Vernon Cottage

Type of visit: Required - 1 Year

On July 11, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met administrator Jose Umana and explained the purpose of today’s visit. The facility is licensed to operate for (6) non-ambulatory, of which (1) may be bedridden in room #4 for elderly adults ages 60 and above. The facility is approved for (4) hospice residents. Currently, there are no hospice resident in care. The facility is a single-story structure located in a residential neighborhood. It consists of the following: (6) residents' rooms, (3) bathrooms, a living area, a dining area, a kitchen, an outside seating area, a laundry room, a powder room, and a garage utilized for storage. 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 105..9 degrees F. A comfortable temperature of 712 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 extinguishers were charged. A review of the Medication Administration Records (MAR) was observed to be maintained in order and complete. (Evaluation Report continues LIC 809-C) All mandated inspection control posters were posted. LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on May 15, 2026 at 3 PM. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance with policy #PC193091533-02 - effective 02/01/26 - 02/01/27. An audit of resident #1-#6 (R1-R6) service files and staff #1-#5 (S1-S5) personnel files. The facility has the current administrator's certification for Edgar Yraheta #6082075740 valid through 05/21/2028 and Jose Umana #7001004740 valid through 07/05/2027. The facility is not current on (CCL) annual dues. DEFICIENCY: The inspection conducted by LPA revealed that resident room #2 lacks a window screen. Deficiencies are issued and an exit interview is conducted with SHAWELLYN MARTIN. A copy of this report is provided along with the appeal rights.the state’s words, verbatim · CDSS document, Jul 11, 2026

Type of visit: Required - 1 Year

On 06/19/2025, Licensing Program Analyst (LPA) Deborah Lee conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Edgar Yraheta, Administrative Assistant. The facility is licensed to operate for (6) non-ambulatory of which (1) may be bedridden elderly adults ages 60 and above. The facility is approved for (4) hospice resident. Physical Plant/Structure: The facility is a single-story structure located in a residential neighborhood. It consists of the following: (6) residents' rooms, (4) bathrooms, (1) staff bedroom, a living area, a dining area, a kitchen, an outside shaded seating area, and a garage used for storage. Bedrooms: LPA inspected all 6 bedrooms; the mattresses were in good condition, adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. Comforters, bed linen, bath towels and mattress protectors were adequately stocked. Bathrooms: Toilets and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. LPA tested hot water temperature, and it measured between 105 and 120 degrees Fahrenheit. There was adequate supply of linens available for the residents. Page 1 of 2 Common Rooms: All common areas are clean and free of obstructions. There is adequate seating for the residents in care. Each common area is equipped with furniture that is in good repair. Required Postings: LPA observed all required documents posted throughout the facility. The facility has a working landline telephone. Kitchen LPA observed a 2-day supply of perishable foods, and a 7-day supply of non-perishable foods properly stored, packaged, and labeled. Sharps were locked away and inaccessible to the residents. Safety LPA observed 2 fully charged fire extinguishers last serviced on 5/12/2025. The last emergency drill was conducted on 6/03/25. Medications: LPA observed all centrally stored medications secured All medications were observed in their original packaging. File Review: LPA reviewed 4 resident files and found that ( 4 ) out of ( 4) had the required documents. LPA reviewed 4 staff files and found that ( 4 ) out ( 4 ) had the required documents, training, and certifications. Infection Control LPA observed required infection control signs posted throughout the facility. LPA observed a sanitizing stations in entryway of facility. No citations issue during todays visit Exit interview conducted. Copy of report provided. Page 2 of 2the state’s words, verbatim · CDSS document, Jun 19, 2025

Type of visit: Required - 1 Year

On 06/27/2024, Licensing Program Analyst (LPA) Mario Leon conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Edgar Yraheta, Administrative Assistant. The facility is licensed to operate for (6) non-ambulatory of which (1) may be bedridden elderly adults ages 60 and above. The facility is approved for (4) hospice resident. The facility is a single-story structure located in a residential neighborhood. It consists of the following: (6) residents' rooms, (4) bathrooms, (1) staff bedroom, a living area, a dining area, a kitchen, an outside shaded seating area, and a garage used for storage. 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 107.2 degrees F. A comfortable temperature of 73 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. Two fire extinguishers were fully charged. A review of the Medication Records Administration (MAR) was observed to be maintained in order and complete. Report continues, see LIC809C. LPA observed First Aid Kit was maintained. A working landline phone was operational. The last emergency fire drill was conducted on 02/09/2024. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 02/01/24 through 02/01/25. An audit of two (2) residents (R1-R2) service files and four (4) staff (S1-S4) personnel files revealed to be complete. The facility has the current administrator's certification on file for Jose Umana. There have been no deficiencies cited during today's visit. An exit interview was held with Edgar Yraheta, Administrative Assistant, and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Jun 27, 2024

Allegation investigated: Licensee does not allow resident to participate in private visitations while in care. Licensee is not allowing resident to participate in outings with family member(s).

