Sterling Senior Living

Type of visit: Required - 1 Year

On 07/27/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced required annual inspection. The department met with House Manager Ricardo Bernal and explained the purpose of the visit. The department was granted entry to the facility. The facility is licensed for six (6) residents age range 60 and over. Of those residents, two (2) may be ambulatory, four (4) may non-ambulatory, of which two (2) may be bedridden. The facility has an approved hospice waiver for two (2) residents. The facility is a single story structure located in a residential neighborhood. This facility consists of the following: five (5) resident bedrooms, one staff bedroom, two (2) bathrooms, an office area, foyer, kitchen, living room, dining area, a wheelchair ramp (located on the right side of the house), backyard patio, and a garage, with a laundry area. The department conducted a tour of the physical plant. There are no bodies of water on the premises. All resident bedrooms were checked. Beds and bedding were in good condition. Adequate lighting is observed, and storage for resident’s personal belonging was observed. Walls and floors were clean and in good repair. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be clean and operational. The water temperature properly measured between 105.0 F and 120.0 F. Continued on LIC809-C A comfortable temperature is maintained in the facility. The department observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning agents, toxins, and sharps were inaccessible to residents. The kitchen was inspected and there was enough perishable and non-perishable food available which is stored properly. Fire extinguisher was charged; smoke detectors and carbon monoxide were operable. First Aid kit along with manual was available. Common areas were clean and clear of hazards; doorways were free of obstructions. The department conducted a records review of six (6) resident service records, and four (4) staff records. All resident and staff records were complete and in order. The department reviewed, three (3) Medication Administration Records and observed discrepancies at the time of visit. Citation will follow. The facility has an administrator certificate for Sheryl Tongol #7021416740 Exp. 12/19/27. The facility has an active Liability Insurance through Kyber Associates Insurance Brokerage LLC, #00136973-3 valid 11/04/25 -11/04/26. The facility fees are current.. Deficiencies are being cited based on observation and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. An exit interview was conducted, and a copy of this report and appeals was discussed and left with House Manager Ricardo Bernal.the state’s words, verbatim · CDSS document, Jul 27, 2026

Allegation investigated: Staff do not ensure spoiled medications for residents are properly discarded. Staff do not ensure residents medication records are properly maintained ,

