Peaceful Kingdom Home Care I

Type of visit: Case Management - Other

At 9:00 a.m., Licensing Program Analyst (LPA) conducted a Case Management visit to confirm the closure of the facility. LPA met with the Licensee and explained the purpose of the visit. During the visit, LPA toured the facility and confirmed that there were no residents residing in the home and that operations had ceased. The Licensee stated that the closure was licensee-initiated due to no longer being interested in maintaining the license. The Licensee reported that prior to the closure, the facility had not had any residents since December 2025 due to plumbing issue at the property. LPA observed a “For Sale” sign posted in front of the facility. The property is currently listed for sale on the market. The Licensee voluntarily surrendered the facility license to LPA during the visit. LPA informed the Licensee that she may not admit or retain any residents who require care and supervision, as the license is no longer active. LPA will submit the file for closure upon returning to the Woodland Hills South Regional Office. An exit interview was conducted, and a copy of this report was reviewed, signed, and provided to the Licensee.the state’s words, verbatim · CDSS document, Mar 4, 2026

Type of visit: Case Management - Other

Licensing Program Analyst, [LPA] Huma Rahimi arrived on 12/30/2025 for an unannounced inspection to follow up on a substantiated allegation of a complaint investigation. Upon arrival LPA observed that the facility is locked and not occupied with any residents. LPA contacted the Licensee Starr Carver via telephone and explained the reason for the visit, which is to deliver enhanced civil penalties (ECP). The Licensee arrived at 2:20 PM to the facility to grant access to the facility. On November 22, 2024, the Department concluded a complaint investigation regarding the following allegation staff neglect led to resident sustaining pressure injuries. The allegation was substantiated, and the licensee was cited for violating California Code of Regulations, (CCR) Title 22, Section 87465(a)(1) Incidental Medical and Dental Care, CCR Title 22, Section 87411(a) Personnel Requirements General, CCR Title 22, Section 87615(a)(1) Prohibited Health Conditions, CCR Title 22, Section 87463(a) Reappraisals, and CCR Title 22, Section 87405(d)(1,2) Administrator Qualifications. At the time of the complaint visit on November 22, 2024, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section 15610.67 defines serious bodily injury as “an injury Continue on LIC 809C involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the facility not providing proper care and supervision that led to stage 3, stage 4, and unstageable pressure wound injuries that resulted in maggot infestation, hospitalization, and debridement. Today, 12/30/2025, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49(f) for a violation that the Department constitutes as serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on November 22, 2024, the amount of the civil penalty issued today will be $9500. Exit interview conducted. A copy of the report issued. Appeal rights provided. The licensee and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Dec 30, 2025

Type of visit: Required - 1 Year

At 9:45 AM, Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with the staff Jaizel Mabuti who granted access to the facility. The staff contacted the Licensee Starr Carver via telephone and LPA explained the purpose of the visit. The Licensee arrived shortly after. LPA and the Licensee conducted a physical plant tour and observed the following: The facility is licensed to serve 6 residents over the age of 60 years old. Facility currently is serving (2) residents on hospice with an exception from the Regional Office. Facility is located in a residential area and consist of a single home with 6 bedrooms and 3 bathrooms, a dining room, a living, room, an office, a kitchen, a front yard, and back yard. Front Yard: Was clean and well maintained. No hazards were observed. Kitchen: LPA observed the kitchen to be clean with sufficient food for at least two (2) days of perishable and seven (7) days of non-perishable. In the refrigerator LPA observed molded bread, carrots with white growth on their skin, and moldy cabbage. LPA observed that the sharps are locked and inaccessible under the sink cabinet. LPA observed that the medication are locked in one of the kitchen cabinets and inaccessible to residents in care. A full fire extinguisher was observed hanging on the kitchen wall and last serviced on 12/5/2024. Laundry: LPA observed laundry next to the kitchen and the washer and dryer in working condition. All laundry detergents and other cleaning supplies in the laundry room were locked and inaccessible to residents in care. LPA observed a cabinet with medications of residents and was unlocked and accessible to residents in care. Continue on LIC 809C Bedrooms: LPA observed five (5) Resident rooms were observed with sufficient lighting, the required furniture and bedding supplies. Room # (6) is observed to be shared. Room #(2) and room # (5) are vacant currently. Room #4 is currently being used as a staff room and LPA observed to be locked and inaccessible to residents in care. Bathrooms: Three (3) Bathrooms were observed clean and in good repair. LPA observed a skid mat/strips in all three (3) bathrooms. Water temperature was tested and measured to be 118.0 degrees F. Dining Room/Living room: Dining room was observed to be clean and contained one table with seating for six (6) residents. Living room was observed to be clean and free of hazards and has TV and furniture in good repair. The living room and dinning room has sufficient lighting. Nearby thermostat by the living room was observed to read 68-degree F. Outside areas: LPA toured the outside area of the facility. LPA observed patio furniture in good repair. All walkways were clean and free from obstruction. All emergency exits were locked with latches from inside and could be easily opened. LPA observed cleaning spray outside by the laundry door accessible and unlocked to residents in care. Smoke detectors/carbon monoxide/sound signals: Facility has a sound devices in each exit door which are in working condition. Smoke/Carbon monoxide detectors were tested and are in working condition. Between 11:20 AM to 1:20 PM, LPA reviewed records of four (4) residents and three (3) staff. Residents and staff records appeared to be complete and updated. Administrative: LPA collected Certificate of Liability Insurance, and LIC500. Deficiencies were issued during today’s visit. Appeal rights explained. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Apr 15, 2025

