A Mystical Rose Villa

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with Nelson Jabon for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 09:30 AM and the following was noted: There is one entrance being utilized at the facility. The facility has a total of four (04) bedrooms and two (02) bathrooms. The facility is fire cleared for six (06) non-ambulatory of which one (01) may be bedridden in Room #2. The facility is currently occupying six (06) residents. The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The living and dining room are neat and clean. The residents' rooms are adequately furnished with appropriate lighting system. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 112.0°F. Towels and washcloths are not shared. There was enough clean linen available. Hallways are well lit. The facility maintains a comfortable temperature at 74°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located near the rear sliding door and kitchen and observed to be fully charged and last inspected 03/19/2025. (continued on LIC 809-C) Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents. LPA observed medication to be locked and inaccessible to residents. Laundry detergents, cleaning agents and other toxins are locked away. Facility maintains a complete first aid kit. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Sep 18, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA), Abeye Duguma, conducted an announced Pre-licensing visit at around 1:30 PM and met with administrator, Nelson Jabon. LPA conducted an entrance interview with the Administrator. With the assistance of the Administrator, LPA conducted a facility tour of both the inside and outside. The facility was inspected for Fire Safety, Personal Accommodations and Services, Medication Procedures and Food Service. This is a single-story property. Fire Clearance is approved for five (05) non-ambulatory and one (01) bedridden resident. Facility has three (03) semi-private bedrooms and one (01) bathroom for residents and one (01) bedroom for staff with its own bathroom. Resident bathroom has properly installed grab bars and shower has non-skid mat. All residents’ bedrooms are adequately furnished. The linens are stored in the storage space located in the hallway. Towels and washcloths are not shared. The common areas are appropriately furnished. The living room and dining room are neat and clean. The LPA observed entertainment equipment and games for activities. Fireplace has appropriate screen. There is sufficient outdoor space with seating and a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. LPA inspected the kitchen and observed the stove and refrigerator to be clean and working. Facility has sufficient quantity and variety of nonperishable food supply. Nonperishable foods are stored in the pantry. Sharps observed to be stored in a locked kitchen drawer. All garbage containers observed to have lids. (CONT. on LIC 809-C) Smoke and carbon monoxide detectors were checked and function properly. There is a fully charged fire extinguishers located in the kitchen area, and near the front entrance, last inspected 02/09/2024. Hot water temperature measured at 111.9ºF during the visit. First-aid kit is complete. LPA observed a washer and dryer in the garage. All chemicals, additional personal hygiene items and other toxins are stored in the locked cabinet in the garage. At the time of this visit the physical plant is meeting Title 22 requirements. The Component III was completed with the LPA. No health and safety hazard were noted during this visit. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Aug 14, 2024

Type of visit: Office

Facility Type: RCFE Application Type:Initial Capacity:6 Census (if any clients in care):N/A COMP II Participants: Nelson Jabon-Admin/Licensee & Aida Tugadi-Licensee Interview Method: Telephone interview On [05/31/2024], applicant(s)/administrator participated in COMP II for the below pending facilities: [list out all of the applicable pending applications in the following format: FACILITY NAME/FACILITY #, ex. Front Street Facility/123456789, Back Alley Facility/987654321, etc…]. Identification of the applicant(s) and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant(s) and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, May 31, 2024