**This amended LIC 9099 supersedes the original LIC 9099 dated 07/01/2026.** On Wednesday, July 1, 2026, Licensing Program Analyst (LPA) Pamela Bunker conducted an initial visit to gather information regarding the above allegations. LPA met with Ricky Ricardo, House Manager, spoke with Licensee Michelle Kellogg by telephone, and explained the purpose of the visit. LPA was granted entry to the facility. The investigation consisted of the following: On July 1, 2026, at 10:30 a.m., the Department requested and reviewed resident's records and obtained copies of the following documents: Personnel Report (01/22/2026), Resident Roster (02/27/2025), Admission Agreement (03/06/2026), Identification and Emergency Information (03/06/2026), Physician's Report (03/06/2026), Medical Assessment (03/06/2026), Consent Forms (03/06/2026), Functional Capability Assessment (03/06/2026), Preplacement Appraisal Information (03/09/2026), Appraisal, Needs and Service Plan (03/09/2026), Personal Rights (03/09/2026), and Medications Records (06/01/2026-07/01/2026), Interviews were conducted with Staff Members #1 and #3 (S1-S3) as well as with residents #1 through #3 (R1-R3). See continued LIC9099-C page 2 Unsubstantiated Continued LIC9099-C page 2 The Department attempted to interview Residents #4 through #6 (R4–R6); however, R4–R6 were unable to answer any questions. Investigation revealed the following: Allegation: Staff does not ensure that spoiled medications for residents are properly discarded. On July 1, 2026, between 12:30 p.m. and 4:30 p.m., the Department conducted interviews with Staff #1 through Staff #3 (S1–S3). 3 out of 3 staff members reported that residents’ discarded pills are never left on the floors of residents’ rooms. 3 out of 3 staff members stated that staff document residents’ records when a resident refuses to take their medication and that no residents’ pills were ever found on the living room floor. 3 out of 3 staff members stated that no one picked up spoiled pills and reported such an incident to staff. 3 out of 3 staff members stated that staff have never taken spoiled pills from anyone and discarded them while indicating it was “no big deal.” 3 out of 3 staff members reported that staff supervise residents to ensure they take their medications according to physician orders. S1–S3 denied the allegation. On July 1, 2026, between 12:30 p.m. and 4:30 p.m., the Department conducted interviews with Residents #1 through #3 (R1–R3) and attempted to interview Residents #4 through #6 (R4–R6); however, R4–R6 were unable to answer any questions. 3 out of 3 residents stated that staff dispense their medications according to physician orders and supervise them to ensure medications are taken as prescribed. 3 out of 3 residents reported that medications are never left on the floor in their rooms or in the living room, and they confirmed that staff document their medication records. R1–R3 denied the allegation. Allegation: Staff does not ensure residents’ medication records are properly maintained. On July 1, 2026, between 12:30 p.m. and 4:30 p.m., the Department conducted interviews with Staff #1 through Staff #3 (S1–S3). 3 out of 3 staff members stated that staff ensures residents’ medication records are properly maintained and that documentation is completed daily according to physician orders. S1–S3 denied the allegation. On July 1, 2026, between 12:30 p.m. and 4:30 p.m., the Department interviewed Residents #1 through #3 (R1–R3) and attempted to interview Residents #4 through #6 (R4–R6), who were unable to respond. 3 out of 3 residents stated that residents’ medication records are properly maintained and that staff documents those records daily. R1–R3 denied the allegation. See continued LIC9099-C page 3 Continued LIC9099-C page 3. On July 1, 2026, the Department conducted a facility tour and did not observe any medications on the floors in any area of the facility. The Department observed residents’ medications and medication records/logs for the period of June 1, 2026, through July 1, 2026. Medications were stored safely in a locked cabinet in the living room, inaccessible to residents. All medications were properly labeled and maintained in accordance with label instructions, and records were documented in compliance with Title 22 regulations and state and federal law. Based on interviews, available evidence, observations, information received, and records reviewed, there was not sufficient evidence to support the allegation. Although the allegation may have occurred or may be valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur; therefore, the allegation is deemed unsubstantiated. A copy of the Complaint Investigation Report LIC9099 and LIC9099-C was provided to Ricky Ricardo, House Manager. No deficiencies were cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, Jul 1, 2026 · control 11-AS-20260623135620

Allegation investigated: Staff are inappropriately restraining a resident resulting in injuries.

On 06/17/26, the department conducted an unannounced subsequent complaint visit to deliver an amended report. *This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 05/06/26.* On 05/06/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to investigate the above mentioned allegation. LPA met with House Manager, Ricky Bernal, and the purpose of the visit was explained. LPA was granted entry to the facility. The investigation consisted of the following: On 05/06/26, the department received the following documents: staff roster, resident roster, and In-Service Training Guide for caregivers (dated: 04/22/26). CONTINUED ON LIC9099-C Substantiated The department reviewed resident #1’s (R1) service file and received the following documents: Admission Agreement (dated: 03/06/26), Physician’s Report (LIC 602), Preplacement Appraisal Information, Needs & Services Plan (dated: 03/09/26), and Physician order (dated: 04/06/26). Additionally, the department conducted interviews with staff #1-#3 (S1-S3), witnesses #1-#2 (W1-W2), residents #1 (R1), #5-#6 (R5-R6), and attempted to interview residents #2-#4 (R2-R4). Furthermore, the department conducted a tour of the facility. The investigation revealed the following: Allegation: Staff are inappropriately restraining a resident resulting in injuries. It is being alleged that a resident sustained bruising to their wrists and ankles due to facility staff restraining them. Record review of R1’s Admission Agreement dated 03/06/26 confirms that R1 was admitted to the facility on 03/06/26. Review of the Physician’s Report dated 03/06/26 indicates that R1 is ambulatory. The department reviewed R1’s Appraisal/Needs and Services Plan dated 03/09/26 and did not observe any documented need for postural supports or restraining devices. Record review of a physician’s order dated 04/06/26 reflects an order authorizing full side rails and a self-releasing seat belt for R1. On 05/06/26, the department conducted a tour of the facility and observed all residents present. During the tour, no bruising was observed on any resident’s wrists, and/or ankles. On 05/06/26, the department conducted interviews with S1–S3. Of those interviewed, 3 out of 3 staff denied the allegation and stated they do not restrain residents without a physician’s order. However, during the interview, S1 disclosed that a wheelchair seat belt had been placed on R1 without a physician’s order from the time of admission until approximately one month ago. S1 stated the seat belt was used depending on R1’s behavior and sundowning episodes and was discontinued once staff were informed that no physician’s order existed. An interview with S2 revealed that a self-releasing seat belt is used on R1 at times, depending on behavior. S2 stated there is a physician’s order authorizing a self-releasing seat belt and full side rails for R1. CONTINUED ON LIC9099-C On 05/06/26, the department conducted interviews with R1 and R5–R6 and attempted to interview R2–R4 but was unable to due to cognitive impairment. Of those interviewed, 3 out of 3 residents could not corroborate the allegation. On 05/06/26, the department conducted interviews with W1-W2. Attempts were made to contact W3-W4 for interviews; however, they did not respond. Of those interviewed, 1 out of 2 witnesses corroborated the allegation. Based on record reviews, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Ricky Bernal, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 11-AS-20260427084652

