Clegg Care Facility

Type of visit: Office

An office meeting was held on July 30, 2026 at 4pm via Microsoft Teams for the purpose of reviewing the Stipulation and Waiver Order. The Stipulation and Waiver; and Order was adopted on July 14, 2026. Licensing Staff Present: Regional Managers: Stephenie Doub, Licensing Program Manager: Stephen Richardson Licensing Program Analyst: Arvin Villanueva Facility/Licensee Representatives Present: Licensee/Administrator, Edna Clegg Assistant Administrator, Abikhay Laureta The Regional Manager discussed the purpose of the meeting and explained the conditions and terms of the Stipulation and Waiver with Order, including but not limited to, revocation of license, revocation of administrator certificate, compliance expectations, waiver of application, condition of employment, landlord capacity. The Stipulation was reviewed in detail with the Licensee/Administrator, who acknowledged understanding of the terms and conditions. At this time, the Licensee initiated a facility closure effective July 31, 2026. All the residents have relocated prior to this meeting. A closure visit was conducted on July 30, 2026 prior to this meeting. Per the California Code of Regulations, Title 22, no violations were cited during this visit. An exit interview was conducted, and a copy of this report was providedthe state’s words, verbatim · CDSS document, Jul 30, 2026

Type of visit: Case Management - Licensee Initiated

On July 30, 2026, Licensing Program Analyst, Arvin Villanueva (LPA) arrived announced to this facility to conduct a case management visit in regard to facility closure. LPA met with administrator Edna Clegg and administrator assistant, Abikhay Laurente. The census is 0. A Notice of Facility Closure was received with a facility closure date of July 31, 2026. Per administrator, the last resident moved out earlier this morning, prior to this visit on July 30, 2026. LPA conducted a tour of the facility with Administrator. A tour of the facility exterior and interior of the facility was conducted, including the front and backyards, living room, dining room, kitchen, bathrooms, and all bedrooms. LPA observed that there were no residents at the facility. LPA obtained the facility license, relocation roster, and eviction notices provided to the residents. LPA will close the facility in the system. LPA discussed the facility closure survey and it was completed by administrator during this vsiit. Link to survey for Facility Closure provided to Licensee. www.surveymonkey.com/r/facilityclosure Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 30, 2026

Type of visit: Required - 1 Year

On July 7, 2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived at this facility unannounced to conduct the annual inspection visit. LPA met with the licensee/ administrator, Edna Clegg (AD), and explained the purpose of the visit. Present during this visit were five residents with one staff on duty. Overview: Facility is a one-story house located in a residential neighborhood. Facility is licensed to serve up to ten elderly residents. AD initiated the closure process, with a proposed closure date of July 31, 2026. Per AD, she informed the Ombudsman when they visited on July 6, 2026. Physical Inspection: LPA and AD toured/inspected the facility is a home with 7 resident bedrooms and 2 bathrooms. Facility has common area, dining area, outdoor area, laundry room and kitchen. The facility has adequate supply of 7-day non-perishable and 2- day perishables stored in the kitchen and pantry. Smoke detectors and carbon monoxide detectors were observed throughout. Fire extinguisher was observed and current. Toxins, sharps and medications were locked and not accessible. Record Reviews: LPA reviewed 5 resident files and are in compliance at this time. Medications are centrally stored and in compliance. Requested documents: LPA emailed the closure procedure and closure roster for all residents. LPA requested AD to fill out the closure roster and submit to LPA. LPA requested a copy of the 60-day Notice that was provided to each of the residents. AD was advised that a closure visit will be conducted at a later date after all residents move out. LPA also requested copy of current Liability Insurance. An exit interview was conducted, and a copy report was left.the state’s words, verbatim · CDSS document, Jul 7, 2026

