Golden Care Living IV

Type of visit: Annual/Random

On 12/12/25 Licensing Program Analyst (LPA) Mario Leon came to conduct a required annual visit. LPA was met by staff two, Margie Balberan - Caretaker and the purpose of the visit was explained. The visit has been conducted on 12/06/25 by LPA Regina Cloyd. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with Iris Baclia-An and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Dec 12, 2025

Type of visit: Required - 1 Year

On 12/06/25, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Staff Iris Baclia-An and spoke with Administrator Charesa Reyes over the phone. The facility is licensed to serve six (6) non-ambulatory residents age range 60 and over, of which one (1) may be bedridden. It has a hospice waiver for six. Currently, the facility does not have any residents receiving hospice. The facility is a one-story home in a residential area and consists of: four (4) resident bedrooms, two (2) staff bedrooms, one (1) common bathroom and one (1) bathroom in the master suite, kitchen, dining room, family/activity room, staff’s den, and an outside patio. The facility is clean, sanitary, and in good repair. Staff accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. Continue to LIC809-C. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Staff tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional. 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. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked cabinet. First Aid kit was available. One fire extinguisher, last serviced June 2025 was observed in the kitchen area. Five (5) staff records were reviewed, five (5) out of five (5) staff records had current first aid certificates and required criminal record clearances or criminal record exemptions. Five (5) resident records were reviewed and, five (5) out of five (5) resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed. An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and emailed to spgfnf@yahoo.com due to printer issues.the state’s words, verbatim · CDSS document, Dec 6, 2025

Allegation investigated: Staff inappropriately restrained resident resulting in injury. Staff handled residents in a rough manner. Staff did not ensure resident a safe environment while in care.

On 07/11/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent, unannounced, complaint visit at the facility. LPA was met by staff number two, Kathleen Mantes - Caregiver (S2), and the purpose of the visit was explained. Investigation consisted of the following: On 07/10/25 LPA obtained Facility record paperwork as follows: Medication Administration Record (MAR) of resident one, two and three (R1 through R3) (dated: 06/01/25 through 07/10/25), Physician's Report for R1&R3 (dated: various). LPA interviewed four (4) residents (R1 through R4), three (3) staff (S1,S2&S3) and one witness (W1). LPA and S2 toured the physical plant. R3 was not available for LPA's interview, due to R3 currently resting. R4 was not available for LPA's interview, due to R4's medical condition.On 07/11/25 LPA conducted a subsequent visit to obtain further records, listed as follows: Identification and Emergency information of R1 through R4 (dated: 08/30/24 through 06/26/25) and R2's physician's report. R2's updated physician report has not been provided to the facility, due to R2's family time constraints. LPA has conducted a case management, please see LIC809. Report continues, see LIC9099-C. Unsubstantiated R1's two (2) discharge paperwork from hospital #1 (H1) and hospital #2 (H2), shift crossover notes (dated: 06/24/25 through 07/05/25) and LPA observed R1's injuries. Please see LIC813-C. LPA attempted to interview R3 once more, R3 was not available for interview due to current medical condition. LPA attempted to interview R4 & R5 and both were not available for LPA's interview. R4 due to medical condition and R5 having denied LPA's interview request. Investigation revealed the following: Regarding the allegation, "Staff inappropriately restrained resident resulting in injury.", it is being alleged that a resident had redness on both forearms from being restrained by staff. On 07/10/25, from 1:30 - 4:30 LPA interviewed S1-S3, R1 & R2, and W1. R3 was not available for LPA's interview, due to R3 currently resting. R4 & R5 were not available for LPA's interview. R4 due to medical condition and R5 having denied LPA's interview. On 07/11/25, from 09:00am - 11:00am, LPA conducted record reviews. Record reviews revealed the following: R1 was discharged from hospital #1 (H1) and was later discharged from H2, which aligns with the date(s) in question. All three staff (S1,S2&S3), resident one and two (R1&R2) and W1 have disagreed the allegation has taken place at the facility. R1 stated, "Two (2) of the guys near the hospital, grabbed me and stomped all over me.", which indicate the allegation has not taken place at this facility. Based on record reviews, LPA observation(s) and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Regarding the allegation, "Staff handled residents in a rough manner.". It is being alleged that a resident was bruised by staff. On 07/10/25, from 1:30 - 4:30 LPA interviewed S1-S3, R1 & R2, and W1. R3 was not available for LPA's interview, due to R3 currently resting. R4 & R5 were not available for LPA's interview. R4 due to medical condition and R5 having denied LPA's interview. On 07/11/25, from 09:00am - 11:00am, LPA conducted record reviews. Record reviews revealed the following: R1 was discharged from hospital #1 (H1) and was later discharged from H2, which aligns with the date(s) in question. All three staff (S1,S2&S3), resident one and two (R1-R2) and W1 have disagreed the allegation has taken place at this care facility. R1 stated, "I guarantee to you that they didn’t do that here. That was at the hospital.", which indicates that the staff at this care facility are appropriately trained to care for the elderly. Based on record reviews, LPA observation(s) and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Report continues, see LIC9099-C. Regarding the allegation, "Staff did not ensure resident a safe environment while in care.". It is being alleged that a resident has been "beat up" at the home. On 07/10/25, from 1:30 - 4:30 LPA interviewed S1-S3, R1 & R2, and W1. R3 was not available for LPA's interview, due to R3 currently resting. R4 & R5 were not available for LPA's interview. R4 due to medical condition and R5 having denied LPA's interview. On 07/11/25, from 09:00am - 11:00am, LPA conducted record reviews. Record reviews revealed the following: R1 was discharged from hospital #1 (H1) and was later discharged from H2, which aligns with the date(s) in question. All three staff (S1,S2&S3), resident one and two (R1&R2) and W1 have disagreed the allegation has taken place at this care facility. R1 stated, "It's so good to be clean and safe here." and "Time here is wonderful, the staff are nice and the food is great. Everything is great here!". Based on LPA observation(s), record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. There have been zero (0) deficiencies cited during today's visit. An exit interview was held with staff two, Kathleen Mantes - Caregiver (S2), and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 11-AS-20250708112102

