Home of Perpetual Care

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vaid conducted an unannounced annual visit. LPA was met by Care giver Stephanie Mariano and explained the purpose of the visit. Administrator Leah Ignacio arrived shortly. Facility is licensed to serve residents over 60 years old six (6) can be non-ambulatory, of which one zero (0) can be on hospice. The facility is a single-story home, located in a residential area. The home consists of a living room, (3) residents’ bedrooms, (1) live-in staff room, (1) room designated for licensee with (1) full bathroom inside the room, (1) resident bathroom, a kitchen, pantry, dining room, living room, detached garage, and shaded patio with seating in the backyard. LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. All rooms are shared. There are extra clean linen and towels in a hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. One carbon monoxide in the hallway is properly operating. One fully charged fire extinguisher which is kept in the kitchen. Cleaning supplies and toxic substances were observed to be inaccessible to clients in kitchen pantry. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. It was observed that facility has a sufficient supply of 2 days perishable & 7 days non-perishable food deficiency cited. 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 was measured between the required range of 105-120 degrees F. No swimming pool or bodies of water on the premises. There is a shaded seating area for the residents located in the backyard. Three (3) Staff files were reviewed and included Criminal clearance record, CPR/training health screening with TB. Administrator certificate pending. Four (4) Client files were reviewed and included physicians report, TB clearance. Fire/earthquake drill was conducted 07/04/2026. Infectious control plan was reviewed. The medications are centrally stored and locked in a cabinet in kitchen. Medications were not reported on medical administration record, deficiency cited. LPA observed a hospital bed and mattress against wall next to shaded patio, deficiency cited. Administrator to provide liability insurance proof by 08/19/2026. 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 to Administrator Leah Ignacio.the state’s words, verbatim · CDSS document, Aug 18, 2026

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Visit-Deficiencies on 08/18/2025, stemming from records reviewed and received on 08/14/2025. LPA was greeted by Administrator Leah Ignacio and explained the purpose of the visit. Case Management findings: On 08/14/2025, LPA Ramirez received a copy of resident#1 (R1) physician report dated 07/17/2025, which indicates R1’s ambulatory status is Bedridden. The facility’s fire clearance is approved to serve six (6) non-ambulatory clients, 60 and over. The facility does not have a fire clearance approved for bedridden. The facility is currently operating beyond their approved fire clearance, which poses an immediate risk to the health, safety, or personal rights of persons in care. Per Title 22, Division 6, Chapter 8, 87202(a)(2)-Fire Clearance –(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons. Based on record review, LPA Ramirez will issue a Type A deficiency and an immediate $500 civil penalty. Exit interview was conducted and a copy of this report, 809-D, LIC 421IM, and appeals rights.the state’s words, verbatim · CDSS document, Aug 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Aug 19, 2025

(a) All facilities shall maintain a fire clearance approved by the city,city and county fire department. Prior to accepting or retaining any of the followingtypes of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city,or city and county fire department, or the State Fire Marshal. This requirement was not met as evidenced by: R1 is bedridden and the facility fire clearance is not approved for bedridden. This poses an immediate risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, Aug 18, 2025

