A Timia Oasis

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced One (1) year Required visit at this facility today. LPA met with Administrator Patria Dufrenne and explained the purpose of this visit. A tour of the physical plant was conducted at 12:12 PM and the following was observed: The facility is within a compound and has only one main gate entrance. There is only one main door of the facility being used. The screening station is located immediately upon entrance. The facility has an approved mitigation and infection plan on file. The facility is a single storey building with three (3) other Residential Care Facility for the Elderly (RCFE) facilities inside the compound. There are five (5) resident bedrooms, four (4) private, one (1) with own bathroom and one (1) shared room. There are three (3) total bathrooms. Resident bedrooms were observed to be appropriately furnished. The facility is fire cleared for six (6) non-ambulatory residents, all of which maybe bedridden. Hospice waiver for six (6) residents. Living and dining room furniture were checked. The living room is neat and clean along with the dining room. Furniture were observed to be in good repair and excellent condition. The facility maintains a comfortable temperature at 74°F. The dual smoke/carbon monoxide alarm are hardwired and interconnected, tested and observed to be operational. There is a Fire extinguisher located in the kitchen last bought on 03/27/25. The facility is equipped with sprinkler system. (continued on LIC 809-C) (continued from LIC 809) Food Service/Kitchen area located in another facility (A Siwa Oasis, for the 4 facilities) was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in the kitchen drawer and inaccessible to residents. Laundry area is located along the bedroom hallway. Laundry detergent, cleaning solutions and other toxins are observed to be locked in the storage area by the gate. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. The Bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was checked and measured at a range of 114.3°F to 115.9°F Towels and washcloths are not shared. There were enough clean linen available in stock at the cabinet. Medications: LPA observed that the medication is kept in the other building (A Siwa Oasis) and was observed to be locked and inaccessible to residents. There was a complete first aid kit located in the office within the facility. Garage: There is no garage at the facility only car ports at the front area. The Backyard had a covered shaded area for clients with outdoor furniture. Sauna, and mini golf course. The swimming pool is appropriately fenced and was observed to be locked during visit. Client records. All four (4) residents record were reviewed and observed to be complete and current. Staff records were also reviewed and observed to be complete and current. Disaster drill was last conducted on 01/13/26. Required posting observed in facility (complaint hot line poster, personal rights, etc). Exit interview conducted. Copy of this report issuedthe state’s words, verbatim · CDSS document, Feb 26, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced One (1) year Required visit at this facility today. LPA met with Assistant Administrator Glacie San Juan and explained the purpose of this visit. A tour of the physical plant was conducted at 11:55 AM and the following was observed: The facility is within a compound and has only one main gate entrance. There is only one main door of the facility being used. The screening station is located immediately upon entrance. The facility has an approved mitigation and infection plan on file. The facility is a single storey building with three (3) other Residential Care Facility for the Elderly (RCFE) facilities inside the compound. There are five (5) resident bedrooms, four (4) private, one (1) with with own bathroom and one (1) shared room. There are three (3) total bathrooms. Resident bedrooms were observed to be appropriately furnished. The facility is fire cleared for six (6) non-ambulatory residents, all of which maybe bedridden. Hospice waiver for six (6) residents. Living and dining room furniture were checked. The living room is neat and clean along with the dining room. Furniture were observed to be in good repair and excellent condition. The facility maintains a comfortable temperature at 74°F. The dual smoke/carbon monoxide alarm are hardwired and interconnected, tested and observed to be operational. There is a Fire extinguisher located in the kitchen last bought on 03/27/25. The facility is equipped with sprinkler system. (continued on LIC 809-C) (continued from LIC 809) Food Service/Kitchen area located in another facility (A Siwa Oasis, for the 4 facilities) was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in the kitchen drawer and inaccessible to residents. Laundry area is located along the bedroom hallway. Laundry detergent, cleaning solutions and other toxins are observed to be locked in the storage area by the gate. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. The Bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was checked and measured at a range of 113.4°F to 116.3°F Towels and washcloths are not shared. There were enough clean linen available in stock at the cabinet. Medications: LPA observed that the medication is kept in the other building (A Siwa Oasis) and was observed to be locked and inaccessible to residents. There was a complete first aid kit located in the office within the facility. Garage: There is no garage at the facility only car ports at the front area. The Backyard had a covered shaded area for clients with outdoor furniture. Sauna, and mini golf course. The swimming pool is appropriately fenced and was observed to be locked during visit. Client records. All five (5) residents record were reviewed and observed to be complete and current. Staff records were also reviewed and observed to be complete and current. Disaster drill was last conducted on 04/11/25. Required posting observed in facility (complaint hot line poster, personal rights, etc). Exit interview conducted. Copy of this report issuedthe state’s words, verbatim · CDSS document, Apr 15, 2025

Allegation investigated: Insufficient staffing to meet the needs of residents in care Staff do not treat residents with dignity or respect Staff are not adequately trained to meet the needs of residents in care