On 06/24/2024, Licensing program Analyst (LPA) Mario Leon conducted a follow-up, unannounced, visit to the above-mentioned facility to deliver this amended document originally delivered on 04/25/2024. LPA was met by Elsa Roman, Assistant Administrator. The investigation consisted of the following: On 04/10/2024, Licensing program Analyst (LPA) Mario Leon conducted an initial complaint visit at the above-mentioned facility. LPA was met by Alexander Ramos, Caregiver (S2). LPA was later met by Elsa Roman, Administrator (S1), and the purpose of the visit was explained. On 04/10/2024 LPA requested facility documents for all staff who were present during resident one's (R1) presence and R1's hospice care plan. LPA interviewed four (4) staff who were present at the facility and three (3) out of six (6) residents. 3 residents were not available for interview. LPA interviewed two (2) witnesses. LPA conducted a plant inspection and records were reviewed. Report continues, see LIC9099C Substantiated The investigation revealed the following: Regarding the allegation: "Licensee does not allow resident to participate in private visitations while in care". It has been alleged that the Administrator, Jose Umana (S3), is not allowing resident one (R1) to have private visitations in his room. Record Reviews of the Provider Information Notices (PINs), PIN 21-48-ASC indicate that: “individuals who have Power of Attorney (POA), regarding both financial and health directive has no legal authority to control resident’s visitation rights, unless explicitly specified in the POA document and if the resident is not objecting. The resident has ultimate authority over such decisions.”. LPA did not observe any court order which would restrict family members from visiting R1. Interviews with R1 indicate that R1 is ok with private visits with family member(s), that R1 holds no preference as to who they hold private visits with, as well as having no preference as to who they can go with on any private outings. Records review of the POA documents indicate that there are no specific authority of control of a resident’s visitation rights. Interviews revealed that 4 out of 4 facilities’ staff claims to have followed a choice to disrupt a visit, based on the POA’s request. 3 out of 3 residents and 2 out of 2 witnesses have denied the allegation Based on record reviews, interviews conducted and LPA’s observation, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D. Regarding the allegation: "Licensee is not allowing resident to participate in outings with family member(s).". It has been alleged that S2 is no longer allowing R1 to leave the facility with family member(s). Interviews revealed that 4 out of 4 staff, 3 out of 3 residents and 2 out of 2 witnesses have denied the allegation. While R1 has stated that they are O.K. to conduct outings with their family member(s), it has been recommended by the Power of Attorney (POA) that R1 should not be let out of the facility, for fear of relocation of R1. Record reviews revealed that, according to Provider Information Notices (PINs), PIN 21-48-ASC, R1 cannot be placed in a facility with secured perimeters. According to Health and Safety, Division 2 – Licensing Provisions, Chapter 3.2 Residential Care Facilities for the Elderly, Article 6.6 Secured Perimeters, 1569.698 (f) Any person who is not a conservatee and is entering a locked or secured perimeter facility pursuant to this section shall sign a statement of voluntary entry. The facility shall retain the original statement and shall send a copy of the statement to the department. R1 has not signed a voluntary entry for any secured perimeter facility and has not objected to conduct outings with family member(s). Report continues, see LIC9099C Based on record reviews and LPA observation, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D. An exit interview was conducted with Elsa Roman, Assistant Administrator, and a copy of the appeal rights and this report has been provided.the state’s words, verbatim · CDSS document, Jun 24, 2024 · control 11-AS-20240405160953

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Jun 28, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to...87468.1, Personal Rights of Residents in All Facilities, residents...shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in...visits, communications, telephone conversations,...and family groups. This has not been met as evidenced by: Licensee has agreed to follow the POA wishes by informing POA any time another family member arrives to visit with R1.the state’s words, verbatim · CDSS document, Jun 24, 2024

Plan of correction: Licensee has agreed to conduct in-staff training at the above-mentioned facility. All staff will read, in a language they understand, CCR 87468.2(a)(1-7) and licensee will provide a sign-in sheet, date(s)/time(s) included. Each staff will also review PIN 21-48-ASC and will sign names as "reviewed". Licensee will send sign-in sheet to LPA via email at MARIO.LEON@DSS.CA.GOV

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.698(f) · Plan of correction due date: Jun 28, 2024

