Sedona Guest Home

Type of visit: Case Management - Annual Continuation

On 05/13/2025, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted a continuation unannounced Required – 1 Year Inspection to the above-named facility Caregiver, Nicanor Santos. The purpose of the visit was explained, and the LPA was allowed entry to the facility. This facility is licensed to serve 6 nonambulatory adults ages 60 and above, of which 6 may be on hospice. A total of 5 residents are currently residing in this facility. The Annual Licensing Fees are current. The following was observed on 05/12/2026: Facility Layout: does not match the facility sketch that was submitted to the department. The facility has two additional staff rooms in the garage. The facility is a one-story house located on a residential street. The home consists of 6 resident bedrooms; 4 full bathrooms; 2 staff bedrooms; garage/laundry room; great room which includes the kitchen area, dining room area, living room area; and an outdoor patio area. Outside Grounds: were toured no bodies of water were observed, walkways around the home were clear of hazards, and there were no security bars or weapons on the premises. Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. There is fire extinguisher in the kitchen area, and it was last serviced on 05/01/2026. There were live and dead vermin observed in the kitchen and kitchen cabinets. The kitchen vent was in disrepair and did not have filters. The kitchen sink is in disrepair (it is rusty). Underneath the kitchen sink inside the cabinet there was a lot of water damage, and the walls were in disrepair as well as the cabinet. Great Room: There is a videoconferencing device and games/activity work for residents. Resident Bedrooms: 6 out of 6 resident bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Bedroom 5 had vermin along with medications accessible to the resident, and there were a lot of items in the bedroom. Bathrooms: Toilets, showers, and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries are accessible to residents. Medications: 5 out of 5 Medication Administration Records (MARs) were reviewed along with their medications. Resident 4’s medication is not stored in medications original container. Some vitamins did not have physician’s order and/or prescription for residents in care. Prescription nonprescription PRN medication documentation did not include the time medication was provided and residents response to the medication. Miscellaneous: Documents are posted as mandated. Last disaster drill was conducted on 04/01/2026. The liability insurance is not current. The facility does not have a surety bond. The last Annual Fire Inspection was completed in 2022. The has an Emergency Disaster Plan and Infection Control Plan. 4 staff records were reviewed, 4 out of 4 staff records did not have required documentation. 5 resident records were reviewed, 5 out of 5 resident records did not have required documentation. Deficiencies are being cited based on observation, interviews, and record review in accordance with the California Code of Regulations, Title 22, see LIC809Ds. Violations ranging from records, facility being in disrepair, vermin in the facility, medication administration, and updating facility sketch. An exit interview was conducted; Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Caregiver, Nicanor Santos.the state’s words, verbatim · CDSS document, May 13, 2026

Type of visit: Required - 1 Year

On 04/24/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced annual inspection to the above facility. LPA met with the Licensee/Administrator, Antonio Arboleda and the purpose of the visit was explained. A tour of the facility was conducted and records were reviewed. Due to time constraints the annual inspection was not completed. An exit interview was conducted and a copy of this report was left with the Licensee/Administrator, Antonio Arboleda.the state’s words, verbatim · CDSS document, May 12, 2026

Type of visit: Case Management - Annual Continuation

On 05/07/2025 Licensing Program Analyst (LPA) Jose Anguiano and Licensing Program Analyst Ernand Dabuet conducted a continuation unannounced visit to facility Sedona Guest Home. The purpose of today’s visit was to conduct the one- year inspection, LPA met with Caregiver Nicanor Santos. Facility is licensed to serve clients 60 years of age and older with a capacity of 6 non- ambulatory residents. Currently the facility has 4 residents in care and 1 resident in Home Health with a total of 4 census. The facility does not have an approved hospice waiver. According to the annual inspection on 04/23/25, LPA Anguiano identified the following deficiencies during that inspection visit and returned to the facility to cite deficiencies from the prior inspection visit. DEFICIENCY’s: During the inspection, LPA Anguiano observed that facility failed to notify CCL of alterations done to the garage as a 2-bedroom living space was added to the physical plant. Staff 1-3 first aid (CPR) were found to be expired. Resident’s medications were not stored and locked securely and were accessible to residents. Residents (MAR) PRN medication records were found to be incomplete since 04/09/2025. Deficiencies were cited during this inspection visit. An exit interview was conducted, and a copy of this report was provided to Nicanor Santos.the state’s words, verbatim · CDSS document, May 7, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87305(a)(b) · Plan of correction due date: Jun 7, 2025

87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit.The licensing agency may require the facility to acquire a local building inspection...to health and safety exists. This requirement is not as evidence by: Based on observtation and records review the facility failed to notify CCL of alterataions done to the garage as a 2 bedroom living space added to the physical plant. This poses a potential health and safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: Licensee administrator shall read title 22, section 87305 and send a written statement to CCL a plan of action by the due date. LIcensee will request STD 850, Facility Sketch, and LIC200. The plan is due to the CCLD/El Segundo ASC offfice by 06/07/2025 fax at (424)544-1016

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c)(1) · Plan of correction due date: May 21, 2025

87411(c)(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 as evidence by: Based on observtationa and records review staff had 3 expired first aid CPR certificates. This poses a potential health and safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: Licensee or administrator shall have first aid certificates for staff 1-3 by due date indicated. The plan is due to the CCLD/El Segundo ASC offfice by 05/21/2025 fax at (424)544-1016