Type of visit: Case Management - Other

On 07/11/25 Licensing Program Analyst (LPA) Mario Leon conducted a case management, related to lack of an updated physician's report for a resident in care, resident two (R2). LPA was met by staff two, Kathleen Mantes - Caregiver (S2) and the reason for this case management report has been provided. On 07/10/25 Licensing Program Analyst (LPA) conducted an initial, unannounced, complaint visit. During the visit, LPA requested a copy of R2's physician report (LIC624a) yet it was not provided. On 07/11/25 LPA returned to conduct a subsequent, unannounced, complaint visit. LPA requested R2's LIC624a. Record reviews revealed that R2's LIC624a shows a Physician has diagnosed (Dx) R2 as having "Dementia" and that this report is not current (dated: 01/23/24), please see LIC809-D. This indicates that this facility needs to obtain an updated LIC624a for R2. LPA was informed that R2's family member(s) have been contacted on 06/24/25, and on 07/10/25, for an updated LIC624a. Further record reviews revealed that R2's family member(s) have been made aware (dated: 06/24/25 & 07/10/25), yet this facility is still without an updated physician's report for R2. During today's visit, one (1) deficiency has been cited, please see LIC809-D. An exit interview was held with staff two, Kathleen Mantes - Caregiver (S2) and a copy of this deficiency, facilities' appeal rights and this report have been provided to Kathleen Mantes - Caregiver (S2).the state’s words, verbatim · CDSS document, Jul 11, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(b) · Plan of correction due date: Jul 18, 2025

87458 Medical Assessment (b) The licensee shall obtain an updated medical assessment when required by the Department. This has not been met as evidenced by: R2's physican report has diagnosed (Dx) R2 with Dementia, last dated 01/23/24. Residents Dx with Dementia requires the facility to obtain a yearly, updated, LIC624a.the state’s words, verbatim · CDSS document, Jul 11, 2025

Plan of correction: Licensee and LPA have agreed that this facility will obtain an updated physician's report (LIC624a) on, or prior to, the POC due date which is 07/18/25. Licensee will forward this updated physican's report to LPA at MARIO.LEON@DSS.CA.GOV