Allegation investigated: Staff neglect led to resident sustaining pressure injuries

At 9:45 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent visit to this facility to deliver the final report. LPA met with Administrator and explained the reason for the visit. On 05/21/2024, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegation, “Staff neglect led to resident sustaining pressure injuries.” The complaint was referred to Community Care Licensing Division’s Investigations Branch. The complaint was assigned to investigators Jasmin Mendez-Chavez and Philippe Ryan Miles. On 05/22/2024 LPA Rahimi conducted an initial 24-hour complaint visit. At 09:45 AM, LPA conducted tour of the facility. At 09:55 AM, LPA obtained copies of pertinent documentation which included but not limited to Physician’s report, Admission Agreement, Appraisal Needs and Services Plan. Investigator Mendez-Chaves conducted interviews with witnesses on 06/20/2024 and 06-25-2024, and facility staff on 07/10/2024 and 09-04-2024. Hospital Medical records were subpoenaed for multiple facilities 06/05/2024, 06/20/2024 and 07/01/2024. Continue on LIC 9099C Substantiated The investigation findings revealed that R1 had been living at this facility since April 07, 2024. Upon R1’s admission to the facility, R1 was noted to have stage 2 pressure injuries near the buttocks in which both staff and the administrator acknowledge. Because of this condition, R1’s responsible party admitted R1 to A1 Palliative and Hospice on 04/09/2024. Approximately mid-April 2024, the LVN from A1 Hospice agency ordered wound specialist for R1 who visited R1 only once at the facility. Although interview with a witness revealed that A1 Palliative and Hospice Care were responsible for providing wound care to R1; and due to staff shortage the agency was unable to provide sufficient wound care to R1, it was facility’s responsibility to contact the resident primary care doctor for alternative medical attention. On 05/12/2024, due to a medical emergency, R1 was admitted to Northridge Hospital where it was discovered that R1 had developed stage 3 through unstageable pressure wounds. Prior to re-admitting R1 back to the facility on 05/15/2024, facility staff failed to do a reassessment for R1. Therefore, the Administrator failed to get R1 on proper medical attention or assist with obtaining a wound specialist to address these issues. Subsequently on 05/19/2024, R1 was re-admitted to the hospital and review of hospital records revealed that R1 beside having stage 3/unstageable pressure wound injuries she/he developed maggots in their wounds. Based on the interviews conducted and supporting documents provided regarding R1’s pressure injuries, the facility retained R1 knowing his/her pressure injuries were worsening and failed to seek medical attention in a timely manner. There is sufficient evidence to support the allegation of Neglect/Lack of Care and Supervision; there for the finding(s) are substantiated. Continue on LIC 9099C The licensee was informed that a civil penalty maybe be assessed based on Health and Safety Code 1569.49(f). Deficiencies and Civil penalties were issued per CA code of Regulations Title 22 or Health and Safety Code. See 9099D's included with this report. Appeal rights issued. Exit interview conducted.the state’s words, verbatim · CDSS document, Nov 22, 2024 · control 31-AS-20240521090631

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Nov 25, 2024

Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall ... (1) The licensee shall... for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interview and record reviews, licensee did not comply with the section cited above by providing care to R1 without hiring a Wound Specialist and or a medical professional from 04/07/2024 to 05/19/24, which poses/posed an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Nov 22, 2024