Licensing Program Analyst (LPA) Tan conducted an unannounced complaint visit at this facility to investigate the above allegations. LPA met with Patria Dufrenne and explained the reason for the visit. LPA conducted physical plant tour at 10:00 AM, requested copies of facility documents relevant to the investigation at 10:15 AM, reviewed records between 10:30 AM to 11:30 AM and interviewed residents and staff between 11:30 to 1:00 PM. Regarding the allegation that the facility has Insufficient staffing to meet the needs of residents in care, it was alleged that the facility is under staff with one (1) staff for twenty-two (22) residents. LPA's record review today revealed that this facility has (1) staff for every shift (Morning, Afternoon and NOC) for the current census of (5) residents. LPA's interview with five (5) residents today between 11:30 AM to 1:00 PM revealed that five (5) out of five (5) residents stated that they have sufficient staff and provide all their care needs. (continued on LIC 9099-C) Unsubstantiated (continued from LIC 9099) Regarding the allegation that Staff do not treat residents with dignity or respect, it was alleged that "patient" is not well treated. LPA's interview with five (5) residents today between 11:30 AM to 1:00 PM revealed that five (5) out of five (5) residents stated that all the staff are respectful and treat them with dignity and respect and provide all the care that their need. Regarding the allegation that Staff are not trained to meet the needs of residents in care, it was alleged that that the facility staff are not equipped to meet the needs of residents. LPA's record review today between 10:30 AM to 11:30 AM revealed that all the staff working at the facility have all the required training on file. LPA's interview with two (2) staff on duty today confirmed that they were all trained before working and continuously since started working. Based on the information gathered during this visit, these allegations are deemed unsubstantiated at this time. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Feb 25, 2025 · control 31-AS-20250219160039

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced case management visit at this facility in conjunction with a complaint investigation control no.: 31-AS-20241127155153. LPA met with staff Flordeliz Chico who called the Designee Patria Dufrenne and the reason for the visit was explained. Ms. Dufrenne designated Ms. Chico to sign the report. On 12/05/24 at around 9:30 AM. LPA & Licensing Program Manager (LPM) Troy Agard conducted a physical plant tour of the four (4) facilities on the property from 9:30 AM to 10:15 AM. The following health and safety violations were observed at this facility: 1) The door leading to the common area was propped open by the sofa at the living area. Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Dec 10, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: Dec 10, 2024

Personal Accommodations and Services: The following space and safety provisions shall apply to all facilities: All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based on LPA and LPM's observation, the licensee did not ensure that the door leading to common area is free of obstruction. This poses a potential health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Dec 10, 2024

Plan of correction: The staff freed the door from the furniture and during this visit, the door has no obstruction. Cleared during visit.

Allegation investigated: Staff are utilizing combination locks on the exits from the property to keep residents in

Licensing Program Analyst (LPA) Gary Tan and Licensing Program Manager (LPM) Troy Agard conducted an unannounced initial complaint visit at this facility to investigate the above allegation. LPA initially met with staff Flordeliz Chico who called the administrator Patria Dufrenne who arrived two (2) hours later. LPA and LPM conducted physical plant tour at 9:30 AM, requested copies of facility documents at 9:45 and interviewed staff and residents between 9:45 AM to 10:15 AM. It was alleged that the main gate going to and from the facility was locked. LPA and LPM observed during physical plant tour that there were two (2) main gates for the entire compound, supposedly one for ingress and one for egress, the ingress gate however is currently not being utilized leaving one gate for car and pedestrian to use. It was observed that it was locked with a combination pad lock and LPA and LPM's interview with Staff #1 (S1) revealed that they were locking the gate due to Resident #1 (R1) always getting out to buy alcohol. Based on the information gathered during this visit, the allegation is deemed substantiated at this time. Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued. Substantiatedthe state’s words, verbatim · CDSS document, Dec 5, 2024 · control 31-AS-20241127143352

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468(1)(a)(6) · Plan of correction due date: Dec 6, 2024

(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department This requirement is not met as evidenced by: Based on observation, licensee failed to ensure that the residents are not locked in the premises which poses an immediate health & safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Dec 5, 2024

Plan of correction: The designee agreed to remove tha pad lock during the day and put a motion sensor to ensure that the staff are alerted when a resident is leaving the facility at anytime.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced One (1) year Required visit at this facility. LPA met with administrator Akilesh Jha and explained the purpose of this visit. The facility is currently no clients at this time. A tour of the physical plant was conducted at 9:02 AM and the following was observed: The facility has one main entrance being used, the main door has required Covid-19 prevention signage (hand washing, coughing etiquette and physical distancing) are posted on the door. The PPE screening station is located immediately upon entrance and had a table equipped with sufficient PPE readily accessible, a thermometer, hand sanitizer, gloves, mask and sign in sheet at the time of visit. The facility has an approved mitigation plan on file. The facility is a single storey duplex type building with three other Residential Care Facility for the Elderly (RCFE) facilities inside the compound . It has five (5) bedrooms and three (3) bathrooms. One (1) bedroom is a shared room and the rest are private. The facility is fire cleared for six (6) non-ambulatory residents, one (1) of which maybe bedridden on Room #1. Hospice waiver for six (6) residents. Living and dining room furniture were checked. The living room is neat and clean along with the dining room. Furniture were observed to be in good repair and excellent condition. The facility maintains a comfortable temperature at 73°F. The dual smoke/carbon monoxide alarm are hardwired and interconnected and observed to be operational. There is a Fire extinguisher is located in the kitchen and observed to be last bought on 11/02/23. The facility is equipped with sprinkler system. (continued on LIC 809-C) (continued from LIC 809) Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in the kitchen drawer and inaccessible to residents. Laundry area is located in the staff office on a separate building beside the facility. Laundry detergent, cleaning solutions and other toxins are observed to be locked in the staff office. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. The Bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was checked and measured at a range of 112.1°F to 117.2°F Towels and washcloths are not shared. There were enough clean linen available in stock at the cabinet. Medications: LPA observed that the medication will be kept in the cabinet in the living room area and was observed to be locked and inaccessible. There was a complete first aid kit located inside the medication cabinet. Garage: There is no garage at the facility only car ports at the front area. The Backyard had a covered shaded area for clients with outdoor furniture. The swimming pool is appropriately fenced and was observed to be locked during visit. Client records. There is no resident at the facility at this time. Exit interview conducted. Copy of this report issuedthe state’s words, verbatim · CDSS document, Apr 28, 2024