Fern Home I

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPA was granted entry and met with Administrator Joi Mae Gubalane and explained the purpose of today's visit. Five (5) residents in care were present during the visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to administrator Joi Mae Gubalane.the state’s words, verbatim · CDSS document, Sep 20, 2023

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPA met with Administrator Joi Mae Gubalane and explained the purpose of today's visit. Five(5) of five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to administrator Joi Mae Gubalane.the state’s words, verbatim · CDSS document, Jul 10, 2023

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Joi Mae Gubalane, who was informed of the purpose of the visit. At the time of the visit there was (2) staff and(5) residents present. The facility is a one-story home with (6) bedrooms and (2) bathrooms. The residents served are elderly adults aged 65 years and older. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and client interviews. LPA observed the following: Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training. Physical Plant: LPA observed the resident's bedrooms and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide was operational, and the hot water temperature 117F. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator, possesses a current administrator's certificate. Record Review and Resident/Staff Files: LPA reviewed (2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) resident files were reviewed, and possessed all required paperwork. Health Related Services/ Incidental Medical Services: All resident medication was locked in a cabinet located in the staff room. LPA reviewed medications for (2) residents and found all medication listed on MARS and all required labeling was found to be in place. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA interviewed administrator inquiring last fire/earthquake drill which met the department requirements. LPA will create technical advisory to have facility keep documentation for the fire/earthquake drills. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the garage and first aid kit with all required items. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Administrator, Joi Mae Gubalane.the state’s words, verbatim · CDSS document, Jul 10, 2023

Type of visit: Case Management - Other

On 5/9/2023, Licensing Program Analysts (LPAs) Chinwe Nwogene and Sara Martinez arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPAs met with Administrator Joi Mae Gubalane and explained the purpose of the visit. Five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPAs observed no health and/or safety hazards inside the facility. LPAs observed all facility utilities to be on and operating without issue. There was a sufficient number of staff present at the facility to provide care. LPAs assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of this report was reviewed with and provided Joi Mae Gubalane.the state’s words, verbatim · CDSS document, May 9, 2023

Allegation investigated: Lack of care and supervision

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to conclude a complaint investigation into the allegation listed above. LPA met with Administrator (AD) Joi Mae Gubalane and discussed the purpose of the visit. Regarding the allegation "Lack of care and supervision". It was alleged that Resident #1's(R1's) pressure injury developed maggots while in care due to neglect. R1 was admitted to the facility on August 28, 2021 and was discharged from the facility on October 17, 2021. During the initial facility visit on October 12, 2021, LPA observed flies in the facility and records reviewed revealed hospice staff had “occasionally” observed flies in the facility. AD Gubalane reported she has to continually remind staff to keep the rear sliding door shut. Interviews conducted with two (2) of two (2) witnesses revealed the wound on R1’s legs were observed to have live maggots on the outside of the bandages and more maggots “poured out” of R1’s bandages when they were cut. During interviews with facility staff, three (3) of three (3) facility staff denied ever observing maggots on R1's wounds. However, photographic evidence obtained by R1’s hospice agency confirmed the presence of live maggots on R1's leg wounds. Hospice records reviewed revealed facility staff were educated on September 27, 2021 and again on September 29, 2021 regarding the need to reposition R1 every two (2) hours to prevent further damage to R1’s pressure injuries.(CONTINUED ON LIC9099-C) Substantiated (CONTINUED FROM LIC9099) Staff were also educated on the use of a foam wedge to assist R1’s positioning. Staff acknowledged understanding of this on both dates. Interview with R1’s hospice agency staff indicated there was “nothing to indicate that they didn’t understand” however, R1 was “always” lying on their back. Interviews with R1 revealed the resident was not repositioned every two hours. Interviews conducted with facility staff revealed staff turned R1 only once in the morning and once in the afternoon. Based on Community Care Licensing staff observations, interviews which were conducted, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099 D. An exit interview was conducted with AD Gubalane, and a copy of this report was provided along with Appeal Rights.the state’s words, verbatim · CDSS document, Feb 8, 2023 · control 18-AS-20211012113454

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2 · Plan of correction due date: Feb 22, 2023

Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1... residents in privately operated residential care facilities for the elderly shall have... the following personal rights:(8)To be free from neglect...or sexual abuse. This requirement was not met as evidenced by: The licensee did not ensure R1 was free from neglect. Based on interviews and record review, facility staff neglected the wounds of R1 which resulted in the development of maggots on R1's leg wounds. This poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 8, 2023