Plan of correction: The facility will develop a plan to either obtain an updated medical assessment for R1 or assist to coordinate alternative placement for R1 based on their assessed needs and required services.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced annual inspection visit on 8/214/2025 and was greeted by Administrator Leah Ignacio. LPA Ramirez identified herself and explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected four (4) resident rooms. All resident bedrooms contained the required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside shower. LPA Ramirez observed non-slip mats in showers. LPA Ramirez observed seated shower chairs in bathrooms. Food Service: LPA Ramirez observed a sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). SEE 809-C for continued narrative Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. One (1) out of the three (3) residents at the facility attends an adult day program. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed the facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. LPA Ramirez observed an emergency food supply located in pantry. During record review, LPA Ramirez observed emergency disaster drill logs were incomplete, as they had been left blank. LPA Ramirez will issue a deficiency based on this record review. Residents with Special Needs: No large bodies of water were observed LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order. During record review, LPA Ramirez observed R1 was admitted into the facility 4/19/2023 and was placed on hospice care on 7/17/2025. The facility currently does not have an approved hospice care waiver. LPA Ramirez will issue a deficiency based on this record review. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication cabinet and in bubble packs and/or original containers. LPA Ramirez observed Centrally Stored Medication and Destruction Record. The facility provides incidental medical services. SEE 809-C for continued narrative Staffing: Administrator Certificate for Leah Ignacio is expired, however, according to Administrator Leah Ignacio, she sent her renewal package months ago and is awaiting processing. LPA Ramirez was unable to locate pending administrator renewal when verified through internal processes. Per Administrator Leah Ignacio, substitute designee Administrator Laura Ignacio assists in her place. LPA Ramirez verified Administrator Laura Ignacio certificate (7005001740) expires on 07/25/2026. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed the required annual training, CPR and First Aid for one (1) out of the one (1) personnel record reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for two (2) out of the two (2) personnel record reviewed. Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for six (6) non-ambulatory residents over the age of 59 years old. During record review, the administrator was unable to provide the current Certificate of Liability Insurance. However, LPA Ramirez did observe a liability insurance binder with a policy number, policy liability limits and start date of liability insurance. LPA Ramirez will issue a Technical Violation. SEE 809-C for continued narrative Resident Records/Incident Reports: LPA reviewed resident records for three (3) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. According to Administrator Leah Ignacio, R1 had a recent hospitalization on 4/2025 due to an illness and on 7/17/2025 was placed on hospice care. During record review, LPA Ramirez did not observe an updated Care Plan/Appraisal/Needs and Services Plan for R1, after R1's recent hospitalization and significant change to needs and services care plan. LPA Ramirez will issue a deficiency based on this record review. LPA Ramirez did not observe a documented report that this licensing agency was notified in writing within 7 days of R1’s hospitalization. LPA Ramirez will issue a deficiency based on this record review. LPA Ramirez did not observe a hospice care plan for R1 during record review. Administrator Leah Ignacio placed a call to R1’s hospice agency and received a copy of R1’s hospice care plan within an hour. LPA Ramirez will issue a Technical Violation based on this record review. Four (4) deficiencies and three (3) technical violations were cited during this annual inspection. Exit interview was conducted. A copy of this report, 809-D, LIC 9102 and appeals rights was provided.the state’s words, verbatim · CDSS document, Aug 14, 2025

The state marks this report as 11 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Allegation investigated: Facility did not issue a refund to resident's responsible party.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 05/08/2025 to address above allegation. Administrator Leah Ignacio arrived shortly after to assist with tour. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident#1 (R1) prior placement discharge/transfer letter, copy of blank admssion agreement, copy of check for R1’s care dated 3/8/2025, Staff#3 interview (S3), Interview with R1’s responsible party, and physical plant tour. Substantiated The investigation revealed the following: regarding the allegation “Facility did not issue a refund to resident’s responsible party.” Review of R1’s facility file and staff interviews revealed R1 was admitted into the facility on 03/04/2025. On 03/16/2025, R1 passed away at the facility. Interviews 03/17/2025, R1’s responsible party picked up R1’s personal belongings. Per Health and Safety code section 1569.652(c) - A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed Interview with staff and records reviewed revealed as of 05/08/2025, a refund fees has not been issued to R1’s responsible party. This poses a potential risk to the health, safety, or personal rights of persons in care. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. One (1) deficiency was issued during this complaint investigation. Exit interview was conducted with Administrator Ignacio. A copy of this report, 9099-D and appeals rights was provided.the state’s words, verbatim · CDSS document, May 8, 2025 · control 28-AS-20250501170249

