Humble Haven RCFE IV

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit on 10/31/2025 and was greeted by two caregivers. LPA stated the purpose of the visit was to conduct an annual inspection. The caregivers confirmed there are four residents. The facility is licensed for five (5) non-ambulatory residents and one bedridden resident. LPA reviewed the resident files at 9:15 am until 9:45 am. LPA observed three out of four residents' files were missing documentation. LPA Spaeth and the caregivers toured the facility at 10:00 am until 10:45 am Common Areas – The family room, dining room, and kitchen are combined. The family room was furnished with comfortable seating and a television. The dining room area contained a dining room table and chairs. Kitchen - LPA Spaeth observed a two-day supply of perishable food and a seven day supply of non-perishable food. The knives were locked. The cleaning solutions were locked underneath the kitchen sink. The fire extinguisher is located near the kitchen and is operable. Medications: LPA observed the resident medications, first aid kit, and PPE supplies were safely locked in a kitchen cabinet. Continued on 809-C Resident Rooms: The resident rooms were furnished with a bed, linens, night stand, lamp and chair. Bathrooms: The bathrooms contained hand soap, paper towels, grab bars, trash can, and slip resistant mats. Laundry Room & Staff Room: LPA observed the laundry room door was not locked and the laundry detergent, washer and dryer were in the room. Another door led to the garage and staff room and that door was not locked. LPA observed tools were laying on the garage floor and were not locked in a secure area. LPA reminded staff the door leading to the laundry room should be locked at all times. Water Temperature: The water temperature was tested at 10:20 am and was 112 Degrees F. Hallway Cabinet- LPA observed the clean linens were located in a cabinet. Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. Comfortable seating is also located in the backyard in a shaded area Smoke/Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested 10:45 am and were operable. LPA Spaeth reviewed the staff files at 10:45 am until 11:15 am. LPA reviewed the medications at 11:15 am until 11:30 am. Based upon Title 22 Division 6 of the CA Code of Regulations, the following deficiencies are issued (See 809-D). Exit interview conducted, appeal rights were discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, Oct 31, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit on 11/01/2024 and was greeted by the caregiver. The Administrator Nicole De Las Alas was called. LPA stated the purpose of the visit was to conduct an annual inspection. The caregiver confirmed there are five residents. The facility is licensed for five (5) non-ambulatory residents and one bedridden resident. LPA Spaeth and the caregiver toured the facility at 10:00 am until 10:30 am. Common Areas – The family room, dining room, and kitchen are combined. The family room was furnished with comfortable seating and a television. The dining room area contained a dining room table and chairs. Kitchen - LPA Spaeth observed a two-day supply of perishable food and a seven day supply of non-perishable food. The knives were locked. The cleaning solutions were locked underneath the kitchen sink. The fire extinguisher is located near the kitchen and is operable. Medications: LPA observed the resident medications, first aid kit, and PPE supplies were safely locked in a kitchen cabinet Continued on 809-C Resident Rooms: The resident rooms were furnished with a bed, linens, night stand, lamp and chair. At 10:20 am, LPA observed there are two residents in the Bedroom 5. LPA also observed an additional empty bed was located in the room and was blocking part of the doorway leading in and out of the room. At 10:35 am, LPA spoke to the Licensee, Nicole De Las Alas and stated the bed needs to be removed as soon as possible. During LPA's visit, the additional bed was removed at 11:00 am Bathrooms: The bathrooms contained hand soap, paper towels, grab bars, trash can, and slip resistant mats. Water Temperature: The water temperature was tested at 10:25 am and was 130 Degrees F. The water heater temperature was lowered. LPA tested the water temperature again at 11:09 am and the temperature was 115.0 degrees F. Hallway Cabinet- LPA observed the clean linens were located in a cabinet. Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. Comfortable seating is also located in the backyard in a shaded area Smoke/Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested at 11:30 am and were operable. LPA Spaeth reviewed the resident files at 10:45 am until 11:07 am and reviewed the staff staff files at 11:07 am until 11:20 am. LPA reviewed the medications at 11:30 am until 11:55 am. Based upon LPA's observations, the following deficiencies were issued. Exit interview conducted, appeal rights were discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, Nov 1, 2024

Allegation investigated: Staff does not provide adequate food service to residents in care.