Type of visit: Case Management - Other

On 06/27/25 Licensing Program Analyst (LPA) Mario Leon conducted a case management, with primary focus on physical plant and medication management. LPA was met by staff two, Kathleen Mantes - Caregiver (S2), later by staff one, Cheresa Reyes - Caregiver (S1) and LPA explained the purpose of today’s visit. During today's tour, LPA observed three (3) staff present, for a ratio of 1:1.67 (one (1) staff to one point six-seven (1.67) resident(s)). The facility is licensed to operate for six (6), non-ambulatory, elderly adults ages 60 and above of which (1) may be bedridden, The facility is approved for six (6) hospice residents. Currently, the facility has five (5) residents in care. One (1) resident is currently receiving hospice services. The facility is a one-story house, located in a residential neighborhood, which consists of the following : four (4) resident bedrooms, two (2) staff bedrooms, two (2) bathrooms, a kitchen, a dining room, a living room, an activity room and an outside, tree-shaded, back yard and patio. LPA observed the facility to be fully furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and two-days of perishable and seven-days of non-perishable food was maintained adequately. An additional freezer is located in the back yard with additional frozen food items. Fire extinguishers are fully charged. The facility has last conducted emergency fire drill on 06/02/25. A review of the Medication Administration Record (MAR) of residents one (1) through five (5) (R1-R5) was observed and all entries have been entered correctly. From 10:00AM - 10:15AM LPA held an interview with resident five (R5). R5 has confirmed that staff are providing appropriate medication management. LPA observed First Aid Kit was maintained. A land-line phone was observed and tested, marked as operational. LPA observed smoke detectors in bedrooms and common areas, and a carbon monoxide detector located in the kitchen. LPA requested all detectors them to be tested and LPA verified all are in operational condition. The facility has current liability insurance on file, effective through 08/19/25. During the visit, LPA observed the facility's infection control practices and LPA observed screening protocols for visitors, staff,... Report continues, see LIC809-C. and residents, and sanitizing stations in common areas and restrooms and all mandated inspection control posters were posted. During today's tour, according to Title 22 regulations, LPA observed one (1) deficiency as follows: Screen, located in room #3, in disrepair. LPA also observed debris located in two (2) backyard exit doorsills and also in doorsill of room #3. Additionally, windowsills and screens have been observed as dirty, needing to be cleaned. Please see LIC809-D. An exit interview was held with staff one, Cheresa Reyes - Administrator designee (S1), and a copy of the facilities' appeal rights, deficiencies cited and this report have been provided.the state’s words, verbatim · CDSS document, Jun 27, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(c) · Plan of correction due date: Jun 30, 2025

87303 Maintenance and Operation (c) All window screens shall be clean and maintained in good repair. This has not been met as evidenced by: based on LPA's observations; the screen, located in room #3, in disrepair. LPA also observed debris located in two (2) backyard exit doorsills and also in doorsill of room #3, which may pose a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 27, 2025

Plan of correction: Licensee and LPA have agreed that the facility will make sure to clean window/doorsills as well as screening throughout the facility. Licensee will provide video/photo evidence of the area(s) in question to LPA at Mario.Leon@DSS,CA.GOV on or prior to POC due date, 06/30/25.

Type of visit: Case Management - Deficiencies

On 10/08/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a Case Management visit at this facility. LPA met with designated administrator Cheresa Reyes who allowed for the entry in this facility. LPA informed Reyes the purpose of the visit is to conduct a health and safety check. Investigation revealed the following: LPA conducted a tour of the entire facility. During the inspection, LPA observed the following: (4) resident bedrooms, (2) staff bedroom, (1) bathroom, kitchen, living/activity room, and an outside patio area. LPA observed (6) resident residing at this home requiring assistance with assisted daily living (ADLs) and (2) residents in hospice care. This property address is licensed to Golden Care Living IV #198320027. According to Residential Lease Agreement (dated: 08/17/24), Golden Care Living IV lost control of the property effective 08/16/24. The Residential Lease Agreement contract had Lester Mark Samson, & Charesa May Francisco Reyes under contract effective 08/17/24. Serene Living Care submitted an Application for A Community Care Facility LIC 200 on 08/28/24 to Central Applications Bureau, which is still under consideration. Based on the Department’s observation and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation of “Unlicensed Care is Being Provided" is found to be: "Substantiated". You are hereby issued a Notice of Operation in Violation of the Law letter. You are to cease operation or submit an application to the CCLD Senior Care Office on or before 10/23/24 or relocate the resident to a licensed assisted living facility. If you fail to: cease operation or relocate the resident a civil penalty will be assessed. (Evaluation Report continues LIC 809-C) Failure to comply will result in civil penalties of $200 per day until a completed application is submitted, operations cease, or written verification from a licensed mental health professional or residents are relocated. The operator was given a copy of the “Notice of Operation in Violation of Law" letter. Deficiency Cited: Health and Safety Code 1569.44. An exit interview was conducted with Cheresa Reyes, and a copy of the report and appeals rights were provided.the state’s words, verbatim · CDSS document, Oct 8, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.44(a) · Plan of correction due date: Oct 23, 2024