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 8, 2025

87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidence by: Based on observation LPA observed medications are not stored and locked securely and accessible to residents.This poses an immediate health and safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: Licensee administrator shall read title 22, section 87465 and send a written statement to CCL a plan of action by the due date. The facility shall store all medications in a locked stoarge. The plan is due to the CCLD/El Segundo ASC offfice by 05/08/2025 fax at (424) 544-1016

From the deficiency page — Deficiency type: Type B · Section cited: CCR47465(d)(3) · Plan of correction due date: May 21, 2025

47465 If the resident is unable to determine... following requirements are met: (3)The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record. This requirement is not as evidence by: Based on observtation and records review staff had incomplete (MAR) since 04/09/2025 This poses a potential health and safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: Licensee administrator shall read title 22, section 47465 and send a written statement to CCL a plan of action by the due date. The facility shall send proof of documentted and maintained (MAR) for residnets in care. The plan is due to the CCLD/El Segundo ASC offfice by 05/21/2025 fax at (424) 544-1016

Type of visit: Case Management - Deficiencies

On May 7, 2025, Licensing Program Analysts (LPAs) Ernand Dabuet and Jose Anguiano conducted a Case Management visit at this facility. The LPAs were greeted by caregiver Nicanor Santos, the (LPAs) explained the purpose of the visit. During the required annual inspection on April 25, 2025, conducted by LPA Anguiano, it was discovered that a resident under hospice care had passed away. Mr. Santos reported that the resident died in the facility. The death was not reported to Community Care Licensing (CCL) within the required seven-day period as mandated by Title 22 Regulations. As of May 7, 2025, the Licensee has failed to notify (CCLD) of this incident with a Death Report LIC624-A for (R1). It's been passed (7) days since the incident. The licensee violates 87211 Title 22 Regulations Reporting Requirements. California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 809-D). An exit interview was conducted and a copy of the Evaluation Report and Appeal Rights were provided to Nicanor Santos.the state’s words, verbatim · CDSS document, May 7, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 8721187211(a)(1)(A) · Plan of correction due date: May 21, 2025

87211 Reporting Requirements (a) licensee shall furnish to the licensing agency such reports as the Department... (1) A written report shall be submitted to the licensing agency... within seven days..(A) Death of any resident from any cause regardless of where the death occurred... This requirement is not met as evidence by: Based on interview with stafff, Licensee failed to report death of resident 04/09/25 who was on hospice care. This poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: Licensee will adhere to the regulations and will ensure any changes in resident's health condition or death will be reported to CCLD. Licensee will ensure to provide proof of correction sent by fax 424-544-1016 to El Segundo Regional office by 05/21/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(d)(1)(2) · Plan of correction due date: May 21, 2025

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d).... If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met, as evidenced by: The administrator's failure to conform to the applicable laws, rules, and regulations led to multiple deficiencies in annual inspection 05/07/25. This poses a potential Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: Licensee will adhere toTitle 22 Reg 87405 and will ensure to read and review. A written confirmation that admnistrator have completed this and send proof of correction to provide proof of correction sent by fax 424-544-1016 to El Segundo Regional office by 05/21/25.

Type of visit: Required - 1 Year

On 04/24/2025 Licensing Program Analyst (LPA) Jose Anguiano conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one- year inspection, LPA met with Caregiver Nicanor Santos. Facility is licensed to serve clients 60 years of age and older with a capacity of 6 non- ambulatory residents. Currently the facility has 3 residents in care and 1 resident in Home Health with a total of 4 census. During today’s visit LPA toured the facility and reviewed (4) resident facility files. This home is a single-story home consisting of: (6) resident bedrooms, (4) Full bathroom, 2 staff bedroom, living room, kitchen with dining area, laundry room (located in the attached garage) and an outdoor shaded patio area. LPA toured the Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 109.0F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. Due to time constraints a subsequent unannounced case Management visit will be conducted. No deficiencies were cited during todays visit. An exit interview was conducted, and a copy of this report was provided to Nicanor Santos.the state’s words, verbatim · CDSS document, Apr 23, 2025

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sparkle Day conducted an unannounced visit to the above facility. The purpose of today’s visit was to conduct the one- year inspection. LPA met with Nicanor Santos and Jennifer Mape, caregivers and the purpose of the visit was discussed. Facility is licensed to serve clients 60 years of age and older with a capacity of 6 non- ambulatory residents. Currently the facility has 3 residents on hospice and 2 residents on Home Health. During todays visit LPA toured the facility and reviewed (2) resident facility files. This home is a single story home consisting of: (5) resident bedrooms, (4) Full bathroom, 2 staff bedroom and 1 office, living room, kitchen with dining area, laundry room (located in the attached garage) and an outdoor shaded patio area. LPA toured the Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 122.1F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Deficiencies cited under California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiencies: -On 4/25/24 at 2:00 PM LPA observed that the facility has 3 residents on hospice and the license does not indicate a hospice waiver for this facility.. Due to time restraints LPA was unable to complete visit today. LPA will return to at a later date. Other citations may be cited at that time. Exit interview conducted and report and appeals rights left at facility at time of visit with Nicanor Santos.the state’s words, verbatim · CDSS document, Apr 25, 2024