Villa Gardens

Type of visit: Required - 1 Year

At approximately 9:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1 Year Required visit and met with Staff Member, Nancy McKee. Licensee, Tina Camaclang, arrived during visit at approximately 10:40AM. Facility provides care and assistance to older adults and has a dementia care program on file. Facility has an approved fire clearance for a total capacity of 12 non-ambulatory residents. Upon arrival, LPA was informed that there were currently 8 residents in care and 3 staff members on-site. At approximately 9:10AM, LPA reviewed the Facility's Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. LPA conducted a walk-through of the facility and made the following observations: Per facility sketch, facility consists of 8 resident rooms, a staff break room, and common areas. Facility has a separate building for laundry and extra storage. Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has an Infection Control Plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins and other hazards were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for all facility sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. During walkthrough, LPA observed the following: Multiple instances of food being unlabelled in facility fridge Facility freezer in need of cleaning - observed frozen liquid and food particles at the bottom of freezer drawer. During visit, LPA observed facility staff put dates on unlabelled foods and clean the freezer drawer of liquid and food particles. Continued on LIC809C Continued from LIC809 Prepoured noon medications for two residents observed on kitchen counter and additional prepoured bedtime medication found in locked medication cabinet for multiple residents LPA observed that a kitchen cabinet door was not attached leaving the facility pots and pans exposed, and a resident's toilet lid and seat was not fastened to the toilet Resident bathroom wastebins did not have lids on them LPA observed that staff break room was being used as additional storage and had multiple bags and other boxed items Facility did not have emergency water supply on-site LPA observed that facility's last documented emergency/disaster drill was conducted December 2025. Per Licensee and facility staff, they had an emergency drill in March 2026 but were unable to provide documented proof of drill. Facility's emergency disaster plan was last reviewed and updated 12/2025. Facility's smoke and carbon monoxide detectors were tested and operational. LPA observed that facility's fire extinguisher was newly purchased per receipt stating 03/2026. LPA reviewed 4 staff files. Staff Files were all found to have current First Aid and CPR certification. 2 of 4 staff files were shown to not have a health screening or negative TB test on file. 1 of 4 staff files showed that Staff Member 4 (S4) was hired by the facility on 10/01/2025 but had their health screening and TB test done on 12/12/2024. Per Title 22 Regulations, a health screening shall be completed no longer than 6 months prior to their employment. Administrator's Certificate for Albertina Camaclang (7002848740) was current with an expiration date of 02/16/2028. LPA reviewed 4 resident files. Resident files had updated assessments and reappraisals. 2 of 4 residents had missing consent forms. 1 of 4 residents did not have their appraisal signed. During walkthrough, LPA observed that Resident 1 (R1) had full bed rails. Review of R1's file showed that R1 has been receiving hospice services since 2025 but did not have a care plan or hospice care plan on file indicating if there was an order or specified need for their full bed rails. LPA conducted a spot audit of 3 Resident medications. LPA observed the following errors: Facility was not completely filling out medication expiration dates and was only documenting month and year instead of month, day, and year as shown on the pharmacy label. Error in filling out expiration and fill dates per pharmacy label Continued on LIC809C Continued from LIC809C Clearlax medication was labelled as "Over the Counter" or OTC, when it had a pharmacy label for the facility to document on the LIC622 or Centrally Stored Medication and Destruction Record Facility had some resident medication that was not logged as required. LPA is requesting the following documents to update facility file: Designation of Facility Responsibility (LIC308) Updated Personnel Report (LIC500) Updated Liability Insurance Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Copy of report, LIC809D (Deficiency Page), LIC9102 (Technical Advisories/Violations), Plan of Corrections, and Appeal Rights discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 1, 2026

The state marks this report as 11 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: Staff caused injury to resident

At approximately 1:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a complaint investigation regarding the above allegation and met with Staff Member, Nancy Mckee. Licensee/Administrator, Tina Camaclang, was available by telephone. During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, "Staff caused injury to resident." Complaint alleged that Resident 1 (R1) stated that they were hit by a caregiver and was observed to have a bruise under their left eye. Report further stated that R1 could not provide any additional information about the caregiver. Review of R1's file showed that they are currently receiving hospice and home health services. R1's physician report dated 05/15/2025, stated that R1 has a diagnosis of dementia and is able to communicate Continued on LIC9099C Unsubstantiated Continued from LIC9099 their needs sometimes due to poor memory. R1's care plan dated 04/23/2025 stated that R1 has confusion and agitation related to their dementia diagnosis. Review of incident report stated that R1 was observed to have redness and pinkish color under their left eye on 12/08/2025. Facility staff notified R1's hospice agency and responsible party. R1's hospice notes dated 12/09/2025 stated that R1 was observed to have a faded bruise under their left eye, and when showed the bruise, R1 stated "that's nothing." Hospice notes continued to state that R1 did not have any other visible injuries or reports of pain. Review of facility notes indicated that a care conference was held on 12/17/2025 to discuss R1's bruise, behavior, agitation, and review medication. An interview with the resident was conducted. Interview with R1 did not reveal any additional or new information. Interviews with facility staff were conducted. 3 of 3 facility staff members stated that they have not observed or heard of residents being roughly handled or treated in a rude way by staff. Based on record review, interviews conducted, and observations made, this allegation is Unsubstantiated. A finding that a complaint allegation is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Exit interview conducted. Copy of report discussed and provided to Staff Member. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 21-AS-20251211210006