Type of visit: Required - 1 Year

On 07/17/2025 at 9:00 AM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived at the facility to conduct an unannounced annual inspection. LPA Hughes met with administrator Edna and explained the purpose of the visit. The current census is 5 with 4 facility staff. This facility is a single story building licensed to serve (5) non-ambulatory and (5) ambulatory residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA's toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 113.4 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in the kitchen area and was last serviced on 06/07/2025. LPA's observed the facility has a public telephone in the kitchen area and the facility has the required posters posted. Facility thermostat was observed at 73 degrees Fahrenheit. LPA observed toxins located in the hallway closet kept locked and inaccessible to residents. LPA observed sharp knives kept locked in the kitchen and inaccessible to residents. Continuation 809-C LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 2 out of 5 residents medications and the medication administration record (MAR) was not in compliance with title 22 regulations. LPA observed 2 out 5 residents medication log without proper documentation of the medication being administered for several days. Administrator stated, they forgot to document medication administration, and that the log would be updated today 7/17/2025. The first aid kit was checked and contained the required components. LPA requested resident and staff files for review. LPA's reviewed 5 out of 5 resident files and they were not complete. LPA's reviewed 5 staff files, and it was not in compliance with Title 22 regulations. LPA observed 3 staff files verification of annual training not updated for the current year. Administrator stated that the training would be purchased and completed. LPA reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared. The following documents will be email to LPA by 07/18/2025 end of day 5:00 PM: (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (3) LIC 610 Current Emergency Disaster Plan (4) Proof of Current Liability Insurance (5) LIC 500 Current Personnel Report As a result of this annual visit, the facility is not in compliance with Title 22 Regulations, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with Edna and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Jul 17, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst, Pang Lee arrived on 02/12/25 for an unannounced inspection to follow up on a substantiated allegation complaint investigation. LPA Lee met with Caregiver/House Manager, Maxwell Llorente who informed LPA Lee that administrator Edna Clegg is on vacation and will return the end of the month. On March 21, 2023, the Department concluded a complaint investigation which alleged the following: Resident sustained a shoulder dislocation while in care. The licensee was cited for California Code of Regulations (CCR) 87464(f)(1) Basic Services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health safety Code section § 1569.49. Facility staff failed to provide adequate care, supervision, and did not follow facility protocol, which is to leave any fallen residents on the floor until medical professionals arrive. Facility staff picked up a resident which resulted in the resident sustaining a bilateral shoulder dislocation. At the time of the complaint visit on March 21, 2023, an immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” Continued LIC 809-C This is evidenced by the facility failing to provide care and supervision in a timely manner due to staff not trained to properly lift residents that resulted in a resident (R1) being diagnosed with a bilateral dislocated shoulder and a pelvis fracture, which is serious bodily injury. Today, 02/12/25 the Department will be issuing a civil penalty per Health and Safety Code §1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount of $10,000. However, since an immediate civil penalty of $500 was previously issued on March 21, 2023, the amount of the civil penalty issued today will be $9,500. Exit interview conducted. A copy of the report has been issued. Appeal rights provided. Facility representative and signature on this report acknowledges receipt of the appeal rights, found on page two of the LIC 421D.the state’s words, verbatim · CDSS document, Feb 12, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Pang Lee arrived at facility unannounced to conduct a case management visit on 01/02/24, at 11:28 AM, LPA Lee met with administrator Edna Clegg and explained the purpose of the visit. The census is 6. The purpose of today's visit is to follow up on a LIC 624 incident report that the department received on 12/22/24. The incident report is regarding an absent without leave (AWOL) event that occurred on 12/15/24. It was learned that resident 1 (R1) left the facility unassisted at 9:30 AM to attend church and did not return to the facility the entire day. It was also learned that administrator Edna observed R1 signing himself out using the facility sign in and out sheet. Facility staff Maxwell contacted local emergency and law enforcement regarding a missing person. In an interview with facility staff Maxwell, the facility overlooked and didn’t recognize that R1 was unable to leave the premises without assistance. Both Administrator Edna and staff member Maxwell stated that they were unaware of how (R1) ended up at the hospital. In an interview with R1’s Service Coordinator, it was revealed that R1 walked to Walmart after church, where R1 experienced a fall and then a pedestrian helped R1 to Walmart, but upon entering the store, R1 had another fell. Walmart then called an ambulance, and R1 was transported to Methodist Hospital. Furthermore, R1's LIC 602 Physician’s Report, dated 08/12/24, indicates that R1 has mild cognitive impairment and is not capable of leaving the facility unassisted. Based on today’s case management, a citation is issued under Title 22, Division 6. An immediate civil penalty in the amount of $500 is assessed on 01/01/25 due to lack of care and supervision and an immediate health and risk to R1. An exit interview was conducted with administrator Edna. A copy of this LIC 809, LIC 809-D, LIC 421-IM and appeal rights was provided to the facility at the end of the visit.the state’s words, verbatim · CDSS document, Jan 2, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Jan 9, 2025