On 05/18/24, Licensing Program Analyst (LPA) Ernand Dabuet made subsequent unannounced visit to this facility and was greeted by caregiver staff #1 Jasmin Bihasa. LPA Dabuet contacted the administrator Nicole De Las Alas who was not available for this visit. LPA explained the purpose for today’s visit is to gather information for the allegation mentioned above and deliver findings. The investigation consisted of the following: An initial 10-Day visit was conducted by (LPA) Melissa Spaeth who met with Albert Gonzalez. (LPA) requested copies of files for resident #1 (R1’s) ID and Emergency Information, Admissions Agreement (dated: 08/03/23), Physicians Report LIC 602A (dated: 07/14/23), Preplacement Appraisal Information LIC 603 (dated: 12/20/21), Register of Facility Residents LIC 9020 (dated: 09/10/23) and Facility Roster, Facility Weekly Menu, and Photos Food Supply (dated: 05/17/24). A review of residents #2-#6 (R2-R6)’s service files. Interviews conducted with residents #1-#6 (R1-R6), staff #1-#3 (S1-S3), and witness #1-#3 (W1-W3). A tour of the facility was performed. (Evaluaiton Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation: Staff does not provide adequate food service to residents in care. The details of the complaint reported the facility staff does not provide adequate food service to residents in care. The complainant reported resident#1 (R1) is not being fed lunch and healthy and sufficient food. Furthermore, the facility is also not following the meal regulations when dinner time is too early and no snacks. The Department conducted an inspection visit on 07/06/23, 05/17/24, and 05/18/24 and observed the facility is following Title 22 Section 87555 General Food Service Requirements. The Department observed food supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. The food supply included milk products, meat, vegetables, fruits, bread, cereals, juices, and desserts. A weekly menu was posted and made available for review for residents. On 05/17/24, between 11:16 am – 11:31 pm, the Department interviewed resident #1 (R1). (R1) confirmed the facility served three meals daily with snacks. (R1) stated the facility provided adequate food portions and a variety. (R1) stated (R1) preferred not having in-between meal snacks as meal portions are sufficient. (R1) claimed (R1) had to be mindful of gaining weight. (R1) reported not having issues with meals being serviced at breakfast at 8 am, lunch at noon, and dinner at 6 pm. On 05/17/24, between 11:32 am – 11:55 am, the Department interviewed (5) out of (5) residents #2 - #6 (R2-R6) who were complimentary of staff. (R2-R6) reported that they were provided with three meals and snacks and that the portion sizes were adequate. (R2-R6) reported the meals were satisfactory and were served at proper mealtimes. On 05/17/24, between 11:56 am – 12:21 pm, the Department interviewed (3) out of (3) staff #1 - #3 (S1-S3) reported that groceries are restocked every week. (Evaluation Report continues LIC 9099-C) (S1-S3) reported following the weekly menu plan and portion sizes. The services of meals as indicated on the plan with breakfast 8:00 am – 9:00 am, lunch 12:00 pm – 01:00 pm, and dinner 5:00 pm – 6:00 pm are followed. In between refreshments are provided to all residents in care according to (S1-S3). On 05/17/24, between 02:32 pm and 03:55 pm, the Department interviewed (3) out of (3) witnesses #1-#3 (W1-W3). Two (2) out of (3) three verified having no issues with the facility's food meals or services. (W1) cited being very pleased with the management and staff at this facility, and the care and services provided were excellent. As a result of the Department reviewing (R1-R6)'s Physician Report LIC 602A, it revealed that (3) out of (6) are not required to be on any dietary restrictions, while the other three are on a mechanical soft diet. Based on the gathered information, the allegation mentioned above cannot be supported. Based on the information collected, an inspection of the facility, observation and interviews conducted, and an analysis of records reviewed, the Department found no evidence to support the allegation mentioned in this complaint. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. No deficiencies were cited. An exit interview is conducted with Jasmin Bihasa and a copy of the report is provided.the state’s words, verbatim · CDSS document, May 18, 2024 · control 31-AS-20230703082026

