyard has a shaded area with adequate furniture for resident use. Emergency passageway was observed to be clear of any obstructions. There are two (2) side gates with latching mechanisms for emergency purposes. No bodies of water noted at the time of the visit. Report Continued on LIC 809C... Report Continued from LIC 809C... Records: Record review began at approximately 011:05 a.m. Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, consent for treatment form, preplacement appraisals, appraisals, and current needs and services plan. All files were in order. Four (4) personnel files were reviewed for, but not limited to: personnel record, health assessment with negative TB test results, criminal record clearance, first aid/CPR training, and the appropriate yearly training. All personnel files were complete. Medications: The LPA conducted a medication review at approximately 01:00 p.m. Medications are centrally stored and kept in a locked cabinet by the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appear to be administered as prescribed at the time of the visit. During the visit, the facility was advised that pre-pouring residents' medications is not permitted and must be discontinued moving forward. Infection Control Plan / Emergency Disaster Plan: During today’s visit, the LPA reviewed the facility's infection control plan and emergency disaster plan, which were observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; last disaster drill conducted on 07/02/2026. No citations issued at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 31, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 11:24AM. LPA met with Head Caregiver (HC) Dexter Olavario. Administrator Belinda Dolinsky could not be on site at the time of the visit, but Dexter Olavario was designated to sign in their place. Entrance interview conducted. Beginning at 11:26AM, the LPA, along with the HC toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguishers were fully charged and last serviced 07/24/2025. Hardwired smoke detectors and carbon monoxide detector in kitchen were tested at 11:45AM and all were functional at the time of the visit. LPA observed exit alarms by all doors which were functional and operating. KITCHEN/GARAGE: LPA inspected the kitchen at 11:26AM. Knives and sharps were stored in a locked drawer. Kitchen appliances were in operable condition. The facility had a sufficient supply of perishable and non-perishable food. LPA observed emergency food and water supply in the pantry next to the kitchen. Food was stored at appropriate temperatures. The locked garage is accessed through the kitchen. LPA observed an additional refrigerator/freezer and cleaning supplies in the garage. BEDROOMS: The facility consists of eight (8) total bedrooms, of which six (6) are designated for single-resident use and two (2) are designated for staff use. All resident rooms have exits to the exterior. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Report Continued on LIC 809-C BATHROOMS: There are six (6) total bathrooms, of which five (5) are attached to resident rooms and 1 (one) is for common use. LPA observed bathrooms to be clean, sanitary and in operating condition with grab bars and slip-resistant surfaces. Hot water temperatures were measured in three (3) bathrooms and were between 105.6 F-119.8 degrees F, which is within the required range. COMMON AREAS/LAUNDRY: This includes the living room, exercise room, and dining room. LPA observed common areas to be clean and properly furnished at the time of the visit. LPA observed a fireplace in the living room that was adequately screened. Facility was maintained at a comfortable temperature. LPA observed surveillance cameras in the common areas. LPA observed storage space closets in hallway containing clean linens for resident use. LPA observed the laundry room adjacent to the staff room. Laundry room had a washer and dryer and locked cleaning supplies. OUTDOOR SPACE: The backyard had a covered patio area with furniture including a table and chairs. There were no bodies of water on the premises. One (1) side pathway is used as an emergency exit which was free of obstruction and had a self-closing and self-latching gate. RECORD REVIEW: LPA began record review at 11:52AM. LPA reviewed six (6) out of six (6) resident files and four (4) staff files for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. LPA observed half rails in five (5) resident rooms and full rails in one (1) resident room. Five (5) resident files were missing the half bed rail orders, and one (1) resident file was missing full rail orders and the resident was not receiving hospice services. Staff files were complete and had no missing documents. MEDICATION REVIEW: Medications are centrally stored and locked in a cabinet in the kitchen. LPA began medication review at 01:05PM and medications for two (2) residents were observed. All medications were labeled and maintained in compliance with label instructions, and state and federal law. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drill was conducted during the visit. Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiency may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 12, 2025