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: May 16, 2025

A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days, after the personal property is removed. This requirement was not as evidenced by: Facility did not issue refund within 15 days to R1's responsible party. This poses a potential risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: Licensee agreed to certfy plan to address when a refund will be issued to R1's responsible party no later than 05/16/2025, via email to LPA Ramirez.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a unannounced Case Management Visit-Deficiency on 05/08/2025, stemming from initial complaint investigation (28-AS-2025050170249) visit on 05/08/2025. Caregiver Stephaine Mariano answered the door, and LPA explained the purpose of the visit. Case Management findings: Upon review of resident#1 (R1) resident record, LPA Ramirez did not observe original signed and dated Admission Agreement for R1. Per Title 22, Division 6, Chapter 8, Article 09. Resident Records- Admission Agreements- 87507(d)- The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. This poses a potential risk to the health, safety, or personal rights of persons in care. LPA Ramirez did not observe pre-admission appraisal for R1. Per Title 22, Division 6, Chapter 8. Article 08. Resident Assessments, Fundamental Services, and Right- Pre-Admission Appraisal- 87457(c)(1)(A)- Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. (1) The appraisal shall document, at a minimum: (A) An evaluation of the prospective resident's functional capabilities, mental condition, and social factors as specified in Sections 87459, Functional Capabilities and 87462, Social Factor. This poses a potential risk to the health, safety, or personal rights of persons in care. Based on observations and records reviewed, LPA Ramirez will issue two (2) deficiencies. Exit interview was conducted. A copy of this report, 809-D and appeals rights was provided via email.the state’s words, verbatim · CDSS document, May 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c)(1)(A) · Plan of correction due date: May 16, 2025

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria. (1)The appraisal shall document, at a minimum: (A) An evaluation of the prospective resident's functional capabilities, mental condition, and social factors. This was not met as evidenced by: No documentation of R1's pre-appraisal was observed. This poses a risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: Licensee will conduct re-training on this regulation and send proof of re-training by 5/16/2025. Proof must be submitted via email.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87507(d) · Plan of correction due date: May 16, 2025

(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This requirement was not met as evidenced by: Licensee did not retain original signed and dated admission agreement in R1's resident file. This poses a risk to the health, safety, or personal rights of persons in care.the state’s words, verbatim · CDSS document, May 8, 2025

Plan of correction: Licensee will conduct re-training on this regulation and send proof of re-training by 5/16/2025. Proof must be submitted via email.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christian Gutierrez conducted an unannounced Annual Required Visit at approximately 8:07 AM. LPA was met by Care giver Stephanie Mariano and explained the purpose of the visit. Administrator Leah Ignacio arrived shortly. Facility is licensed to serve residents over 60 years old six (6) can be non-ambulatory, of which one zero (0) can be on hospice. It was observed that facility has one resident receiving hospice care without a waiver from department. Deficiency has been cited.The facility is a single-story home, located in a residential area. The home consists of a living room, (3) residents’ bedrooms, (1) live-in staff room, (1) room designated for licensee with (1) full bathroom inside the room, (1) resident bathroom, a kitchen, pantry, dining room, living room, detached garage, and shaded patio with seating in the backyard. LPA toured the facility and observed the following: Each client bedroom has the required furniture and bedding. Bedroom one (B1) is a shared room and it was observed to have a camera on dresser of resident (R2). Bedroom four (B4) was observed to have full bed rails without physicians’ orders. 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 extinguisher which is kept in the kitchen. Cleaning supplies and toxic substances were observed to be inaccessible to clients in kitchen pantry. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. It was observed that facility did not have a sufficient supply of 2 days perishable & 7 days non-perishable food deficiency cited. Sharps are locked and placed in cabinet in kitchen. During tour of facility, it was observed that resident R1 was walking around unsupervised with scissors. 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 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. LPA observed a hospital bed and mattress against wall next to shaded patio deficiency cited. The garage is clean and has extra supplies. Three (3) Staff files were reviewed and included Criminal clearance record, CPR/training was missing for S3, and health screening with TB. Administrator certificate pending. Five (5) Client files were reviewed and included physicians report, TB clearance. Fire/earthquake drill was not conducted deficiency cited. Infectious control plan was reviewed. The medications are centrally stored and locked in a cabinet in kitchen it was observed that facility had medication in refrigerator not locked in separate box deficiency cited. LPA reviewed medications for all clients and the following was observed R2 was missing Gabapentin 300mg, Citalopram 10 mg, and Melatonin deficiency cited. 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 to Administrator Leah Ignacio.the state’s words, verbatim · CDSS document, Aug 9, 2024