Elishama's Villa

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to conduct an annnual inspection. Upon arrival LPA met with Rayjennia Adams, Administrator and she was informed of the purpose of the visit. Facility is licensed to serve 6 non- ambulatory residents age 60 and over of which (1) maybe bedridden . The facility has an approved hospice waiver for (6) residents. Currently there are two (2) residents in care and both are receiving home health care. This home is a single story home consisting of: four (4) bedrooms, (2) Full bathroom, living room, kitchen with dining area, laundry room and an outdoor shaded patio area. At 2:45 PM, LPA toured the Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident. The bathrooms toilets and faucets were in working condition, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, the water temperature measured between 105- 118.1 F. There was adequate bath towels, toiletries and personal hygiene supplies available. The common areas appeared to be clean and free of hazards; doorways were free of obstructions. LPA Allen observed that facilities kitchen to have a 5-day supply of perishables and a 7-day supply of non-perishables food items for the number of residents in care which were stored and maintained properly. There was also a storage area for additional cleaning supplies, and toxins which were inaccessible to clients. At LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings, which appeared to be current and two (2) clients files for admission agreements, updated physician reports, needs and services plan which appeared to be up to date. Smoke/carbon monoxide detectors were observed to be fully changed, tested and operating. The fire extinguishers were fully charged, and the last fire drill and emergency drill was conducted on 4/5/2026. During the inspection LPA Allen did not observe deficiencies therefore no citations were issued. An exit interview was conducted, where this report was discussed and provided to Rayjennia Adams- Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, May 11, 2026

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 Rayjennia Adams, Administrator and the purpose of the visit was discussed. Facility is licensed to serve 6 non- ambulatory residents age 60 and over of which (1) maybe bedridden . The facility has an approved hospice waiver for (6) residents. Four (4) residents are diagnosed with dementia, (2) residents are receiving home health and (1) resident is receiving hospice care services. The facility does not handle any of the residents’ money. This home is a single story home consisting of: (4) resident bedrooms, (2) Full bathroom, living room, kitchen with dining area, laundry room 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 118.1F. 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. Smoke detectors were working properly and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. During todays visit LPA did not observe any deficiencies. Exit interview conducted with Rayjennia Adams, Administrator and a copy of this report was provided at time of visit.the state’s words, verbatim · CDSS document, Mar 5, 2025

Type of visit: Prelicensing

On 03/18/24 Licensing Program Analysts (LPA’s) Socorro Leandro and Troy Watson conducted a pre-licensing evaluation for an RCFE facility type. Today’s pre-licensing evaluation was conducted with authorized licensee: RayJennia Adams. The licensee has applied for a license to serve 6 elderly residents ages 60 and older. The fire clearance is approved for 5 non-ambulatory residents and 1 bedridden resident. Bedrooms 1, 2 and 3 are approved for non-ambulatory residents and bedroom 4 is approved for one bedridden resident. A tour of the Kitchen, Dining Room, Living Room, 4 Bedrooms, 2 Bathrooms, 1 attached Garage, 2 Storage units for all supplies, and 1 Patio area were observed and evaluated as being in compliance. The following was observed during this visit: MEDICATIONS: There is a locked centralized storage area for resident medications. Report continues LIC 809C PHYSICAL PLANT: Facility is clean, sanitary, and in good repair. Protective devices are in place. Indoor and outdoor passageways, stairways, open porches, and other areas of potential hazard are free of obstructions. All window screens are clean and in good repair. Facility temperature is between 68°F. degrees and 73°F. degrees. Open porches, and areas of potential hazard are well-lit. All 7 smoke alarms operate properly. Carbon monoxide detectors operate properly. BEDROOMS: There is a bed for each client with a mattress, mattress pad, bedsprings, and pillow(s) which are clean and in good repair. Mattresses and pillows are flame-retardant. There is dresser and closet space for each client that includes 8 cubic feet of dresser space per client. There is a chair and lamp for each client and at least 1 night stand per client. BATHROOMS: There is at least 2 toilet and washbasin per 6 clients, family, and personnel. There is at least 2 showers or bathtub per 6 clients and personnel. The hot water temperature is 117.6° Fahrenheit. The bathroom is located near the client’s bedrooms. There are night-lights in the hallways outside non-private bathrooms, Report continues LIC 809C SUPPLIES: There are clients’ personal hygiene supplies to include soap, toothpaste, toilet paper, and comb. There is a sufficient supply of clean linens to permit weekly changing or more of client top sheets, bottom sheets, bedspreads, blankets, pillowcases, mattress covers, bath towels, hand towels, and washcloths. FOOD SERVICE: Dining room is near kitchen. Refrigerator(s) and freezer(s) are clean and large enough for the storage of at least 2 days of perishable foods. Freezer is 0° Fahrenheit. Refrigerator is a maximum of 45° Fahrenheit. A 7 day supply of non-perishable food is present. There are enough tableware, tables, dishes, and utensils. There is enough equipment for the storage, preparation, and service of food. All equipment, dishes, and utensils are clean and well maintained. All kitchen, food storage, and preparation areas are clean. RECORDS: There is confidential storage of personnel records at the facility. There is confidential storage of client records at the facility. ADMINISTRATION: The emergency exiting plan and emergency phone numbers are posted. Client Personal Rights are posted. Posting both sides of the Personal Rights form LIC 613 meets this requirement. Facility Visiting Policy is posted. A Licensing Complaint Poster is posted. There is space available for resident council meetings and resident council postings. Report continues LIC 809C ACTIVITIES: There is an outdoor activity space with a shaded area and furnished for outdoor use. There is at least one common room available to clients for visitors. MISCELLANEOUS: There are first-aid supplies to include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual. There is space and equipment for laundry. There is a space for clean linen storage and a separate space for soiled linen. There is an operating telephone available to clients. Emergency lighting and supplies to include flashlights with batteries. During this pre-licensing inspection, LPA observed corner space in garage occupied by a desk and art supplies. Licensee was asked to remove items located in corner of garage, in which licensee complied. This was the only correction that was needed and immediate corrected by the Licensee. LPA conducted the Component III Orientation with the Licensee and copy of this report was provided. A copy of the facility evaluation report will be available to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with their assigned CAU Analyst.the state’s words, verbatim · CDSS document, Mar 18, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Interview Method: Telephone interview On 2/6/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Feb 6, 2024