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Jun 24, 2026

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement was not met as evidenced by: Based on interviews conducted and records reviewed, S1 acknowledged that a seatbelt was placed on R1 since being admitted. The licensee did not have a physician’s order for Postural Supports until 04/06/26. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2026

Plan of correction: The licensee agreed to conduct an in service training for all staff on section cited and residents personal rights. The licensee shall submit to the department a copy of the sign in sheet, and training materials, by the POC due date.

Allegation investigated: Staff are inappropriately restraining a resident resulting in injuries.

On 05/06/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to investigate the above mentioned allegation. LPA met with House Manager, Ricky Bernal, and the purpose of the visit was explained. LPA was granted entry to the facility. The investigation consisted of the following: On 05/06/26, the department received the following documents: staff roster, resident roster, and In-Service Training Guide for caregivers (dated: 04/22/26). The department reviewed resident #1’s (R1) service file and received the following documents: Admission Agreement (dated: 03/06/26), Physician’s Report (LIC 602), Preplacement Appraisal Information, Needs & Services Plan (dated: 03/09/26), Physician order (dated: 04/06/26). Continued on LIC9099 Substantiated The investigation revealed the following: Allegation: Staff are inappropriately restraining a resident resulting in injuries. Record review of R1’s Admission Agreement dated 03/06/26 confirms that R1 was admitted to the facility on 03/06/26. Review of the Physician’s Report dated 03/06/26 indicates that R1 is ambulatory. The department reviewed R1’s Appraisal/Needs and Services Plan dated 03/09/26 and did not observe any documented need for postural supports or restraining devices. Record review of a physician’s order dated 04/06/26 reflects an order authorizing full side rails and a self releasing seat belt for R1. On 05/06/26, the department conducted interviews with S1–S3. Of those interviewed, 3 out of 3 staff denied the allegation and stated they do not restrain residents without a physician’s order. However, during the interview, S1 disclosed that a wheelchair seat belt had been placed on R1 without a physician’s order from the time of admission until approximately one month ago. S1 stated the seat belt was used depending on R1’s behavior and sundowning episodes and was discontinued once staff were informed that no physician’s order existed. An interview with S2 revealed that a self releasing seat belt is used on R1 at times, depending on behavior. S2 stated there is a physician’s order authorizing a self releasing seat belt and full side rails for R1. On 05/06/26, the department conducted interviews with R1 and R5–R6 and attempted to interview R2–R4 but was unable to due to cognitive impairment. Of those interviewed, 3 out of 3 residents could not corroborate the allegation. On 05/06/26, the department conducted interviews with W1-W2. Attempts were made to contact W3-W4 for interviews; however, they did not respond. Of those interviewed, 1 out of 2 witnesses corroborated the allegation. Based on record reviews, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Ricky Bernal, and a copy of this report and the Appeal Rights were provided.the state’s words, verbatim · CDSS document, May 6, 2026 · control 11-AS-20260427084652

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: May 13, 2026

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement was not met as evidenced by: Based on interviews conducte and records reviewed, S1 acknowledged that a seabelt was placed on R1 since being admitted. The licensee did not have a physician’s order for Postural Supports until 04/06/26. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 6, 2026

Plan of correction: The licensee agreed to conduct an in service training for all staff on section cited and residents personal rights. The licensee shall submit to the department a copy of the sign in sheet, and training materials, by the POC due date.

