My Mother's Place

Type of visit: Case Management - Annual Continuation

At 9:20AM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct a continuation annual inspection. LPA Allen was greeted by Administrator Hilda Lozano upon arrival. LPA introduced herself and explained the purpose of the visit. During the prior visit LPA observed bedrooms 1,2,3,4 and 5 to have cameras installed however it has been determined that the device is a Vtec Baby monitor not cameras. On 10/22/2025 there was a typo LPA reviewed files for Resident 1-5 (R1-R5) and observed that all files were missing required documentation needs and service plans or current physicians’ report for R3, R4 and R5. The administrator has agreed to get current needs and service plans or current physicians’ report for R3, R4 and R5. A citation will be issued for not having complete files S1,S2 and S4 needs to be fingerprinted and associated to work at the facility Hilda Lozano have been informed and agreed that any staff who are not cleared should not be working until clearance is issued. A citation will be issued for not having staff cleared/associated. Staff members S1-S5 (S1-S5) did not have complete files to review during the visit and was cited based on regulation 87412(a) LPA advised Hilda Lozano Administrator was informed that due to insufficient time LPA would return to complete the annual inspection on another date and citations will be issued for not following Title 22 Regulations on the continuation inspection visit. An exit interview was conducted, and this report was discussed and provided to Gabriela Torreblaca Support Staff at the conclusion of the visit.the state’s words, verbatim · CDSS document, Nov 4, 2025

The state marks this report as 5 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

At 12:45PM, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct an annual inspection. LPA Allen was greeted by Gabriela Torreblaca Support Staff upon arrival. LPA introduced herself and explained the purpose of the visit. The Administrator Hilda Lozano was called by the staff. LPA spoke directly to Hilda Lozano and she explained that she could not come to the facility and confirmed that the staff files were not available for review during the inspection. Hilda said the staff doesn't have access and for LPA to document findings and she would handle them upon her arrival. The facility is licensed to serve 6 Non-Ambulatory Residents aged 60 and above. The current census is four (4) residents. The home has living/dining room, kitchen, 6 bedrooms, 3 bathrooms, laundry area in garage backyard area with seating, storage area for additional food and supplies. At 2:30PM LPA and Rosa Pioquinto toured that facility and observed the following. Bedrooms 1,2,3,4 and 5 had cameras installed. The bedroom at the front door could not be opened during the inspection. The cabinet in the kitchen where medications are stored has a broken lock that needs to be repaired and the Drawer where the knives/sharps are stored is broken and needs to be repaired. LPA did not observe the LIC610D nor could it be provided at the time of inspection visit. Continued.... LPA reviewed files for Resident 1-5 (S1-S5) and observed that all files were missing required documentation needs and service plans or current physicians’ reports. The kitchen was inspected, and there was a 5-day supply of perishable and a 7day supply of non-perishable food items available, which was adequately maintained/stored. Overall, the facility appeared to be clean, sanitary, and in good repair All window screens are clean and in good repair. LPA advised Gabriela Torreblaca Support Staff that due to insufficient time LPA would return to complete the annual inspection on another date and citations will be issued for not following Title 22 Regulations on the continuation inspection visit. An exit interview was conducted, and this report was discussed and provided to Gabriela Torreblaca Support Staff at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 22, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff did not dispense medication to resident as prescribed by physician.

This report supersedes report dated 03/21/2025. It does not change the findings only clarify them. On 05/29/2025, Licensing Program Analyst (LPA) Troy Watson conducted an unannounced complaint investigation at the facility listed above. LPA Watson arrived at the facility and was greeted by the administrator Hilda Lozano. LPA Watson explained the purpose of the visit was to deliver findings about the allegation listed above and was granted entry into the facility. On 02/12/2025 the department interviewed the Administrator and requested and received the following documents: Medication List, Register of Facility Client/Residents Roster LIC9020, and Staff Roster Personnel Report LIC500. On 02/12/2025 the Department interviewed staff #1-Staff#4 and interviewed residents #1-#4, an attempt to interview resident #5 was made, but it was found the (R5) was non-verbal. CONTINUED REPORT ON LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not dispense medication to resident as prescribed by physician. On 02/12/2025 the department conducted interviews with staff#1 – staff #4 (S1-S4). The department asked the staff, do you dispense medication to resident as prescribed by the physician? Of those interviewed, 2 out of 4 staff denied the allegation and 2 out 4 staff do not administer medications. On 02/12/2025 the department interviewed residents 1 – residents 4 (R1-R4). The department attempted to interview resident #5, but (R5) was non-verbal. The department asked residents, do the staff dispense medication as prescribed by your physician? Of those interviewed, 4 out 4 residents answered yes to getting their medicine as prescribed and denied the above allegation. Based on the information gathered, there is insufficient evidence to support the stated allegation. On 02/12/2025 the department reviewed medication list for R1. Per medication list medication should be administered 3 times a week as prescribed by the physician. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is deemed unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the administrator Hilda Lozano.the state’s words, verbatim · CDSS document, May 29, 2025 · control 11-AS-20250203171330