1569.312(a) Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidence by: Based on records review and interviews with the facility staff the facility did not comply with section cited above. R1 left the facility unassisted and did not return to the care home. R1 had a fall and then was transported to the hospital. The LIC 602 states R1 was not allowed to leave the facility unassisted. This presents an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Jan 2, 2025

Plan of correction: The Licensee/Administrator shall conduct an in-service training with staff to go over what and how staff shall ensure that residents do not AWOL. Licensee/Administrator shall send the in-service training materials, plan on how staff will ensure residents do not AWOL and a signature sheet of all staff who attended the in-service. Licensee/Administrator will also provide LPA Lee an updated LIC 500 to ensure sufficient staffing at all times and in writing staffing schedule to be put in place immediately to ensure the safety of the residents in care. POC due to LPA Lee by 01/09/2025 end of day 5:00 PM

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Pang Lee arrived at facility unannounced to conduct a quarterly visit on 12/12/2024, LPA Lee met with administrator Edna Clegg and explained the purpose of the visit. The purpose of the visit today is to conduct a quarterly visit. LPA toured 6 resident bedrooms. All rooms were observed to meet the resident's needs at this time. Living area, dining area and other resident areas were observed. Furniture was observed to be in good repair. LPA observed a sufficient amount of 2-day perishable and 7-day non-perishable food supply at this time. Toxins were observed to be locked and made inaccessible to residents. Smoke detectors and carbon monoxide was observed to be in good repair. Indoor temperature of the facility was 70 * F. LPA Lee followed up with the following: · Eviction Procedures: No current evictions issue. · Personal Rights: kitchen and pantry were not lock during today’s visit. · Fire Clearance: carbon monoxide detector and fire alarm was in good repair. · Maintenance and Operation: facility hot water was measured at 112.5 * F. · Incidental Medical and Dental Care Services: LPA Lee reviewed 2 out of 6 client MAR logs and they were not accurate. LPA observed two resident’s medication are in the bubble pack; however, the medications are not documented on the MAR logs. · Personal Records: 2 facility staff files were reviewed, and it was complete and has TB test. · Bed Bugs: facility does not have any bed bugs. Continued LIC 809-C · Reporting Requirements: LPA Lee reviewed Community Care Licensing Department (CCLD) Unusual Incident Report (UIR) LIC 624 files for December 2023 to December 2024 and did not observe any incident reports reported to the department. LPA Lee observed 5 resident’s file and there are no incident reports. Per administrator Edna and staff Maxwell residents don’t have any incidents and residents have not been to the hospital. LPA Lee observed resident 1 (R1)’s file and it was learned that R1 had hip surgery on 12/02/2024 and is still at the hospital during today's visit. It was also learned that on 04/19/23, R1 was in a serious car accident with R1’s service coordinator from Telecare. LPA Lee did not observe an incident report regarding the 04/19/23 incident in the file. An hour and a half later, staff Maxwell brought the LIC 625 incident report to LPA Lee. It was also learned that the facility does not keep fax receipt. The facility was not able to provide LPA Lee proof of incident reports being reported/fax to the department. · Resident Records: LPA Lee reviewed 6 resident’s file and they were complete; however, LPA Lee observed 6 out of 6 resident’s LIC 625 Needs and Service Plans are missing the resident/conservator signature. · Facility staff annual training: LPA Lee reviewed 2 staff files and it was complete and the staff had the required continued annual training. As a result of this quarterly visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Dec 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 97465(c)(3) · Plan of correction due date: Dec 19, 2024

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication… (3) A record of each dose is maintained in the resident's record... This requirement was not met as evidence by: Based on records review and interviews the Licensee did ensure that resident’s medication record is maintained. This posed a immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: The administrator agrees to read the regulation being cited today and submit a signed declaration of understanding. The administrator will also conduct an in-service for Incidental Medical and Dental Care training in regard to the regulation being cited and provided LPA Lee documents used for the training. The administrator will also provide LPA Lee a staff sign in sheet. POC will be emailed to LPA Lee at pang.lee@dss.ca.gov by 12/19/2024 by end of day 5:00 PM

From the deficiency page — Deficiency type: Type B · Section cited: CCR97211(a)(1) · Plan of correction due date: Dec 19, 2024