Type of visit: Post Licensing

At approximately 12:15PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Post-Licensing visit and met with Staff Member, Nancy McKee. Licensee, Tina Camaclang, arrived during visit at approximately 1:30PM. Facility provides care and assistance to older adults and has a dementia care program on file. Facility has an approved fire clearance for a total capacity of 12 non-ambulatory residents. Upon arrival, LPA was informed that there are currently 8 residents in care and 3 staff members on-site. At approximately 12:25PM, LPA reviewed the Facility's Staff Roster and found that all staff members on site were background cleared and associated to the facility per regulation. LPA conducted a walk-through of the facility and made the following observations: Facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has an Infection Control Plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Mattress pads were in place or available for Resident use. Hot water temperatures for all facility sinks were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility's fire extinguisher were newly purchased and were observed to be fully charged. Facility's smoke and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted May 2025. During walkthrough, LPA observed that food in facility fridge were not labelled and dated (technical advisory issued). LPA reviewed staff and resident files and resident medications. Staff Files were all found to have current First Aid and CPR certification. Administrator's Certificate for Albertina Camaclang (7002848740) was current with an expiration date of 02/16/2026. Resident Files had updated Admissions Agreements and Care Plans. Resident medication was centrally stored and secure. Review of 9 of 9 resident files showed missing consent forms (technical advisory issued). No Deficiencies Cited. Exit interview conducted. Copy of report and LIC9102 (Technical Advisories) discussed and provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 24, 2025

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Prelicensing

At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Pre-Licensing visit and met with Staff Member, Nancy McKee. Applicant, Tina Camaclang, arrived during visit at approximately 10AM. Applicant has applied for a Change of Ownership for an existing Residential Facility for the Elderly (RCFE) identified as Schon Hyme Rest Home (210102881). Facility currently provides care to older adults and has a dementia care program on file. Facility received an approved fire clearance dated 02/13/2025 that allows for a total capacity of 12 non-ambulatory residents. Upon arrival, LPA was informed that there are currently 4 residents in care. LPA conducted a physical plant walk-through. LPA observed the following: Per facility sketch, facility is a one story residence with 8 resident bedrooms, 5 1/2 bathrooms, 1 staff break room, and common areas. Facility has a separate building on-site for laundry. Facility was found to be clean with all exits free from obstruction. Facility had emergency lighting. Facility's door alarms were tested and operational. LPA observed required postings including the CCL Complaint Poster and Personal Rights. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility's hot water temperatures for all sinks were within Title 22 Regulations of 105F to 120F. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Toxins were observed to be stored inaccessible to residents. Bathrooms were equipped with necessary grab bars and non-slip floors/mats were present. All resident rooms were furnished with a bed, lamp, dresser, and chair. Facility has sufficient items for cooking and eating. Facility has indoor/outdoor areas for visiting and activities. Facility's fire extinguishers were newly purchased and were observed to be fully charged. Facility's smoke and carbon monoxide detectors were tested and operational. LPA confirmed that contents of the facility's First Aid Kit were sufficient. Continued on LIC809C Continued from LIC809 LPA and Applicant discussed the following items: Hospice Waiver - Applicant to apply for a waiver if it's decided they want hospice care in the facility Updated Admission Agreements and Care Plans - Applicant understands that they will need to complete new Agreements and Care Plans for all residents once Facility License is approved. Complaint Poster (PUB 475) - Applicant to ensure required poster is correct size (20x26). Protective Mattress Pads - Applicant understands that mattress pads should be available on-site for resident use if requested Guardian background clearances and associations - Applicant understands that all current staff members associated to Schon Hyme Rest Home (210102881) will need to be transferred and associated to new facility license once approved. Applicant to submit proof of protective mattress pads and correctly sized Complaint Poster. Proof to be submitted to Community Care Licensing (CCL) by 04/18/2025. Component III was reviewed with Applicant. No Deficiencies or Advisories given during visit. Pre-Licensing completed. Facility is ready to be Licensed as an Residential Facility for the Elderly (RCFE). LPA will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicant of Status. Exit interview conducted. Copy of report discussed and provided. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 9, 2025

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: CHOW Capacity: 12 Census (if any clients in care): 4 COMP II Participants: Albertina Camaclang (Board Member/Administrator) Interview Method: Virtual interview via Microsoft Teams On March 14, 2025, 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, Mar 14, 2025