Mauna Loa Oaks "LLC"

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual inspection visit. LPA was greeted by Administrator Liubov Shevtsova and the purpose for the visit was explained. The facility is licensed to serve six (6) elderly residents ages 60 and above, of which five (5) may be non-ambulatory, one (1) may be bedridden, and has a hospice waiver approved for three(3) residents. The facility is a single-story home located in a residential area of Glendora. The home consists of a living room, dining area, kitchen, four (4) resident bedrooms, two (2) bathrooms, one (1) staff bedroom, a shaded patio in the backyard and an attached garage with laundry. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environmental Safety: The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded area located in the backyard with sufficient seating for residents in care. Passageways and exits are free of obstructions. continued on LIC 809C continued from LIC 809 (page 2) The water temperature was tested in bathroom #1 in the hallway and measured 127.5 degrees F, which is above the required 105 degrees F - 120 degrees F. Bathroom #2 water temperature measured 126.1 degrees F. Administrator adjusted the water temperature at time of visit. LPA observed grab bars and non-skid mats. Resident bedrooms all have required furniture which includes, for each resident, a bed, a chair, nightstand, and lights sufficient for reading. Resident beds have the required linen and linens were observed to be in good repair. There is closet storage space for clothing and other belongings. Hallway cabinet contained PPE supplies, surplus hygiene supplies and extra, clean linens. Smoke detectors were observed throughout the facility and are operable. There is a carbon monoxide detector located in the kitchen, was tested and is operable. There are two (2) fire extinguishers located in the kitchen, and garage. Emergency drills conducted quarterly, last drill conducted 08/25/25. All kitchen areas observed clean and free of litter, rodents, vermin and insects. Kitchen appliances such as refrigerators, stove and microwave are clean and were operating at the time of the visit. Sharps are locked in a kitchen drawer and are secured, inaccessible to residents. Cleaning supplies and disinfectants are secured under the sink and are inaccessible to the residents and separate from food supply. Sufficient supply of 2 days perishable and 7 days non-perishable foods were observed. Containers storing waste are in good repair and free of leaks. Telephone service on the premises Dining area and living room are clean and free of obstructions and have sufficient seating for residents in care. Attached garage has laundry area. Washing machine and dryer wear clean and operable at the time of visit. There is a cabinet with laundry supplies. Staffing: Administrator and two (2) staff have current CPR training. Staffing sufficient in number and competent to meet resident need. LPA observed training logs for all staff. continued on LIC 809C page 3 Personnel Records- training: LPA reviewed files for three (3) staff. Personnel record maintained for each employee to contain the following: criminal record clearance, first aid/CPR, fingerprint clearance, personnel record, health screening, TB test Residents Rights: Personal Rights are posted. Planned Activities: LPA observed board games and books for resident use. Resident Records/Incident Reports: LPA reviewed three (3) resident files. Each file contained admission agreement, recent medical assessment, ambulatory status, medical consent form, identification/face sheet, appraisal needs and service plan. File for R1 did not contain TB clearance, deficiency cited. Medications are centrally stored in the secured in a locked kitchen cabinet. Medications are documented properly and given as prescribed. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided to the Administrator Liubov Shevtsova.the state’s words, verbatim · CDSS document, Dec 9, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met Administrator Liubov Shevtsova at approximately 8:15 AM and explained reason for visit. The facility is a one-story home located in a residential area. It is licensed to serve (6) elderly residents, ages 60 and over, of which (5) may be non-ambulatory, (1) may be bedridden, and has a hospice waiver approved for (3). The home consists of a living room, kitchen, dining room, (4) resident bedrooms, (2) resident bathrooms, (1) staff bedroom, a shaded patio in the backyard with seating, and an attached garage. LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. There is extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the hallway and is properly operating. The facility has one (1) fully charged fire extinguishers which is kept in the kitchen. Cleaning supplies and toxic substances were observed to be accessible to clients in cabinet next to dining room deficiency cited. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. Sharps are locked and placed in cabinet in kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The shower accommodates non-ambulatory residents and has the required grab-bars and non-skid mat. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. The garage is clean and has extra supplies. SEE LIC 809C Four (4) Staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Three (3) Client files were reviewed and included physicians report, TB clearance. Fire/earthquake drill was conducted in April 2024 TV was given. Infectious control plan was reviewed. The medications are centrally stored and locked in a cabinet in kitchen The facility uses the Medication. LPA reviewed medications for all clients, and they are being administered as prescribed by the physician. Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 18, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit at the facility for the purpose of conducting the required annual inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Administrator, Liubov Shevtsova, and explained the purpose for the visit. During today's visit, LPA Maldonado conducted a tour of the physical plant with Administrator, observed the facility food supplies, reviewed (4) resident medications, (4) resident files, (3) staff files, and conducted interviews with (2) staff, and attempted interviews with (4) residents. The facility is a single-story home, operating as a Residential Care Facility for the Elderly. It is licensed to serve (6) older adults, ages 60 and over. There is a fire clearance approved for (5) non-ambulatory residents and (1) bedridden resident. It has an approved Dementia Care Plan and a Hospice Waiver approved for (3) residents. There is currently (1) resident receiving hospice services. An approved mitigation plan is in place and Infection Control plan has been submitted to the department for review. The facility has an active and current liability insurance policy on file. LPA observed all resident bedrooms to have the required furniture, sufficient lighting, and closet/storage space. There are 1 full and one half bathrooms in the home- both equipped with required grab bars and non-skid mat for the shower. The hot water was tested and measured at 112*F, which is in compliance. Food supplies was observed and was sufficient as required. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. The last fire drill was conducted on 11/20/2023. Auditory devices were observed at all entrances/exits of the home. (4) of (4) resident files were reviewed and observed to be missing Functional Capabilities Assessments and Needs and Services Plans. (1) of (4) resident files were observed to be missing an updated medical assessment/Physician's Report, as required annually due to their cognitive impairment. (3) staff files were reviewed and had all the required documentation. (4) resident medications were reviewed and were observed to be documented properly and given as prescribed. Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on the attached LIC9099-D page. Exit interview was conducted and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Dec 15, 2023