87211(a)(1) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified… This requirement was not met as evidence by: Based on records review and interviews the licensee is not ensuring that incident reports are being reported to CCLD. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 12, 2024

Plan of correction: The administrator agrees to read the regulation (Reporting Requirement) being cited today and submit a signed declaration of understanding. The administrator will also train all facility staff in regard to the regulation being cited today and provided LPA Lee documents used for the training. The administrator will also provide LPA Lee a staff sign in sheet. POC will be emailed to LPA Lee at pang.lee@dss.ca.gov by 12/19/2024 by end of day 5:00 PM

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted an unannounced required 1 year annual inspection. LPA met with Administrator and explained the purpose of the visit. Administrator certificate expires on 7/15/2024. This facility is a single story building licensed to serve ten (10) non-ambulatory residents. LPA and administrator toured the physical plant including but not limited to resident bedrooms, resident bathrooms, dining room, patio, and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 113.2 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers; smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 12/11/2023. Fire drill conducted on 3/29/2024. LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to residents. LPA reviewed five resident files and three staff files, including criminal record clearances. A review of staff records indicates that all staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews. LPA requested the following updated documents for community care licensing to be submitted via email by June 6, 2024: LIC 308 Designation of Administrator, LIC 500 - Personnel Report, Copy of Administrator's Certificate, and Copy of Liability Insurance with expiration date. ruth.wallace@dss.ca.gov Based on today’s visit, Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies observed or cited today. Exit interview conducted with administrator. A copy of report and LIC 811 (Confidential Names) left at facility.the state’s words, verbatim · CDSS document, May 29, 2024

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced health and safety check visit at facility. LPA met with administrator and explained purpose of the visit. This facility is a single story building licensed to serve ten (10) non-ambulatory residents. LPA observed the centrally stored medications area to be locked and inaccessible to residents. Centrally stored medication logs are maintained for residents at facility. Physician signed and dated for each written order for residents. Maintenance of facility including clean, safe, sanitary, and good repair at all times; licensee is ensuring for residents, employees, and visitors. LPA did not observe any hazards or lack of care and supervision during this visit. All chemicals are safety locked up and inaccessible for residents. LPA reviewed staff records and initial and training was documented as required for personnel requirements for senior care facilities. Based on today’s visit, Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies observed or cited today. Exit interview conducted with administrator. A copy of report left at facility.the state’s words, verbatim · CDSS document, May 29, 2024

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Pang Lee arrived unannounced to conduct a health and safety case management visit. The facility is on quarterly visits due to non-compliance concerns discussed during a zoom meeting on 11/14/2023. LPA Lee met with licensee, Edna Clegg and explained the purpose of the visit. The census is 6 with 2 facility staff. During today's visit, LPA Lee reviewed facility records, residents medications and toured the facility. During the review of residents medications, LPA Lee observed medications made inaccessible to residents. LPA Lee also observed sharp objects made accessible to residents during today's visit. Due to insufficient time LPA Lee will return at a later date to complete the case management. As a result of this case management visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facilitythe state’s words, verbatim · CDSS document, Feb 16, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Feb 23, 2024

87465(h)(2) Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not meet as evidenced by: Based on observations and interview the licensee did not comply with the section cited above. The licensee did not ensure that resident’s medication was made inaccessible to residents in care; which this poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 16, 2024

Plan of correction: The licensee agrees to ensure before that all resident medications are locked at all times and made inaccessible to residents in care. The licensee will review the regulation cited and write a statement of acknowledgement of understanding of the regulation cited. POC will be emailed to LPA Lee by POC date 02/23/2024 by POC date end of day 5:00 PM.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Feb 23, 2024

9. 87309(a) Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidence by: Based on observation and interviews, licensee did not ensure that multiple disinfectants and cleaning solutions were made inaccessible to residents in care, which poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 16, 2024