Type of visit: Case Management - Deficiencies

On 05/18/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management inspection visit at this facility. LPA met with caregiver Jasmin Bihasa and explained the purpose of the visit is in association with a complaint investigation conducted on 05/17/24 and 05/18/24. During the investigation visit on 05/17/24, LPA Dabuet audited the staff files and identified staff #3 (S3) did not have a Criminal Clearance Background Clearance Transfer. (S3) was not associated at this facility when the facility was approved to operate with a Community Care Licensing (CCL) on 11/01/22. (S3) did not appear in (CCLD) Guardian nor Licensing Information System (LIS536). The licensee is being cited with Title 22 Criminal Clearance Record Regulations 87355(e)(2). Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8. Deficiency is issued and an exit interview is conducted with (Jasmin Bihasa) . A copy of this report, appeal rights, and civil penalty were provided. *Immediate Civil Penalty*the state’s words, verbatim · CDSS document, May 18, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: May 19, 2024

87355 Criminal Record Clearance - (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidenced by: Based on audit review of records, the licensee did not comply with the section. LPA identified staff #3 did not have a Criminal Clearance Background Clearance Transfer associated at this facility. This violation poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 18, 2024

Plan of correction: Licensee to ensure that all staff prior to working in the facility obtain a Criminal Background Clearance and Criminal Background Transfer Request and provide proof of correction to CCLD by POC due date. Proof of Correction due date: 05/19/24 to ernand.dabuet@dsss.ca.gov *A CIVIL PENALTY IS BEING ISSUED TODAY 05/18/24*

Type of visit: Case Management - Deficiencies

On 05/17/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management inspection visit at this facility. LPA met with caregivers Jasmin, Joselito, and Jennifer Bihasa and explained the purpose of the visit. During a complaint investigation visit on 05/17/24, LPA Dabuet was informed that (4) out of (6) residents are in hospice care. The residents on hospice are (R1), (R2), (R4), and (R5). The facility is approved by the Community Care Licensing Department (CCLD) for (3) hospice residents. The licensee shall not operate a facility beyond the conditions and limitations specified on the license. On 05/17/24, between 11:15 am - 11:35 am, LPA Dabuet reviewed staff files and observed that staff #2 and #3 had no current First Aid/CPR certificate for training. (S2-S3) communicated that they have not renewed their required training for First Aid/CPR. Based on interviews, observation, and record reviews the licensee violated Title 22 Regulations. California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 9099-D). An exit interview was conducted and a copy of the Evaluation Report and Appeal Rights were provided to Jasmin Bihasa. Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *the state’s words, verbatim · CDSS document, May 17, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87204(a) · Plan of correction due date: May 31, 2024

(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time... An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity. This requirement is not met as evidenced by: Based on [(observation) (interview) (record review)], the licensee did not comply with the section. The facility is approved for (3) hospice waiver and is now operating with (4) hospice residents beyond the conditions and limitations specified on the license. This violation which poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 17, 2024

Plan of correction: Licensee agreed to request for hospice waiver increase request to CCLD by correction date 05/31/24 understands that it is their responsibility to follow up on waiver requests and hospice residents should not reside at the facility until a hospice waiver is granted by CCL. Plan of correction must be submitted by 05/31/24 to ernand.dabuet@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c)(1) · Plan of correction due date: May 31, 2024

(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 is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above . LPA identified staff #2 & #3 did not have a current First Aid/CPR Training. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 17, 2024