Plan of correction: The Administrator has agreed to the following: All staff take state approved training on the regulation Incidental Medical and Dental Services and recognizing the signs of developing pressure injuries. Submit training schedule with the vendors name, date of schedule. This is a zero tolerance and an immediate civil penalty of $500.00 will be assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 25, 2024

87411 (a) Personnel Requirements – General (a) Facility personnel shall at all times be ... competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: The communication form shall become an addendum to the plan of operation. Based on staff interviews and review of medical records facility staff lack the knowledge to recognize signs of illness which require medical attention. This is an immediate health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Nov 22, 2024

Plan of correction: The Administrator has agreed to the following: All staff take state approved training on the regulation Personnel Requirement. Submit training schedule with the vendors name, date of schedule. Submit a complete the body check forms for each resident for the next two week. Submit a blank form and cover sheet to indicate addendum. Upon completion submit the training material and staff sign in sheet. Submit a communication form in which staff do daily body checks. As of completion of the training

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Nov 25, 2024

87615(a)(1) Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not....shall not be admitted or retained in a residential ...for the elderly: (1) Stage 3 pressure injuries. This requirement is not met as evidenced by: Based on staff interviews and review of medical records the licensee retained resident with Stage III pressure injuries. This is an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 22, 2024

Plan of correction: The Administrator has agreed to the following: All staff take state approved training on the regulation Prohibited Health Conditions. Submit training schedule with the vendors name. date of schedule. Upon completion submit the training material and staff sign in sheet.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Dec 2, 2024

Reappraisals: (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary....... the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical... This requirement is not met as evidenced by: Based on interview and record reviews, licensee did not comply with the section cited above. Administrator confirmed that upon R1's discharge from the hospital on 05/12/24 and 05/15/24, R1's reappraisals were not updated, which poses/posed a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Nov 22, 2024

Plan of correction: Administrator agreed to submit a statement of understanding on how all residents will have a proper reappraisal when changes occur and coming out of the hospital to ensure their needs are met. Proof of statement shall be submitted to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(1,2) · Plan of correction due date: Dec 2, 2024

Administrator Qualifications - 87405 (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator... (1) Knowledge of the requirements... This requirement is not met as evidenced by: Based on interviews, the licensee failed to ensure that the administrator had knowledge of licensing rules and regulations which poses a health and potential safety risk to the residents in care.the state’s words, verbatim · CDSS document, Nov 22, 2024

Plan of correction: Licensee agrees to follow proper guidelines for Administrator Qualifications. LPA discussed with the Administrators’ section 87405. Licensee agrees to submit a written letter to CCL indicating that they have read the regulations, have full understanding.