Plan of correction: Licensee removed multiple disinfectants and cleaning solutions and placed them in a locked cabinet. The licensee will review the regulation cited and write a statement of acknowledgement of understanding of the regulation cited. POC will be emailed to LPA Lee by POC date 02/23/2024 by POC date end of day 5:00 PM.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Pang Lee arrived unannounced to conduct a health and safety case management visit. The facility is on quarterly visits due to non-compliance concerns discussed during a zoom meeting on 11/14/2023. LPA Lee met with licensee, Edna Clegg and explained the purpose of the visit. The census is 6 with 2 facility staff. At 8:31 AM, LPA Lee entered the facility and observed three residents sitting in the common area watching a movie. The residents appeared to be clean and comfortable. LPA Lee and licensee Edna Clegg toured the physical plant to ensure compliance with Title 22 regulations. LPA Lee observed resident bedrooms, bathrooms, common areas, dining area, laundry room, kitchen, and exterior plants of the facility. LPA Lee observed resident bedrooms to have the necessary furniture and furnishings. The temperature inside the home was measured at 72*F. LPA Lee observed the fire extinguisher located in the kitchen next to the pantry. The fire extinguisher was last serviced on 12/01/2023. LPA Lee observed the carbon monoxide and fire alarm was in good repair. LPA Lee observed no emergency exits were obstructed. The first aid kit was checked and contained all the required components. At 8:43 AM, LPA Lee also observed multiple chemicals made accessible to residents in care. At 8:45 AM, LPA Lee observed a mini refrigerator out in the dining area unlocked. LPA Lee observed 4 water bottles, 1 Sunsweet prune juice and a 26 Fl oz Phillips milk of magnesia inside the mini refrigerator. It was learned that magnesia is for resident 1 (R1) and there is no PRN order and doctor’s note for (R1). Based on interview, licensee Edna Clegg admitted to buying (R1) the Sunsweet prune juice for (R1) constipation without a doctor’s order or note. LPA Lee advised licensee that any resident PRN medication needs a doctor’s order or a doctor’s note. LPA Lee also advised licensee that she can not give (R1) prune juice without a doctor’s order or note. Continued LIC 809-C At 8:48 AM, LPA Lee observed a knife on top of the kitchen counter and two scissors on the dish rack made accessible to residents in care. LPA Lee asked the licensee where she kept sharp objects and the license stated that she keeps them in a drawer below the dish rack. LPA Lee observed the drawer unlocked and inside the drawer LPA Lee observed four knives. Licensee continues to show LPA Lee where the additional knives are kept as well. Additional knives were kept on a kitchen shelf made accessible to residents. At 8:52 AM, LPA Lee observed (R2) Latanoprost medication and licensee eye drops in the refrigerator made accessible to residents and stored with condiments. Licensee admitted that (R2) is no longer taking (R2) Latanoprost medication. Based on observation (R2) Latanoprost medication was supposed to be discarded after 09/30/2021. During today’s visit, LPA Lee observed licensee removed (R2) and licensee’s eye drop from the refrigerator. LPA Lee advised the licensee that all sharp objects and chemicals need to be locked at all times. LPA Lee also advised licensee that all resident’s medication needs to be made inaccessible to resident at all times. LPA Lee also advised licensee that medications cannot be stored with food. Based on observations today, at 8:55 AM, LPA Lee observed resident bathroom #1 toilet seat was not in good repair. The top of the seat is broken. The toilet was also observed to be unclean. During the inspection Licensee cleaned the toilet and apologized for it being unclean. LPA Lee also observed licensee fixed broken toilet. The resident bathroom observed to have handrails and non-slip mat. At 8:57 AM, LPA Lee observed resident bedroom #4 sliding door is hard to open and the sliding screen is not in good repair due to rips and holes. Based on records review at 9:10 AM, LPA Lee observed waterlog only from 09/01/2023 to 09/11/2023. At 9:30 AM, LPA Lee measured the water temperature and it a measured at 115.2 degrees Fahrenheit which is within the required regulations of 105 to 120 degrees Fahrenheit. Based on records review and interviews with licensee Edna and caregiver Maxwell Llorente admitted to not having a maintenance and ground checklist completed. Maxwell stated that he will create a maintenance and ground checklist and provide it to LPA Lee. At. 10:29 AM, LPA Lee observed a small tray of snacks out in the dinning island counter. Inside the tray were 8 small packs of 0.2 oz of Frootloops cereal and 1 pack of 6 oz Whisp Cheese Crips bag. At 10:37 AM, LPA Lee observed 10 of (R1) medication Clobetasol Propionate lotion in an unlocked cabinet in the laundry made accessible to residents. During today’s visit, LPA Lee observed licensee removed (R2) and licensee’s eye drop from the refrigerator. Continued LIC 809-C LPA requested to review resident files and staff files. LPA Lee reviewed 6 out of 6 resident files and 4 out of 6 staff files, and they were not complete. LPA Lee observed 6 out of 6 resident’s LIC 625 Appraisal Needs and Services was completed; however, it does not have licensee and residents’ signature. LPA Lee also observed 6 out of 6 residents missing LIC 601 in the file. LPA Lee observed 4 out of 6 facility staff files missing 20 hours of continued education for the year 2023. LPA Lee reviewed and compared 6 out of 6 residents medication records. Licensee stated that she does not use the MAR to administer residents’ medication. It was learned that licensee uses the Centrally Store Medication Destruction Record (CSMDR); however, based on records review and observations the licensee did not keep adequate records of the (CSMDR) for 6 out of 6 residents. LPA Lee observed (R3) (CSMDR) last start dated was 03/11/2022. LPA Lee observed (R2) (CSMDR) last start dated was on 02/07/2019. In addition, (R2) (CSMDR) shows (R2) has medication Benztropine 0.05 mg; however, the medication was not in resident medication box. Licensee admitted that (R2) is no longer take Benztropine. LPA Lee also observed 5 out of 6 residents (CSMDR) does not have a start date of when all of resident’s medication was administer to residents. As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Feb 16, 2024