Allegation investigated: Staff member yelled at hospice worker in the presence of residents in care. Staff do not ensure that resident is administered their medication as prescribed by their physician.

On 11/14/2025, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to deliver findings on the above allegations. LPA met with Caregiver Marjorie Ravao and the purpose of the visit was explained. Investigation consisted of the following: On 10/09/2025, LPA obtained Personnel Report (dated 02/27/25), Register of Residents (04/07/25), Resident #1’s Physician's Report (07/14/25), Medication Administration Record (September and October 2025), and Needs and Services Plan. LPA interviewed Staff #1 – 3, Witness #1 – 2, and Residents #2 - #3. On 10/10/25, LPA received Hospice Record for R1. On 10/16/25, LPA interviewed Staff #1 - 2, #4, and #5. LPA left voicemails for Witness #4 -#5. On 10/24/25, Witness #3 left LPA a voicemail. On 11/03/25, LPA received ring camera videos (10/01/2025 11:45 AM – 2:30 PM). On 11/13/25, LPA interviewed Witness #6. Note: Resident #1 moved from the facility on 10/05/25. Continue to LIC9099-C. Unsubstantiated Allegation: Staff member yelled at hospice worker in the presence of residents in care. Record review of Hospice Record Incident Report (10/01/25 14:03) revealed Staff #1 became verbally aggressive (yelling) and physically came (within 2 feet) towards hospice worker to the point where another caregiver had to pull S1 away from the hospice worker. Hospice worker reported the incident occurred in front of other residents in the home. Record review of video recording revealed S1 and Hospice Staff having a disagreement over a resident’s medication and pain level. S1 also indicated that S1 can prevent the Hospice Staff from returning to the facility. From the beginning to the end of the discussion, S1 and the hospice staff maintained a personal conversational distance. The discussion occurred in front of the common bathroom and R1’s room (45 seconds) and in the entryway hallways (60 seconds). Two alert residents were in the living room for about one minute during the disagreement. The living room is about eleven feet from the common bathroom and about sixteen feet from the entryway. S1 indicated that S1’s voice is naturally loud and the hospice staff walked off while S1 was still talking. Staff #2 indicated that S1 and the Hospice Staff had an argument because of the pill box. The Administrator indicated that S1 started to question the Hospice Staff and Staff snapped back at S1. S1 wasn't screaming at the Hospice Staff. R1’s Responsible Party/Witness 1 indicated R1 was treated great at the facility. Two out of two responsible parties/witnesses (W2 – W3) indicated staff is professional and wonderful. Regarding the allegation, “Staff member yelled at hospice worker in the presence of residents in care,” based on record review and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. Allegation: Staff do not ensure that resident is administered their medication as prescribed by their physician. Regarding the allegation, “Staff do not ensure that resident is administered their medication as prescribed by their physician,” it is being alleged that three days of Norco medication was still in stock on 09/22/25. Review of Medication Administration Record (September) revealed Norco was refused on 09/13/25 – 09/14/25 (AM, Noon, and PM) and 09/29/25 – 09/30/25 (PM). Review of Hospice Record Visit Note Addendum (signed 10/09/25) revealed R1 had three days’ worth of medication. Continue to LIC9099-C. R1 should have ran out on 09/19/25. The present caregivers contacted Staff #4 and S4 indicated that R1 had not missed medication. Record review of Hospice Record Incident Report (10/01/25 14:03) revealed S1 indicated if R1 cannot take medication then S1 will not administer it. Hospice informed S1 to let Hospice know when patient is unable to take medications. S1 indicated that R1 refuses medication or is asleep. S1 indicated that hospice is not called since they come to the facility twice per week, check the medication bottle, and review the medication administration record. S1 indicated that the nurse is informed then. Staff #2 indicated that R1 refuses medication and is sleep during lunch. Staff #3 indicated that R1 refuses medication and sometimes sleep the full day. Staff #4 indicated that R1 is typically asleep, and some medication is missed. Administrator indicated that R1 refuses medication, or it is given when R1 wakes up late. The nurse is notified when she comes in. R1’s Responsible Party/W1 indicated that medication was not administered because R1 would sleep for a day and a half and not eat, refuse medication, and get angry, yell at people, and tell them to get out of the room. W1 indicated R1 has refused medication from W1 in the past. Interview with Hospice Representative/Witness 6 indicated if a resident missed medication for a day then they will document it and report it to whoever follows up that week. If it is ongoing then they should report it to hospice agency. W6 indicated that facilities should wake residents up for routine medication. Two out of two responsible parties/witnesses (W2 – W3) indicated they do not have medication complaints. Resident #2 indicated R2 does not have medication complaints. Regarding the allegation, “Staff do not ensure that resident is administered their medication as prescribed by their physician” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated. No deficiencies cited. An exit interview was conducted and a copy of this report was provided to Caregiver Marjorie Ravao.the state’s words, verbatim · CDSS document, Nov 14, 2025 · control 11-AS-20251002144249