Plan of correction: The facility states training will be conducted with all staff regarding the importance of following directions given by hospice staff. Proof of training to be provided to CCL by POC due date of 2/22/2023.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPA met with Administrator Joi Mae Gubalane and explained the purpose of the visit. Five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Gubalane.the state’s words, verbatim · CDSS document, Feb 8, 2023

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPA met with Administrator Joi Mae Gubalane and explained the purpose of the visit. Five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Gubalane.the state’s words, verbatim · CDSS document, Dec 9, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPA met with Administrator Joi Mae Gubalane and explained the purpose of the visit. Five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Gubalane.the state’s words, verbatim · CDSS document, Sep 22, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPA met with Caregiver Joselyn Tolentino and explained the purpose of the visit. Five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Tolentino.the state’s words, verbatim · CDSS document, Aug 19, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA arrived at 1:30 PM, LPA was met by Administrator Joi Mae Gubalane and explained the purpose of the visit. Present in the facility during time of visit were three (3) staff as well as five (5) residents. There are currently no cases of COVID-19 within the facility. During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed insufficient signage throughout the facility, insufficient hand hygiene supplies, insufficient cleaning and disinfecting provisions, and proper use of face coverings by staff. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, PPE supplies need to be maintained at the facility, cleaning and disinfection provisions are in inadequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19, when and how to isolate/quarantine residents, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas. The facility also needs to maintain a plan to monitor resident(s) regularly for any changes in condition and to subsequently notify the resident(s) physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses. Based on the observations made during today’s visit, nine (9) Technical Assistance were issued , no deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 20, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPA met with Caregiver Joselyn Tolentino and explained the purpose of the visit. Five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. LPA inspected the outside perimeter of the facility and observed no health and/or safety hazards. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Tolentino.the state’s words, verbatim · CDSS document, Jul 19, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPA met with Administrator Joi Mae Gubalane and explained the purpose of the visit. Four (4) of five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. LPA inspected the outside perimeter of the facility and observed no health and/or safety hazards. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Per Gubalane, there are no residents currently on hospice at this facility. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Gubalane.the state’s words, verbatim · CDSS document, Jun 22, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPA met with Administrator Joi Mae Gubalane and explained the purpose of the visit. Five (5) of five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. LPA inspected the outside perimeter of the facility and observed no health and/or safety hazards. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Gubalane.the state’s words, verbatim · CDSS document, May 19, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPA met with Caregiver Jocelyn Tolentino and explained the purpose of the visit. Five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. LPA inspected the outside perimeter of the facility and observed no health and/or safety hazards. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Tolentino.the state’s words, verbatim · CDSS document, May 12, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPA met with Administrator Joi Mae Gubalane and explained the purpose of the visit. Five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. LPA inspected the outside perimeter of the facility and observed no health and/or safety hazards. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Gubalane.the state’s words, verbatim · CDSS document, May 5, 2022

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Tricia Danielson and Chinwe Nwogene arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPAs met with Administrator Joi Mae Gubalane and explained the purpose of the visit. Five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. LPA inspected the outside perimeter of the facility and observed no health and/or safety hazards. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Gubalane.the state’s words, verbatim · CDSS document, Apr 29, 2022

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Tricia Danielson and Chinwe Nwogene arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPAs met with Administrator Joi Mae Gubalane and explained the purpose of the visit. Five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. LPA inspected the outside perimeter of the facility and observed no health and/or safety hazards. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Gubalane.the state’s words, verbatim · CDSS document, Apr 21, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPAs met with Administrator Joi Mae Gubalane and explained the purpose of the visit. Five (5) of five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. LPA inspected the outside perimeter of the facility and observed no health and/or safety hazards. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Staff were observed preparing lunch. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Gubalane.the state’s words, verbatim · CDSS document, Apr 15, 2022

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Tricia Danielson and Chinwe Nwogene arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPAs met with Administrator Joi Mae Gubalane and explained the purpose of the visit. Four (4) of five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. LPA inspected the outside perimeter of the facility and observed no health and/or safety hazards. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Gubalane.the state’s words, verbatim · CDSS document, Apr 4, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPA met with Administrator Joi Mae Gubalane and explained the purpose of the visit. Five (5) of five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. LPA inspected the outside perimeter of the facility and observed no health and/or safety hazards. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Monce and Tolentino.the state’s words, verbatim · CDSS document, Mar 29, 2022