1569.698 Building standards; adoption; locked and secured perimeters in residential care facilities; persons with dementia (f) Any person who is not a conservatee...shall sign a statement of voluntary entry. The facility shall retain the original statement and shall send a copy of the statement to the department. This has not been met as evidenced by: Licensee did not allow a family member to take R1 on outings.the state’s words, verbatim · CDSS document, Jun 24, 2024

Plan of correction: Licensee has agreed to conduct in-staff training at the above-mentioned facility. All staff will read, in a language they understand, HSC 1569.698(f) and licensee will provide a sign-in sheet, date(s)/time(s) included. Licensee will send sign-in sheet to LPA via email at MARIO.LEON@DSS.CA.GOV

Allegation investigated: Licensee did not allow a resident to have a visitation

On 06/24/2024, Licensing program Analyst (LPA) Mario Leon conducted a follow-up, unannounced, visit to the above-mentioned facility to deliver this amended document, originally delivered on 04/26/2024. The purpose of this amended document is to remove identifying information from the narrative. LPA was met by Edgar Yraheta, Administrator Assistant, and the purpose of the visit was explained. The investigation consisted of the following: On 04/26/2024 LPA conducted an initial complaint visit at the above-mentioned facility. LPA was met by Shawellyn Martin, Caregiver (S4). LPA was later met by Jose Umana, Administrator (S1) and Edgar Yraheta, Administrator Assistant (S2) and the purpose of the visit was explained. On 04/25/2024 LPA requested facility documents for all visits conducted by Long Beach Police Department (LBPD) on 04/13/2024. On 04/26/2024 LPA interviewed four (4) staff (S1-S4) and three (3) out of five (5) residents (R1-R3), two (2) residents (R4-R5) were resting and preferred not to be interviewed, and two (2) witnesses (W1-W2). LPA conducted a plant inspection and records were reviewed. Report continues, see LIC9099C. Unsubstantiated The investigation revealed the following: Regarding the allegation: "Licensee did not allow a resident to have a visitation". It has been alleged that on 4/13/2024 visitor(s) were asked to leave the facility during visiting hours. Record reviews revealed the following: The Sign in/out sheet, on 04/13/2024, logged that a visitor was there to visit a resident. The facility house rules indicates that residents are allowed to have visitors between the hours of 09:00AM - 7:00PM, but that "visitors must be respectful of other residents and staff. Disruptive guests will be asked to leave.". Record reviews of the Serious Incident Report (SIR), submitted on 04/17/2024, indicates that on 04/13/2024 around 11:30AM a visitor was escorted out of the facility by LBPD officers after verbally threatening staff and family member(s). Interviews revealed the following: 4 out of 4 staff and 3 out of 3 residents have disagreed with the allegation. Interviews also indicate that on 04/13/2024 Administrator S1 and LBPD requested a visitor to depart from the facility due to that visitor’s disruptive behavior to staff, which disrupted three (3) residents in care. Based on 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 no deficiencies cited today. An exit interview was held with Edgar Yraheta (S2) and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Apr 26, 2024 · control 11-AS-20240417145929

Allegation investigated: Staff member engages in inappropriate behavior with family member in the presence of resident in care.

On 06/24/2024, Licensing program Analyst (LPA) Mario Leon conducted a follow-up, unannounced, visit to the above-mentioned facility to deliver this amended document originally delivered on 04/25/2024. LPA was met by Elsa Roman, Assistant Administrator. The investigation consisted of the following: On 04/10/2024, Licensing program Analyst (LPA) Mario Leon conducted an initial complaint visit at the above-mentioned facility. LPA was met by Alexander Ramos, Caregiver (S2). LPA was later met by Elsa Roman, Administrator (S1), and the purpose of the visit was explained. On 04/10/2024 LPA requested facility documents for all staff who were present during resident one's (R1) presence and R1's hospice care plan. LPA interviewed four (4) staff who were present at the facility and three (3) out of six (6) residents. 3 residents were not available for interview. LPA interviewed two (2) witnesses. LPA conducted a plant inspection and records were reviewed. Report continues, see LIC9099C Unsubstantiated The investigation revealed the following: Regarding the allegation: "Staff member engages in inappropriate behavior with family member in the presence of resident in care.". It has been alleged that family member(s) was in R1's room having a private conversation with R1 and S2 interrupted the family member and R1's conversation. Interviews revealed that 4 out of 4 staff, 3 out of 3 residents and 2 out of 2 witnesses have denied the allegation. Record reviews revealed that all 4 staff have appropriate training records, according to CA Code of Regulations: Title 22, Division 6, Chapter 8 - Article 07. "87411 Personnel Requirements - General". Based on 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. An exit interview was conducted with Elsa Roman, Assistant Administrator, and a copy of this report has been provided.the state’s words, verbatim · CDSS document, Apr 10, 2024 · control 11-AS-20240405160953