Type of visit: POC

At 9:00 AM, Licensing Program Manager, (LPM) Nichelle Gilyard, and Licensing Program Analyst, (LPA) Huma Rahimi, conducted an unannounced Plan of Correction (POC) visit. LPM and LPA met with the staff Jaizel Mabuti. The Administrator Jose Hernandez was contacted via telephone and explained the reason for the visit. Facility designee Maria Victoria Paredes appeared to assist with the visit and to accept the report. The purpose of the plan of correction visit to make sure deficiencies from annual visit dated May 11, 2024, and Case management visit May 22, 2024, were corrected. Entrance interview conducted. Case management visit- May 22, 2024: 1. Plan of correction met. Incident report for May 11, 2024, was emailed to LPA by the due date, however Incident report for May 19, 2024, in regard to a hospitalization was not submitted to CCL. It is now more than 7 days a new citation and civil penalty will be issued. Annual visit- May 11, 2024- The following is not cleared: 1. 87303 ( e)(5)-LPA toured facility hall bathroom, next to room #3. No non-skid mat observed in the shower. This is posses a potential slip and fall hazard to the resident in care. Plan of correction not met. 2. 1569.625(b)(2)- LPA reviewed staff records. No training presented. Plan of correct not met. 3. 1569.625(b)(1)- LPA reviewed staff records. No training presented. Plan of correction not met. 4. 87458(a)- LPA reviewed resident records. No updated Physicians report for R2/R3. Plan of correction not met. 5. 87506(b)- LPA reviewed resident records. While the Admissions agreement was complete for R2, the appraisal for R3 was not completed. Plan of correction not met. Continue on LIC 809C 6. 87458(b)(1)- LPA reviewed resident records. No TB clearance for R1/R2. Plan of correction not met. 7. 1569.695(c)- LPA reviewed and requested documentation for updated emergency disaster drill. No documentation presented. Plan of correction not met. 8. 87608(a)(5)(A)- LPA did not observe any documentation for full bed rails from the doctor for R1. Plan of correction not met. 9. 87355(e)(3)- LPA did not observe that S3 is associated to the facility. Plan of correction not met because the plan of correction was not cleared within 10 working days by the department it shall be recited. Observations: 1. While waiting for facility designee LPA Rahimi checked staff for criminal records, staff # 3 is not associated with the facility. LPA observed transfer request form in file. However, staff was not associated. Citation issued. 2. During physical plant tour the Long-Term Care Ombudsman and Community Care Licensing Complaint posters were posted at the main entrance behind the propped open front door. Staff moved the posters during the visit. 3. LPA/LPM observed there to be insufficient supply of 7-day non-perishable foods. Licensee shall go to the store and purchase a sufficient supply of 7-day non-perishable food. Submit a receipt to LPA by 06/03/2024. 4. LPA/LPM observed the stove top and tea kettle to have a build up of grease which needs to be clean. Staff is working to clean up the stove during the visit. 5. LPA/LPM observed what appeared to be a build up of rusted mold by the sink area in the kitchen. The licensee shall remove and clean the rusted mold behind the kitchen sink. The Licensee shall submit a photo to LPA by 06/03/2024. 6. LPA/LPM observed staining on bedding in room #2. Also designated Exit door in the room was stuck and hard to open. This needs to be addressed this is a health and safety issue. The bedding was replaced during visit. The licensee shall submit proof that the door was repaired and no longer sticks due by 06/03/2024. 7. LPA conducted a file review for the Administrator. The following is missing: First Aid/CPR. The Administrator shall submit a training certificate of First Aid/CPR to LPA by 06/03/2024. 8. May 19th incident involving R2’s hospitalization was not submitted w/7days of the incident to CCL. Citation issued/civil penalty issued. Due by 05/31/2024. 9. LPA/LPM did not observe completed Hospice and Home Health files, no plan of care or notes maintained. Due by 06/03/2024. Continue on LIC 809C 10. Fees were due April 25, 2024. Amount of $742 is due immediately. LPA left information of the amount and the pin number with the designee. Due 05/31/2024. 11. Documentation on Jose Hernandez, the Administrator was not received. The licensee is to immediately submit LIC 500, LIC 501, LIC 503, LIC 508, Finger Print Clearance, 1st Aid/CPR, Copy of the Administrator certificate, and LIC 308 designation of facility responsibility naming Jose Hernandez as the Administrator, and Board resolution naming Jose Hernandez as the Administrator of the facility. Due by 06/03/2024. 12. Based on the plan of correction visit, the administrator failed to submit corrections to the department by the required due date, and it appears that the Administrator lacks the knowledge of licensing rules and regulations. Citation issued. Plans of corrections letters were issued for deficiencies cleared today. LPA explained report and civil penalties to the Administrator over the phone. LPA left a copy of the report. Additional citations and civil penalties were issued during this visit. Appeal rights given and exit interview conducted.the state’s words, verbatim · CDSS document, May 31, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Jun 3, 2024

Criminal Record Clearance-(e) All individuals subject to a criminal record review.... (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 3 staff is not associate to the facility, S3 was not associated to the facility and has been working at the facility since 5/10/24 which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 31, 2024

Plan of correction: Administrator will associate S3 to the facility by POC due date 06/03/24 and submit a copy of guardian's roster to the department by POC due date 06/03/24. Or submit LIC 9182 transfer request form and a clear copy S3 Identification to CCL for association.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)A,B&D · Plan of correction due date: May 31, 2024

Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding R1's hospitalization on 05/19/24, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 31, 2024

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R1's incident report shall be submitted to LPA by POC date. Second citation within 12 months. Civil Penalty issued.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(1,2) · Plan of correction due date: Jun 3, 2024

Administrator Qualifications - 87405 (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator... (1) Knowledge of the requirements... This requirement is not met as evidenced by: Based on the plan of correction visit, the administrator failed to submit corrections to the department by the required due date, and it appears that the Administrator lacks the knowledge of licensing rules and regulations which poses an immediate health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, May 31, 2024