Type of visit: Case Management - Other

On 11/14/25, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced case management - other visit. The purpose of the visit is to provide technical support and this was explained to the Caregiver Marjorie Ravao. The facility's Plan of Operation (Medication Documentation) revealed "each medication dose will be logged on the MAR". For unused and/or discontinued medications, staff in charge has to contact MD each time client refuses to take medication. The facility has two ring cameras in the common living room. Under no circumstances may video surveillance in facilities use an audio component and the Licensee has to ensure that clients' dignity and privacy rights are not violated by negligent and/or abusive surveillance practices The facility has a hospice waiver and residents' hospice plan shall include which duties are the Licensee and which are the hospice staff. Continue to LIC809-C. Training from hospice should also be documented and the facility shall maintain the training records for at least three years. Residents shall be encouraged to maintain and develop their quality of life through physical activities that maintain physical health including exercises, and other similar activities that promote balance, strength, coordination, flexibility, and range of motion. An exit interview was conducted, technical assistance provided, and a copy of this report was provided to the Caregiver Marjorie Ravao.the state’s words, verbatim · CDSS document, Nov 14, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced annual required visit with the primary focus on infection control measures and using the new CARE Inspection Tool. LPA Bunker met with House Manager Rickie Vernal and Staff Member Kian Pascual to explain the purpose of today's annual inspection. There are currently five residents in placement. The facility's annual fees are current. The following 12 Domains will be observed and reviewed: Infection Control, Operational Requirements, Physical Plant & Environmental Safety, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Planned Activities, Food Service, Incidental Medical and Dental, Resident Records/Incident Reports, Disaster Preparedness, and Residents with Special Health Needs. "LPA Bunker will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." Mr. Vernal and LPA Bunker toured the facility. The facility is a single-story family home located in a residential neighborhood. Which consists of a living room, dining area, kitchen, 3 bedrooms, 2 bathrooms, laundry area in the garage, attached garage, and an indoor/outdoor activity area. A shaded area furnished with outdoor patio furniture, including tables and chairs. Bedrooms #1,3, 4, and 5 are designated as the resident's bedrooms. Bedroom #2 is designated for the living staff. See continued LIC809-C page 2 Continued LIC802-C page 2 Documents have been posted, as mandated, on the bulletin board in the entrance hallway. The following Title 22 regulated areas were audited and found to be in compliance: The facility telephones are working. Bedrooms: All bedrooms meet the required standards for furniture, safety, privacy, and comfort. The facility has an adequate supply of linen. Bathrooms: The bathrooms are clean and operational, and residents are provided with the necessary personal accommodations with non-skid surface mats ensuring safety and privacy. Kitchen and Food Service: The kitchen is adequately equipped for food preparation and service. A review of the food service revealed an ample supply of perishable and nonperishable food, stored appropriately. Medication Storage and Management: Medications are centrally stored in a locked cabinet in the living room with up-to-date records, ensuring proper storage and documentation. Common Areas: The Living room, dining room, and common areas are well-maintained, free of potential hazards, and meet the cleanliness standards necessary for the safety and well-being of residents. Safety Equipment and Measures: The facility is equipped with a fully stocked first aid kit with manual, functional smoke and carbon monoxide detectors, and the fire extinguishers are in compliance and have been properly charged. The hot water temperature is measured at 111 degrees and is maintained within the standard range of 105-120 degrees Fahrenheit. Emergency Preparedness: All exit doors are in compliance, the resident's bedroom windows are equipped with sliding window locks without thumbscrews, and the facility conducted a fire drill on April 07, 2025. Environmental Safety: The yard is free from debris and hazards, trash cans are covered, and no firearms or bodies of water are present on the premises. Hazardous items are kept inaccessible to residents. Staff Training: Staff members have received training on reporting dependent adult and elder abuse. Administrative Compliance: The Administrator Certificate courses that have been completed are currently valid. Compliance with HIV/TB requirements has also been verified. LPA Bunker provided staff with a copy of the facility evaluation reports. There were no deficiencies cited. An exit interview was conducted.the state’s words, verbatim · CDSS document, May 8, 2025