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Tricia Danielson and Chinwe Nwogene arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPA met with Caregivers Alejandra Monce and Joselyn Tolentino and explained the purpose of the visit. Administrator Joi Mae Gubalane was present during today's visit but was on a phone call. Five (5) of five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. LPA inspected the outside perimeter of the facility and observed no health and/or safety hazards. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Monce and Tolentino.the state’s words, verbatim · CDSS document, Mar 24, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPA met with Caregivers Alejandra Monce and Joselyn Tolentino and explained the purpose of the visit. Administrator Joi Mae Gubalane was unavailable for today's visit. Five (5) of five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. LPA inspected the outside perimeter of the facility and observed no health and/or safety hazards. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Monce and Tolentino.the state’s words, verbatim · CDSS document, Mar 18, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPA met with Joi Mae Gubalane, Administrator and explained the purpose of the visit. Five (5) of five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. LPA inspected the outside perimeter of the facility and observed no health and/or safety hazards. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Gubalane.the state’s words, verbatim · CDSS document, Mar 8, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPA met with Joi Mae Gubalane, Administrator and explained the purpose of the visit. Five (5) of five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. LPA inspected the outside perimeter of the facility and observed no health and/or safety hazards. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Gubalane.the state’s words, verbatim · CDSS document, Mar 1, 2022

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct a case management visit in conjunction with complaint 18-AS-20220216102150 to check on the health, safety, and welfare of residents in care. LPA met with Joi Mae Gubalane, Administrator and explained the purpose of the visit. Three (3) of five (5) residents in care were present during visit. No imminent health and/or safety concerns were observed at the time of visit. LPA observed no health and/or safety hazards inside the facility. LPA observed all facility utilities to be on and operating without issue. LPA inspected the outside perimeter of the facility and observed no health and/or safety hazards. There was a sufficient amount of staff present at the facility to provide care. LPA assessed the available food supply and observed that the supply exceeds the requirement of a two (2) day supply of perishable foods and a seven (7) day supply of non-perishable foods. Medications were found to be in sufficient supply as well. Based on the information obtained during today's visit, there are no immediate threats to the health, safety, and welfare of the residents in care. No deficiencies were cited during today's visit. An exit interview was conducted and a copy of this report was provided to Gubalane.the state’s words, verbatim · CDSS document, Feb 23, 2022

Allegation investigated: Facility staff did not keep the facility free of flies Facility is not kept clean

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to initiate a complaint investigation into the allegations list above. LPA was greeted upon entry by caregiver Joselyn Tolentino. Tolentino phoned Administrator (AD) Joi Mae Gubalane of LPA's presence in the facility and she arrived moments later. LPA discussed the purpose of the visit with AD. During today's visit, LPA toured the facility, interviewed four (4) of five (5) residents, one (1) staff, and reviewed pertinent documents and records. LPA also obtained copies of pertinent documents and records. Regarding the allegation "facility did not keep the facility free of flies", one (1) of two (2) residents interviewed who were reliable historians, reported the facility has an issue with flies. Two (2) other residents interviewed were not reliable historians. The fifth (5th) resident of the facility was not home at the time of LPA's visit and was therefore not interviewed. LPA personally observed flies in the front TV room of the facility as well as a fly swatter being stored on top of the wall furnance in the same room. Interview with AD revealed the facility does have flies in the facility on occasion. Regarding the allegation "facility is not kept clean", it was alleged that the room of resident #1 (R1) was not kept in a clean manner. LPA observed (CONTINUED ON LIC9099C) Substantiated (CONTINUED FROM LIC9099) numerous stacks of adult briefs being kept in a corner of R1's room. LPA also observed a box of goldfish crackers on a bedside table in R1's room and tins of cookies being kept on top of the stacked adult briefs. In the kitchen, LPA observed a grease splattered wall behind the stove and the microwave above the stove was also grease splattered. LPA also observed the stove top itself to be unclean. Based on LPA's observations, interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code Of Regulations, Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099 D. An exit interview was conducted with AD Gubalane and a copy of this report was provided along with Appeal Rights.the state’s words, verbatim · CDSS document, Oct 12, 2021 · control 18-AS-20211012113454

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 22, 2021

Maintenance and Operation- (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by: Based on LPA's observations, the licensee did not ensure the faciltiy was maintained in a clean manner. LPA observed the stove top, microwave, and kitchen wall behind the stove to be splattered with grease. LPA also observed flies in the facility and a fly swatter being stored in a very easily accessable (cont in right column)the state’s words, verbatim · CDSS document, Oct 12, 2021

Plan of correction: Licensee states facility staff will ensure the rear facility door is not left open to allow flies into the facility and conduct a training. Licensee stated the facility will store the adult briefs in a storage closet. Licensee stated facility staff will clean the kitchen stove, microwave and walls and maintain it in a clean manner by POC due date. manner. 1 of 2 residents interviewed reported the facility has flies. Interview with AD also revealed the facility has an issue with flies. LPA also observed multiple stacks of adult briefs being stored in room #2. This poses a potential health, safety, and personal rights risk to residents in care.