Plan of correction: Administrator agrees to review and complete all deficiencies and other concerns indicated in this report and the annual visit from 05/11/2024. The Administrator shall submit all corrections to the department.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Huma Rahimi conducted unannounced visit to this facility in conjunction with a complaint control # 31-AS-20240521090631. LPA met with Staff #1 (S1) who granted access to facility. The Administrator was contacted and shortly after, the Administrator arrived and LPA explained the reason for the visit. During the visit, LPA was informed that R1 had GI bleed due to ischemic colitis on 05/11/2024. 9-1-1 was called and R1 was taken to the hospital. However, no incident report was submitted to the Community Care Licensing Department (CCLD) in a timely manner. LPA reviewed all incident reports on a system and did not observe an Incident Report regarding R1. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting. LPA informed the Administrator to submit two incident reports that occurred on: 05/11/24 (incident # 1) 05/19/24 (incident # 2)the state’s words, verbatim · CDSS document, May 22, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)A,B&D · Plan of correction due date: May 23, 2024

Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on record reviews, conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding R1's hospitalization on 05/11/24, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 22, 2024

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. R1's incident report shall be submitted to LPA by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual visit at the facility using the CARE inspection tool. LPA met with Gliceria Mabuti and explained the reason for the visit. The facility is licensed to serve 6 residents over the age of 60 years old, of which 6 may be bedridden, with a hospice waiver for 3. Facility currently is serving (3) residents on hospice. Facility is located in a residential area and consist of a single home with 6 bedrooms and 3 bathrooms, a dining room, a living, room, a family room, a kitchen, a front yard, and back yard. LPA Flores conducted a tour with Jaizel Mabuti - Caregiver and observed the following: Facility is in good repair inside and outside. Kitchen was observed clean and sufficient food for at least 2 days of perishables and 7 days of non-perishables were observed. Medication and sharps were observed locked in kitchen cabinets. Laundry area is clean and cleaning supplies were observed locked. Five (5) Resident rooms were observed with sufficient lighting, the required furniture and bedding supplies. Half bed rails were observed on room #5 and #6 and full bed rails were observed on room #3 in resident's beds. Room #4 was not observed as it is currently being used as a staff room. Three (3) Bathrooms were observed clean and in good repair. Bathroom #3 in room #6 was observed without a skid mat/strips. Water temperature was tested in each bathroom and tested between 115.5 - 117.8 degrees F., which is within the required 105-120 degrees F. Facility has a sound devices in each exit door which are in working condition. Smoke/Carbon monoxide detectors were tested and are in working condition, detector in room #3 had a faint noise. Fire extinguisher was observed by the kitchen and was last checked on 12/9/23. Backyard and front yard are clean and have a seating area. PUB 475 or Local Ombudsman posters were posted behind the entry door at the facility. LPA reviewed medication for 2 residents, and files for 3 residents. (CONTINUED ON LIC 809C) Resident #1(R1) is missing TB test clearance, Resident #2(R2) is missing an admission agreement, physician's report, TB clearance, and Resident #3 (R3) has a diagnosis of dementia and physician report was last done on 2/22/22 and appraisal was last reviewed on 1/10/23. Hospice plan was not observed on file for (3) residents. Administrator's file was not available for review. Per staff current administrator is Jose Hernandez, LPA observed administrator's certificate posted at the facility for Jose Hernandez #6064133740 exp. date: 11/4/24. Per staff he has been the administrator for the last 2 years and Victoria Paredes is no longer working with the facility. Administrator will contact Regional Office to notify of change of administrator and submit all required documentation for change of administrator by 5/17/24. Three (3) staff files were reviewed, Staff #3(S3) was not associated to the facility at the time of visit day, date of employment is 5/10/24, and file is missing health screening, and TB clearance. Per staff, staff #4 (S4) relieves staff on days off and first aid/CPR training was not observed on file. Initial 40 hours of training were not observed for any of the staff, and there were 8 hours of training provided within the last 12 months to Staff #2(S2) and S4. LPA reviewed Infection Control plan and requested a copy be submitted to the regional office by 5/13/24. Emergency Disaster Plan was reviewed 12/5/22. Last fire/emergency drill was conducted on 4/6/23. A copy of Liability Insurance was not able to be provided at the time of the visit, LPA requested a copy be submitted to the Regional Office by 5/13/24. LPA interviewed 2 staff and 2 residents. Deficiencies were noted during this visit per Title 22 Regulations. Exit interview was conducted with Jaziel Mabuti and a copy of this report, LIC 809D, Technical Violations, and appeal rights were provided.the state’s words, verbatim · CDSS document, May 11, 2024

The state marks this report as 15 pages; the online copy we transcribed has 11. You can request the full file from the county licensing office.