Type of visit: Required - 1 Year

On 06/21/24 at 8:23 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with House Manager Ricardo Bernal. The facility is licensed for two (2) ambulatory and four (4) non-ambulatory, of which two (2) may be bedridden. Facility has two approved hospice waivers. Annual fees are current. This facility consists of an office area, foyer, kitchen, living room, dining area, a wheelchair ramp (located on the right side of the house), five (5) resident bedrooms, one staff bedroom, two (2) bathrooms, backyard patio, and a garage (washer/dryer). The facility is clean, sanitary, and in good repair. The House Manager 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. 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. 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, hot water temperature properly measured between 111 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Continue to LIC809-C. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxics were kept in locked storage cabinet. First Aid kit was available. The facility has a total of three fire extinguishers, last serviced March 20, 2024. House Manager tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional. 5 staff records were reviewed, 5 out of 5 staff records had required criminal record clearances or criminal record exemptions. 6 resident records were reviewed and, 6 out of 6 resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed. Deficiencies are being cited based on LPA observation and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. LPA did not observe one medication being given to Resident #1 from June 1 – June 20, 2024 which poses a potential health risk to client in care. An exit interview was conducted, technical assistance provided, plan of correction developed, and a copy of this report and appeals was discussed and left with House Manager Ricardo Bernal.the state’s words, verbatim · CDSS document, Jun 21, 2024

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility failed to maintain complete and accurate resident records.