Plan of correction: Licensee/Administrator will ensure that all staff involved with resident's daily care must have a current First Aid/CPR training. Proof of correction must be sent to by POC due date: 05/31/24 to ernand.dabuet.@dss.ca.gov

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by two caregivers (S1 and S2). LPA observed a third person and was informed it was a family member of the two caregivers. Upon entry at 9:15 am, LPA observed the delayed egress notification was not working at the front door. LPA stated the purpose of the visit was to conduct an annual inspection. The staff confirmed there are six residents. The facility is licensed for five non-ambulatory residents and one (1) bedridden resident. LPA Spaeth reviewed resident records at 10:00 am to 11:00 am. LPA Spaeth & caregiver toured the facility at 11:00 to 11:30 am. Living Room. - When entering the facility, the living room is located to the right and is a room with three walls. LPA observed a curtain was used as a door. LPA observed the room is used as a staff room and contained two twin beds. At 9:30 am, LPA observed staff member's medication was sitting out on a dresser. At 9:33 am, LPA observed the caregiver locked the medication in the resident's medication cabinet. Kitchen/Family Room - LPA Spaeth observed the kitchen and family room are combined. The facility contained a two day supply of perishable food and a seven day supply of non-perishable foods. The knives were locked in a kitchen cabinet. The cleaning solutions are securely locked underneath the kitchen sink. The fire extinguisher is located in the kitchen and is operable. Medication - LPA observed the resident medications, and first aid kit, are safely locked in a kitchen cabinet. The resident and staff files were also locked in the cabinet. Delayed Egress: LPA observed the delayed egress to all exits were turned off and not working. Continued on 809-C Garage//Washer & Dryer – The laundry room was locked and contained the washer/dryer. The laundry soap was stored in the room. The door leading to the garage was locked. at 11:40 am, LPA observed a section of the garage was converted into a room. LPA observed a bed, microwave, portable toilet, and a person's belongings. There is an exit out of the room to the front yard. The caregivers stated a person is renting the room. They also stated the individual uses the portable toilet at night but will go through the front door to use the restroom and shower during the day. The caregivers confirmed the resident does not receive care and supervision. Resident Rooms: The resident rooms were furnished with a bed, linens, night stand, lamp and chair. Based upon the Fire Safety Inspection Request document issued by the Los Angeles Fire Department which was dated 9/2022, the facility may have five non-ambulatory residents and one bedridden resident. Bedrooms 1, 2, 3, and 4 are non-ambulatory rooms. Bedroom 5 is the designated bedridden room. LPA observed two bedridden residents living in Bedroom 1 (one) and Bedroom 3 (three). Bathrooms: The bathrooms contained hand soap, paper towels, grab bars, trash can, and slip resistant mats. When observing bathroom two, LPA observed cleaning solutions were unlocked underneath the sink. LPA observed the caregiver moved the solutions to a locked cabinet. Water Temperature: LPA tested the water temperature at 11:45 am which was 141.1 degrees F. LPA instructed the caregiver to adjust the water temperature to the hot water heat. LPA observed the caregiver did turn the temperature at 11:50 am. Contd' 809-C Surrounding Grounds: The backyard contained comfortable seating. LPA observed a spa is located in backyard. The spa cover was only cover one quarter of the spa. There was no water in the spa but a portable step was located next to the spa which allows access into the spa. Smoke/Carbon Monoxide Detectors: The smoke/carbon monoxide detectors were tested at 11:55 am. Based upon Title 22 Regulations, the following deficiency is substantiated. (See 809-D page). LPA Spaeth read the report to the Administrator, Nicole De Las Alas at 3:00 pm until 3:15 pm. The Administrator stated to LPA Spaeth that the caregiver may sign the report. LPA Spaeth also informed the Administrator that an additional unannounced visit may be warranted to address the staff living in the living room area. Exit interview was conducted, appeal rights discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, Mar 22, 2024