From the deficiency page — Deficiency type: Type B · Section cited: ILS 87465(e) · Plan of correction due date: Feb 28, 2024

87465 Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician… This requirement is not meet as evidenced by: Based on observations, interviews, and record review, the licensee did not comply with the section cited above. The licensee did not ensure that R1 had a doctor’s order for magnesia and Sunsweet prune juice, which poses a potential health and safety risk to persons in care, which this posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 16, 2024

Plan of correction: The licensee agrees to ensure before that all resident has a doctor’s order or note prior to any PRN medication being administered to residents in care. The licensee will review the regulation cited and write a statement of acknowledgement of understanding of the regulation cited. POC will be emailed to LPA Lee by POC date 02/28/2024 by POC date end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(6) · Plan of correction due date: Feb 28, 2024

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement is not meet as evidenced by: Based on observations record review the licensee did not comply with the section cited above. The licensee did not ensure that residents’ that a record of centrally store prescription of medications for residents were maintained, which this poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 16, 2024

Plan of correction: The licensee agrees to ensure that all resident centrally stored prescriptions medications records are adequate and up to date at all times. The licensee will review the regulation cited and write a statement of acknowledgement of understanding of the regulation cited. The licensee will send LPA Lee updated (CSMDR) records for 6 out of 6 residents for the month of February 2024. POC will be emailed to LPA Lee by POC date 02/28/2024 by POC date end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(c) · Plan of correction due date: Feb 28, 2024

87405 Administrator - Qualifications and Duties (c) Failure to comply with all licensing requirements pertaining to certified administrators may constitute cause for revocation of the license of the facility. This requirement is not meet as evidenced by: Based on observations, record review, and interview the licensee did not comply with the section cited above. The licensee did not ensure that licensee complies with all licensing requirements during NCC meeting on 11/14/2023; which poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 16, 2024

Plan of correction: The licensee agrees to review NCC report on 11/14/2023 and comply with what licensee stated and agrees to follow during NCC meeting on 11/14/2023. The licensee will review the regulation cited and write a statement of acknowledgement of understanding of the regulation cited. POC will be emailed to LPA Lee by POC date 02/28/2024 by POC date end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(d) · Plan of correction due date: Feb 28, 2024

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. This requirement is not meet as evidenced by: Based on observations, record review, and interview the licensee did not comply with the section cited above. The licensee did not ensure that licensee complied with all title 22 regulations knowledge of and ability to conform to applicable laws, rules and regulations, which this poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 16, 2024

Plan of correction: The licensee will review the regulation cited and write a statement of acknowledgement of understanding of the regulation cited. POC will be emailed to LPA Lee by POC date 02/28/2024 by POC date end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Feb 28, 2024

87411 Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not meet as evidenced by: Based on observations, record review, and interview the licensee did not comply with the section cited above. The licensee did not ensure that 4 out of 6 staff are receiving initial and annual training. Based on record review, no training for 2023 was documented for 4 out of 6 staff files, which this poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 16, 2024