The state marks this report as 8 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 9:45AM. LPA met with Head Caregiver (HC) Dexter Olavario. Administrator Belinda Dolinsky could not be on site at the time of the visit, but Dexter Olavario was designated to sign in their place. Entrance interview conducted. Beginning at 9:52AM, the LPA, along with the HC toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguishers are fully charged and were last serviced 06/06/2024. Hardwired smoke detectors and carbon monoxide detector in kitchen were tested at 11:17AM and all were functional at the time of the visit. LPA observed exit alarms by all doors which were functional and operating. COMMON AREAS: This includes the living room, physical therapy room, and dining room. LPA observed common areas to be clean and properly furnished at the time of the visit. At 09:53AM, LPA observed a fireplace in the living room not appropriately screened. Facility is maintained at a comfortable temperature. LPA observed surveillance cameras in the common areas. LPA observed storage space closets in hallway containing clean linens for resident use. BEDROOMS: The facility consists of eight (8) total bedrooms, of which six (6) are designated for single-resident use and two (2) are designated for staff use. All resident rooms have exits to the exterior. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Staff bedrooms were observed and were occupied by staff. Report Continued on LIC 809-C BATHROOMS: There are six (6) total bathrooms, of which five (5) are attached to resident rooms and 1 (one) is for common use. Restrooms were observed to contain nonskid mats and grab bars by the showers and toilets. Water temperatures in resident bathrooms were measured between 138.0 and 142.1 degrees Fahrenheit between 09:58AM-11:22AM, which is outside of the required range. LAUNDRY ROOM: LPA observed the laundry room adjacent to the staff rooms. Laundry room has a washer and dryer and locked cleaning supplies. KITCHEN/GARAGE: LPA inspected the kitchen at 10:05AM. Knives and sharps are stored in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed emergency food and water supply in the pantry next to the kitchen. Food was stored at appropriate temperatures. The locked garage is accessed through the kitchen. LPA observed an additional refrigerator/freezer and cleaning supplies in the garage. OUTDOOR SPACE: The backyard has a covered patio area with furniture including a table and chairs. There were no bodies of water on the premises. One (1) side pathway is used as an emergency exit which was free of obstruction and had a self-closing and self-latching gate. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 05/27/2024. RECORD REVIEW: LPA began record review at 10:20AM. LPA reviewed 5 (five) out of 5 (five) resident files and 4 (four) staff files for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Three (3) out of five (5) resident files were missing documents. Staff files were complete and had no missing documents. Report Continued on LIC 809-C MEDICATION REVIEW: Medications are centrally stored and locked in a cabinet in the kitchen. LPA began medication review at 11:24AM and medications for 2 (two) residents were observed. All medications were labeled and maintained in compliance with label instructions, and state and federal law INTERVIEWS: During today's visit, LPAs interviewed two (2) staff and one (1) family member of resident. Residents did not want to be interviewed. During today's visit, LPA obtained a copy of the facility's liability insurance. Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties. Exit interview conducted, report issued, and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 22, 2024

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff did not allow resident to have a personal caregiver Resident has unexplained bruising due to being mishandle by staff

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility to conduct an initial 10-day complaint visit. Upon arrival, LPA was greeted by House Lead Dexter Olavario who contacted Administrator Belinda Dolinsky via phone. Administrator was unable to be present at this time; however, authorized lead staff Olavario to continue with investigation and to sign report at the end of the visit. At 10:30 a.m., LPA Conway conducted a physical plant tour, reviewed facility documents included but not limited to personnel schedule, residents’ roster and hospice files. Also, at 11:06 a.m., LPA conducted interviews with staff, residents, and family members. Continued on LIC 9099 C Unsubstantiated Continued from LIC 9099 It was reported that Resident #1 (R1) has unexplained bruising due to staff mishandling R1. Interviews conducted with R1’s family reflected that they visit the facility often and staff are friendly, dedicated and provide the residents with the care and assistance they require. R1’s family further stated that they have never observed R1 mistreated or handled in a rough manner by facility staff. Interviews and records reviewed further reflected that R1 tends to bruise easily due to R1’s health issues and underlying conditions. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Resident has unexplained bruising due to being mishandle by staff” is deemed UNSUBSTANTIATED at this time. It was further alleged that the facility staff did not allow resident to have a visitor, as R1’s private companion was not allowed to visit R1. Interviews conducted during the course of the investigation reflected that R1’s family and friends often visit the facility and that no visitors were ever denied visitation. Families are allowed to stay later, and some visitors are also able to make arrangements to come after visiting hours, if necessary. Staff denied every refusing anyone entry to visit a resident. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the above allegation “Staff did not allow resident to have a personal caregiver” is deemed UNSUBSTANTIATED at this time Exit interview, appeals rights provided. A copy report given to lead staff.the state’s words, verbatim · CDSS document, Apr 2, 2024 · control 29-AS-20240325154909