On 12/12/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced complaint visit at the facility listed above. LPA met with House Manager, Ricardo “Rickey” Bernal, and explained the purpose of today’s visit. During today’s visit LPA conducted a facility inspection, interviewed Staff (S1-S2) , interviewed Residents (R1-R6), and received documents pertinent to the investigation. The following documents were received and reviewed. Resident Roster, Centrally Stored Medications, Medication Administration Record (MAR), Admission Agreement, Physicians Report, Resident Appraisal, Needs and Service Plan, Safeguard for Property/Valuables. Continued on LIC9099-C Substantiated The investigation revealed the following: Allegation: Facility failed to maintain a complete and accurate resident’s records. The allegation alleges that the facility has incomplete resident records. During the facility file review LPA reviewed and received copies of required documents to maintain for Residents. LPA reviewed six (6) Resident files, three (3) out of the six (6) Resident files had the required documents. During file review LPA observed the following documents were missing: Resident R2 was missing the Appraisal, Needs and Service Plan, and Safeguard for Property/Valuables. Resident R3 was missing the Appraisal, Needs and Service Plan, TB test, and Safeguard of Property/Valuables. Resident R4 was missing a Physicians Report and TB test. Interviews with Staff S1 and S2, two out of two stated they do not handle the Residents files, that the Administrator is responsible for making sure they have the required documents. Based on LPAs observations and record reviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number8), are being cited on the attached LIC 9099D. An exit interview was conducted with House Manager, Rickey Bernal, and a copy of this report and the Appeal Rights were provided. Allegation Facility is in disrepair. The allegation alleges that the facility is in disrepair. LPA interviewed S1-S2, two out of two stated the facility is not in disrepair. S1 stated there is a maintenance person who comes in and makes repairs as needed. Dring interviews with Resident’s R1-R6, six out of six stated the facility is not in disrepair and they have no complaints about their accommodations. LPA toured the facility and observed it to be well-maintained. All rooms, bathrooms, and the exterior were checked and found to be compliant with Title 22 regulations. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Based on interviews and observations, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Facility failed to maintain complete and accurate staff records. The allegation alleges that the facility has incomplete staff records. During the facility file review LPA reviewed and received copies of the required documents to be maintained in the staff files. LPA reviewed four (4) staff files (S1-S4), four out of four files had the required CCL documents including Personnel Record, Fingerprint Clearance, Criminal Record Statement, Health Screening, TB test, Employee Rights, Elder Abuse Index, First Aid/CPR Certificate, Education Verification, Medical Training and Staff Training Logs. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. An exit interview was conducted with Licensee, Albert Pimentel, and a copy of this report was provided. Allegation: Facility staff failed to properly administer resident’s medication The allegation alleges that there have been medication errors. During record review, LPA reviewed residents Medication Administration Records (MARs) and medications for six residents. Six (6) out of six (6) resident’s MARs and medication are consistent with properly documented records. LPA interviewed Staff (S1 & S1) two out of two staff stated they receive training annually for medication administration. LPA interviewed five Residents (R1-R6), and six (6) out of six (6) residents stated they receive their medications daily and on time. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated. Allegation: Facility is not adequately staffed The allegation alleges that facility is insufficiently staffed. During interviews with Resident’s (R1-R6), six (6) out of six (6) stated they receive assistance when needed and have not had to wait to receive assistance. Additionally, six (6) out of six (6) stated the facility has enough staff to provide care to the residents. During interview with Staff (S1-S2) two (2) out of two (2) stated they are able to provide care to residents as needed. Additionally, Staff stated there are two (2) staff on during the day and evening shift, and one on the night. Staff S2 stated additional staff would be useful. S1 stated if they require additional assistance, they can call the administrator and either they would come and help or they send staff from another location to come and assist. During the time of visit, LPA observed all resident cares being met, the residents did not have to wait before they received assistance. LPA reviewed the Staff Roster and observed there are four (4) staff and administrator who work regularly. During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Based on the interviews conducted, observation and records review, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.the state’s words, verbatim · CDSS document, Dec 12, 2023 · control 11-AS-20231211140253

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(10) · Plan of correction due date: Dec 12, 2023

87506 Resident Records (b)each resident record shall contain at least the following information (10)reports of medical assessment specified in section 87458, Medical Assessment and of any special problem or precautions This requirement was not met as evidency by: Based on LPA's record review at 10:30am, LPA did not observe a medical assessment (Physician's Report) for Resident R4, which poses a potential health or safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2023

Plan of correction: Administrator will submitt a medical assessment (Physician's Report) for Resident R4 to LPA by 12/26/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87606(b)(17)(A) · Plan of correction due date: Dec 12, 2023

87506 Resident Records (b)each resident record shall contain at least the following information (17)documents and information required by the following (A) Section 87457, PreAdmission Appraisal. This requirement was not met as evidence by: Based on LPA's record review at 10:30am, LPA did not observe a Pre Admission Appraisal for residents (R2 and R4), which poses a potential health or safety risk to residents in carethe state’s words, verbatim · CDSS document, Dec 12, 2023

Plan of correction: Administrator will submitt a Pre Admission Appraisal for Resident's R2 and R3 to LPA by 12/26/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(b)(1) · Plan of correction due date: Dec 12, 2023

87458 Medical Assessment (b)the medical assessment shall include, but not be limited to: (1)A physical examination of the resident indicating the physicians primary diagnosis and secondary diagnosis, if any and results of the examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions wich ould preclude care of the person by the facility. This requirement was not met as evidence by: Based on LPA's record review atthe state’s words, verbatim · CDSS document, Dec 12, 2023

Plan of correction: Administrator will submitt a tuberculosis test for Resident's R2 and R3 to LPA by 12/26/23. 10:30am, LPA did not observe a tuberculosis test for residents (R3 and R4), which poses a potential health or safety risk to residents in care