1569.44(a) Unlicensed residential care facility for the elderly; definition; operation without license prohibited; procedure upon discovery (a) A facility shall be deemed to be an "unlicensed residential care facility for the elderly" and "maintained and operated to provide residential care" if it is unlicensed and not exempt from the licensee, and any one of the following conditions is satisfied: This requirement is not met as evidence by: Based on interviews conducted and observation the operator is providing unlicensed care to R1-R6 who require elements of care and supervision. The facility is not licensed by CCLD. This poses a potential Health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 8, 2024

Plan of correction: The unlicensed operator shall either cease operation of the unlicensed facility or operations ceased or submit an application to the licensing agency within 15 calendar days by 10/23/24. Failure to comply will result in civil penalties of $200 per day until a completed application is submitted.

Type of visit: Required - 1 Year

On 10/08/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Cheresa Reyes. LPA explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory of which (1) maybe bedridden elderly adults ages 60 and above. Currently, the facility has (2) hospice resident in care. The facility is approved for (6) hospice residents. The facility consists of one-story level: (4) resident bedrooms, (2) staff bedrooms, (1) bathroom, kitchen, dining room, living room/activity room and an outside patio. LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 114.8 degrees F. A comfortable temperature of 77 degrees F. was maintained in the facility. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguisher were charged. The facility has conducted emergency fire drills on 10/01/24. A review of the Medication Administration Record (MAR) was observed to be maintained in order. (Evaluation Report continues LIC 809-C) LPA observed First Aid Kit was maintained. A working landline phone was operational. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 08/19/24 through 08/19/25. The facility is current with CCLD annual license dues. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. All mandated inspection control posters were posted. An audit of residents #1-#6 (R1-R6) service files and staff #1-#5 (S1-S5) personnel files. The facility has the current administrator's certification on file for Gian Paula Dizon #6071096740 Expiration 07/29/26 and Cheresa Reyes #6004109740 Expiration 11/20/24. DEFICIENCIES: No window screens for Activity Room and for resident room #2. Window screens require replacement for Hallway and Kitchen. Resident #6 not on hospice care had full extended bed rails without physician's prescription. Obstruction of exit passageway for room #3 with end table furniture. Refilled medications for resident #3 with dementia were stored in a unlocked hall closed accessible to residents in care According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 809-D). An exit interview conducted with Cheresa Reyes, a copy of report and appeal rights provided. 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, Oct 8, 2024

Allegation investigated: Staff do not distribute resident's medication as prescribed