Allegation investigated: Staff did not dispense medication to resident as prescribed by physician.

"Please note that this amended Complaint Investigation Report LIC9099 dated 3/20/2024 will supersede the original LIC9099 dated 3/12/2024 to clarify findings. On 02/12/2025, Licensing Program Analyst (LPA) Troy Watson conducted an unannounced complaint investigation at the facility listed above. LPA Watson arrived at the facility and was greeted by the administrator Hilda Lozano. LPA Watson explained the purpose of the visit was to investigate the allegation listed above and was granted entry into the facility. On 02/12/2025 the department interviewed the Administrator and requested and received the following documents: Physicians Order Medimark II, Register of Facility Client/Residents Roster LIC9020, and Staff Roster Personnel Report LIC500. On 02/12/2025 the Department interviewed staff #1-Staff#4 and interviewed residents #1-#4, and attempt to interview resident #5 was made, but it was found the (R5) was non-verbal. CONTINUED ON LIC9099-C Unsubstantiated The investigation revealed the following: Allegation: Staff did not dispense medication to resident as prescribed by physician. On 02/12/2025 the department conducted interviews with staff#1 – staff #4 (S1-S4). The department asked the staff, do you dispense medication to resident as prescribed by the physician? Of those interviewed, 4 out of 4 staff denied the allegation. On 02/12/2025 the department interviewed residents 1 – residents 4 (R1-R4). The department attempted to interview resident #5, but (R5) was non-verbal. The department asked residents, do the staff dispense medication as prescribed by your physician? Of those interviewed, 4 out 4 residents denied the allegation. Based on the information gathered, there is insufficient evidence to support the stated allegation. After reviewing the medication records for resident#1 (R1) it was revealed that medication for (R1) is administered 3 times a week as prescribed by the physician. A blood test taken by Kaiser Cadillac for R1 was conducted and it was verified that the level of medication administered to R1 was normal. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is deemed unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the assistant administrator Hilda Lozano.the state’s words, verbatim · CDSS document, Mar 21, 2025 · control 11-AS-20250203171330

Allegation investigated: Staff did not dispense medication to resident as prescribed by physician.

On 02/12/2025, Licensing Program Analyst (LPA) Troy Watson conducted an unannounced complaint investigation at the facility listed above. LPA Watson arrived at the facility and was greeted by the administrator Hilda Lozano. LPA Watson explained the purpose of the visit was to investigate the allegation listed above and was granted entry into the facility. The investigation consisted of the following: CONTINUED ON LIC9099-C Unsubstantiated On 02/12/2025 the department interviewed the Administrator and requested and received the following documents: Physicians Order Medimark II, Register of Facility Client/Residents Roster LIC9020, and Staff Roster Personnel Report LIC500. On 02/12/2025 the Department interviewed staff #1-Staff#4 and interviewed residents #1-#4, and attempt to interview resident #5 was made, but it was found the (R5) was non-verbal. The investigation revealed the following: Allegation: Staff did not dispense medication to resident as prescribed by physician. On 02/12/2025 the department conducted interviews with staff#1 – staff #4 (S1-S4). The department asked the staff, do you dispense medication to resident as prescribed by the physician? Of those interviewed, 4 out of 4 staff answered no. On 02/12/2025 the department interviewed residents 1 – residents 4 (R1-R4). The department attempted to interview resident #5, but (R5) was non-verbal. The department asked residents, do the staff dispense medication as prescribed by your physician? Of those interviewed, 4 out 4 residents answered no. Based on the information gathered, there is insufficient evidence to support the stated allegation. After reviewing the medication records for resident#1 (R1) it was revealed that medication for (R1) is administered 3 times a week as prescribed by the physician. A blood test taken by Kaiser Cadillac for R1 was conducted and it was verified that the level of medication administered to R1 was normal. Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegation. While the allegation may be valid or have occurred, there is insufficient evidence to establish whether the alleged violation took place or did not. Therefore, the allegation is deemed unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the assistant administrator Hilda Lozano.the state’s words, verbatim · CDSS document, Feb 12, 2025 · control 11-AS-20250203171330