Plan of correction: The licensee will review the regulation cited and write a statement of acknowledgement of understanding of the regulation cited. Licensee will ensure and conduct training for all facility staff and ensure training are documented. Licensee will send proof of initial training for staff for 2024. POC will be emailed to LPA Lee by POC date 02/28/2024 by POC date end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Feb 28, 2024

87303 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 is not meet as evidenced by: Based on observations the licensee did not comply with the section cited above. The licensee did not ensure that the resident bathroom and the sliding door screen were in good repair, which poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 16, 2024

Plan of correction: The licensee will review the regulation cited and write a statement of acknowledgement of understanding of the regulation cited. The licensee agrees to have the sliding door screen repaired. During today’s visit LPA Lee observed the licensee fix the broken toilet seat. POC will be emailed to LPA Lee by POC date 02/28/2024 by POC date end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(24) · Plan of correction due date: Feb 28, 2024

8. 87555 General Food Service Requirements The following food service requirements shall apply...Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas, or where kitchen equipment or utensils are stored. This requirement was not met as evidence by: This requirement is not meet as evidenced by: Based on observation and interview Licensee did not ensure insulin medication was stored separately from resident food, which poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 16, 2024

Plan of correction: Facility staff remove resident and licensee medication out of resident food. The licensee will review the regulation cited and write a statement of acknowledgement of understanding of the regulation cited. POC will be emailed to LPA Lee by POC date 02/28/2024 by POC date end of day 5:00 PM.

Type of visit: Case Management - Legal/Non-compliance

A Non-Compliance Conference (NCC) was conducted on this day, 11/14/2023, by the Sacramento South Regional Office via office visit. The purpose of this Non-Compliance Conference meeting was to follow up with the facility after an initial NCC was held on 11/02/2023. Due to facility technology issues the NCC meeting was rescheduled for today. Present in the meeting was Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Lisa Rios, Licensing Program Analyst (LPA) Pang Lee. Facility representatives present include Licensee, Edna Clegg, and Caregiver/House Manager, Maxwell Llorente. During this virtual meeting, the Non-Compliance Conference process was explained to the Licensees. A Non-Compliance Conference Summary (LIC 9111) was generated to document this office meeting. A copy of this report and LIC 9111 was provided to the licensee. The facility has previously received 4 Type A citations and 9 Type B citations since 01/14/2020. Issues discussed during the meeting were: · The citation regarding resident's rights due to neglect resident sustained a shoulder dislocation. · Following plan of operations · Evictions procedure: 30 days eviction notice if facility can no longer meet resident's need. · Personal Rights (locked kitchen/pantry and confiscated residents' snacks and tool set) · Fire Clearance (carbon monoxide detector not in good repair) · Maintenance and Operation (hot water measured at 150 *F) · Incidental Medical and Dental Care Services (MAR sheets and CSMDR sheet missing) · Personal Records (Administrator missing TB test) Continued LIC 809-C · Bed Bugs · Reporting Requirements · Residents Records · Annual Training The facility has stated they will agree to do the following: · Licensee have put another refrigerator in the dining area made accessible to residents. · Licensee have put another pantry out in the dining area made accessible to residents. · Licensee agrees to follow plan of operation regarding falls. If a resident falls and can’t get up independently and will call 911 for assistant and not lift residents. · Licensee agrees to notify the department regarding issuing eviction and following eviction procedures. · Licensee have put in place a daily log of hot water temperature check. · Licensee agrees to do a monthly maintenance and ground checklist. · Licensee agrees to report UIR to the facility within 7 days and when administrator is out of town or have a designated person in place. · Licensee agrees to ensure all staff received 20 hours of continue educations each year. · Licensee agrees to use the CSMDR or MAR sheets to document residents’ medications being administered. · Licensee agrees to ensure staff and residents files are update and completed. During today’s meeting it was discussed that TSP engagement is available and the Regional Office will make a referral to the Unit to provide services to the facility. Licensee declined TSP referral and will reach out to LPA if they decide take the TSP referral. The Regional Office (RO) will continue to monitor the facilities’ progress. The RO will continue increased monitoring to verify compliance with issues discussed during the meeting on 11/14/2023. The RO will revisit compliance in 9-12 months and begin the legal process if the facility is not in compliance.the state’s words, verbatim · CDSS document, Nov 14, 2023