On 5/13/2024 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Cathy Espino/Administrator. LPA explained the purpose of this visit. Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1). LPA reviewed the following documents: Copies of the Medication Administration Records-MARs for R#1-R#4 for the months of May and March 2024 and pictures taken by LAP of resident’s medications (R#1-R#4). Evaluation Report continues LIC 9099-C Substantiated Investigation Revealed the Following: Allegation: Staff do not distribute resident's medication as prescribed. The details of the complaint alleged that facility staff are not distributing resident’s medications as prescribed. During the records review, LPA Iniguez reviewed the following: For (R#1) MARs in May 2024, facility staff did not document three prescribed medications on the 4th, 5th, and 6th days. (R#1)’s prescribed medications stated they were to be taken daily. One medication was prescribed to be taken twice a day, but there is only documentation in the MARs that the medication was given once from May 1st to the 14th. For March 2024, facility staff must document MARs for (R#1), a medication prescribed at bedtime, on March 1st, 2nd, 3rd, 4th, 5th, and 6th. (R#2)’s Medication Administration Records (MARs) for the month of May 2024 showed that facility staff documented the days of the 1st, 2nd, and 3rd of May; the rest of the days are blank. (R#2)’s prescribed medications state that they are to be taken once a day. For March 2024 MARs for (R#2), LPA observed that facility staff needed to document medications given on the 10th, 11th, 12th, 13th, 14th, and 15th. (R#2) ’s prescribed medications state that they ought to be given daily. (R#3)’s Medication Administration Records-MARs for March 2024 showed that facility staff did not document for the whole month if they prescribed medication. (R#3)’s prescribed medication is to be given 3x daily; MARs showed medication was given twice only by facility staff. Evaluation Report continues LIC 9099-C (R#4)’s Medication Administration Records-MARs for April 2024 showed that facility staff did not document if prescribed medication was given on the 10th, 11th, 12th, 13th, 14th, and 15th of the month. (R#4)’s prescribed medication states to be given twice daily before meals. For March 2024 MARs for (R#4), LPA observed that facility staff needed to document medications given on the 28th, 29th, 30th, and 31st. (R#4) Prescribed medications are to be given daily. In addition, LPA reviewed (R#1-R#3) Physicians Report for Residential Care Facilities for the Elderly (RCFE) LIC 602A. The report shows that all 3 residents are not able to administer their own Prescription Medications. During this investigation, LPA found sufficient evidence to support the above-mentioned allegation. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099D.) An exit interview was conducted, and a copy of the Complaint Report was given to Cathy Espino/Administrator. Investigation Revealed the Following: Allegation: Staff do not ensure that a resident's incontinence needs are met. The details of the complaint alleged that facility staff are not ensuring that resident’s incontinence needs are meet. During a physical tour of the facility, the LPA inspected (R#1-R#3) changing supplies. The LPA observed that each resident had enough supplies for at least two weeks. The items observed by the LPA included disposable adult diapers, disposable bed pads, and cleaning lotions used for continence care. Additionally, upon arrival at the facility, the LPA observed two caregivers present. During the records review, the LPA observed the Personnel Report—LIC 500 and noted that two caregivers were scheduled at the facility during the daytime and two for nighttime. During an interview with the administrator (A#1), she stated that there are always two caregivers at the facility during the day and at night. Additionally, (A#1) indicated that the facility staff are meeting the residents' continence care needs and that there are enough supplies for them to use. Also, (A#1) stated that no resident in care has ever been left in a soiled diaper for an extended period. The facility has a policy that requires changing residents' diapers three times per day or as needed. During interviews with residents (R#1-R#3), (2) out of (3) stated that there are always two caregivers on site and their continence needs are being met. In addition, (2) out of (3) indicated that they had never been left in a soiled diaper for an extended period. Evaluation Report continues LIC 9099-C During an interview with Witness 1 (W#1), they stated that there are always two caregivers every time they visit (R#3). Also, (W#1) stated that (the facility is meeting (R#3) 's continence needs; they said, "I am always at the facility; “I will know if (R#3) is not being changed”. In addition, (W#1) stated that (R#3) has never been left on a soiled diaper for an extended period. During interviews with staff (S#1-S#2), (2) out (2) stated that there are always two caregivers in the day and night. Also, (2) out of (2) staff said that they are meeting the residents in care continence needs. They both stated that they change the residents thrice a day or as needed and check them every two hours. In addition, (2) out of (2) state that they have never left a resident on a soiled diaper for an extended period. During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations. Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted, and a copy of the Complaint Report was given to Cathy Espino /Administrator.the state’s words, verbatim · CDSS document, May 14, 2024 · control 11-AS-20240509102813

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(6) · Plan of correction due date: May 31, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observations and records review, the licensee did not comply with the section cited above as residents (R#1-R#4) medications were not checked off on MARs for the months of May and March 2024 and there is no documentation detailing if residents took or refused their prescribed medications which poses/posed a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 14, 2024

Plan of correction: Licensee will ensure facility staff documents medications given to/refused by residents at all times. As plan of correction, licensee will re-train facility staff on how to document medications on MARs properly. A copy of this training will be sent to LPA before POC due date.

Type of visit: Required - 1 Year

On 11/09/23, Licensing Program Analyst (LPA) Villegas conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Catherine D. Espino as the purpose of the visit was explained. The facility is licensed for (6) non-ambulatroy of which (1) may be bedridden and have an approved hospice waiver for (6) ages 60 and over. Facility has a current census of (2). Information on upcoming annual fees was provided. Liability insurance is active. The facility is a single-story structure located in a residential neighborhood. It consists (6) bedrooms of which 2 bedrooms are for staff, (2) full bathrooms, shaded back yard, front yard, there are 3 ramps along side the perimeter of facility laundry area, shed, and a detached 2 car garage. No weapons nor bodies of water on the premises. A supply of perishable and non-perishable food was observed. Emergency Water supply is found in the garage. Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F.. LPA conducted a records review of 2 staff records, 2 resident records, and 2 medication administration records. Medications were centrally stored and properly locked. The last fire was conducted on 11/03/23, 1 fire extinguisher fully charged, carbon monoxide and smoke detectors observed and are operational. Landline and internet were observed.During today’s visit the discrepancies were observed and documented on 809D. Exit interview conducted with Administrator Catherine D. Espino, appeals rights explained and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 13, 2023