Type of visit: POC

On 11/13/24, Licensing Program Analysts (LPA) Perry Scott conducted an unannounced POC visit. LPA Scott met with Hilda Lozano, Administrator. LPA Scott, informed Hilda Lozano that the purpose of today's visit was to ensure that the deficiencies cited during the annual inspection visit on 11/07/24 were corrected and in compliance with Title 22 Regulations. LPA Scott observed that the following deficiencies were corrected: 87412(a) Personnel Records LPA did not have access to personnel records during the annual inspection. LPA Scott observed all records and did not find any deficiencies. 87465(a)(6) Incidental Medical and Dental Care LPA did not have access to resident records. LPA Scott observed all Medication Administration Records and did not find any deficiencies. 87506(b) Resident Records LPA did not have access to resident records during the annual inspection. LPA Scott observed all resident records and did not find any deficiencies. HSC 1569.695(e) Emergency Plans A facility shall have all of the following information readily available to facility staff during an emergency: Emergency and Disaster Plan Report Continued on LIC 809-C LPA Scott observed the Emergency and Disaster Plan and did not find any deficiencies. HSC 1569.695(e)(1) (e) A facility shall have all of the following information readily available to facility staff during an emergency: (1) A resident roster with the date of birth for each resident. LPA Scott observed the Resident Roster and did not find any deficiencies. HSC 1569.695(e)(3) (e) A facility shall have all of the following information readily available to facility staff during an emergency: (3) A resident medication list for residents with centrally stored medications. LPA Scott observed the Resident Medication Roster list and did not find any deficiencies. LPA Scott provided Letters of Deficiency Citations Cleared. No deficiencies observed during this visit. An exit interview was conducted, and a copy of this Facility Evaluation Report was given to Hilda Lozano, Administrator.the state’s words, verbatim · CDSS document, Nov 13, 2024

Type of visit: Required - 1 Year

On 11/7/24, at 1:30pm, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced visit to My Mother’s Place. The purpose of today’s visit was to conduct the required annual inspection, using the new Care Tool. LPA was met by Rosa Pioquinto, staff, and the purpose of today’s visit was explained. The facility is licensed to serve six (6) non-ambulatory residents aged 60 and over. Currently, the home has (3) residents in care. The facilities’ annual fees are current. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, living room, dining area, kitchen, laundry room, backyard patio, and a garage. LPA could not conduct a records review because the resident and staff files were not available. LPA could not a medication review because the Medication Administration record was not available for review. LPA could not verify that an emergency drill was done because the records were not available for review. LPA could not verify the staff roster nor resident roster because the facility records were not available for review. Deficiencies were cited during the inspection. At 1:50pm, LPA and staff toured the physical plant. There are no bodies of water or firearm/ammunition on the premises. All resident rooms were checked. Beds and bedding were in good condition, adequate lighting provided, adequate storage for client personal belongings was observed. Walls and floors were in good repair. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations. Toilets and water faucets worked properly. The shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature measured 108.5F. A comfortable temperature is maintained in the facility. Report continued on LIC809-C LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for cleaning agents, toxins, and sharps were inaccessible to clients. The kitchen was inspected and there is enough perishable and non-perishable food available, which is stored properly. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. The fire extinguishers were charged and last inspected on 8/22/2024. Smoke/ Carbon Monoxide detectors were operable. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents. LPA observed that sanitizing stations were in common areas and restrooms. LPA observed that the facility had the required postings, posted throughout the facility. LPA further observed the facility to have a 90-day supply of Personal Protective Equipment (PPE). LPA advised the administrator to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing (www.cdss.ca.gov) for Provider Informational Notices (PIN) and for any updates relating to COVID-19 guidance and other related issues. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did observe deficiencies during the visit. Citations were issued during the annual inspection, and are listed on LIC9099-D. An exit interview was held, and a copy of the Facility Evaluation Report was provided Rosa Pioquinto, staff.the state’s words, verbatim · CDSS document, Nov 7, 2024