Lexie Rae's Care Home

Type of visit: Required - 1 Year

On 6/19/2026, Licensing Program Analyst (LPA) Reza Jamaly and Licensing Program Manager (LPM) Stephen Richardson arrived unannounced at this facility to conduct required 1 year visit. LPA met with the Staff 1 (S1) Marvin Rodriguez and stated the purpose of the visit. Administrator (A1), Annie Lyn Rodriguez later arrived and assisted with facility tour. There were 6 residents in care, 5 present and 1 in hospital with 2 staff on duty. The facility is licensed for a capacity of 6 non-ambulatory residents of which 1 maybe bedridden in Room 3, Hospice waiver granted for three but there is only one resident on hospice in Room 4. During this visit Administrator certificate was observed to be expired on 6/2/2025 per, administrator application for renewal submitted on March 25, 2025 but no update has been received as of today. LPM sent an email to Administrator Certification Bureau to follow-up on the application status since the A1 provided proof to LPM and LPA that the application was submitted with a check in the amount of the required fee. LPA and LPM toured the facility including but not limited to the common areas, kitchen, dining area, resident's bedrooms, bathrooms, laundry room and outdoor ground of the facility to ensure compliance with Title 22 regulations. LPA and LPM observed the facility to be free of odor, clean and in good repair. LPA and LPM observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA and LPM toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Refrigerator temperature was measured 30 degree Fahrenheit and Freezer temperature measured to be 20 degrees which is not in range of below 0 Degree as outlined in regulations. LPM observed one head of cauliflower in a plastic wrap to have beginning stages of mold on it. LPM asked facility staff to discard the item immediately and staff threw away the item immediately. Hot water temperature measured 111.7 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. Hot water temperature measured 109.4 degrees in common area bathroom sink, which was within required range as well. Room temperature during this visit was measured at 71 degrees Fahrenheit. Continues on LIC 9099C on page 2. Page 2. 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 hallway and was last serviced on March 2026. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication cabinet was observed to be locked in the office area of the facility and inaccessible to the residents at this time. LPA and LPM checked the medication of 2 out 6 residents. MAR for R1 was checked, it was learned that the month of medication being administrated was not recorded on the form. A Technical Advisory was issued. A tour of 4 of 4 resident bedrooms and 2 of 2 restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Linen closet, located in the resident hallway, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time. First aid kit was observed to be present and contained all of the required components at this time. Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gates, and exits was conducted and found to be in good repair at this time. LPA and LPM conducted file reviews of 3 out 6 residents. Continues on LIC 9099C Page 3. Page 3 A review of (3) facility resident files was conducted and noted on the following LIC 858. A review of (2) facility personnel files was conducted and noted on the following LIC 859. Both staff reviewed are associated to this facility and have current 1st aid/CPR certificate. LPA observed the approved plan of operation and infection control plan to be present at the facility. During this visit, 2 residents were watching TV at the living room, 3 residents were in their bedroom and one resident was on hospital. The following forms and documents were obtained during this visit: LIC 308 - Designation of administrative responsibility LIC 409 - Administration organization LIC 500 - Personnel report LIC 610E - Emergency Disaster Plan As a result of this annual visit, the facility is not in compliance with Title 22 Regulations, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with Annie 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, Jun 19, 2026

Type of visit: Required - 1 Year

On 4/8/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct their annual inspection visit. LPA met with the administrator, Annie Lyn Rodriguez, and stated the purpose of this visit. Present today visit were 6 residents in care with 2 staff on duty. It was learned that there were (3) residents under the care of hospice at this time. This facility has an approved hospice waiver for (3) residents at any given time. This facility also has, on file, a program to accept and retain residents diagnosed with dementia at this time. A tour of this facility was conducted. Administrator certificate was observed to be present and in compliance at this time. Kitchen area was toured. Cabinets and drawers were reviewed. Food preparation stations, dishwashing station, and other areas intended for meal preps were toured. During the inspection of the kitchen, LPA observed a small fridge that is locked; per discussion with the administrator, it contains resident's medication that require refrigeration. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication cabinet, located in the office area, was reviewed. The medication cabinet was observed to be locked and made inaccessible to the residents at this time. A tour of 3 of 4 resident bedrooms and 1 of 2 restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Grab bars and non skid mats were observed to be present and in good repair at this time. Hot water temperature was taken in 1 of 2 bathroom and measured at 109 degrees Fahrenheit. Room temperature during this visit was measured at 71 degrees Fahrenheit. {1 of 2} Linen closet, located in the resident hallway cabinet, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time. Fire extinguishers, located throughout this facility, were observed to have been annually inspected on 3/5/25. Facility conducts quarterly emergency drills. First aid kit was observed to be present and contained all of the required components at this time. Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gates, and exits was conducted and found to be in good repair at this time. A review of (3) facility resident files was conducted and noted on the following LIC 858. 1 of 3 resident did not have PRN authorization on file. Per discussion with the administrator, she will obtain one from hospice doctor. A review of (2) facility personnel files was conducted and noted on the following LIC 859. Both staff reviewed are associated to this facility and have current 1st aid/CPR certificate. During this visit, 2 residents were watching TV at the living room, 2 residents were in their bedroom and one resident had a visitor from an outside agency. The following forms and documents were obtained during this visit: LIC 308 - Designation of administrative responsibility LIC 409 - Administration organization LIC 500 - Personnel report LIC 610E - Emergency Disaster Plan Lease Agreement No deficiencies were observed from today's visit. Exit interview was conducted and a copy of this report was provided. {2 of 2}the state’s words, verbatim · CDSS document, Apr 8, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

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

On 2/4/2025, at 9:55pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct their quarterly case management visit due to a current stipulation order in place. The facility is licensed under a probationary license. LPA met with the designated staff, Marvin Juan (S1) Rodriguez and stated the purpose of this visit. The facility administrator, Annie Lyn Rodriguez is currently out of the country. The designated administrator Monalisa Salipan (AD) was notified and arrived shortly after. Present in today's visit were 4 residents in care with 1 staff on duty. Facility is approved for 6 non-ambulatory elderly residents, fire cleared for 1 bedridden resident, and approved for 3 hospice resident. LPA conducted a physical inspection of the facility. Room temperature was measured at 74*F and hot water temperature was measured at 118*F in one of the bathrooms. 2 of 4 bedrooms were inspected and were observed to be clean and good repair. 1 of 2 bathrooms was inspected and was observed to be maintained and in good repair. Medications, sharp objects and toxic chemicals were observed to be locked and inaccessible to residents in care. Kitchen was observed to be clean at this time. Stipulation was observed in a conspicuous place at the office desk area. Since last visit on 10/15/24, there was one new admission. LPA reviewed resident's files. Resident records reviewed have medical assessment with TB test, admission agreement, preplacement assessment and hospice care plan. Technical advisory for staff to complete needs and services plan. Per review of the hospice care plan, R1 was diagnosed with a health condition (H1). Per interview with AD and S1, the H1 is not a result from a pressure injury but from a medical condition (M2). During this visit, LPA obtained relevant records for R1 for further review. Per stipulation, facility conducts monthly staff training. Last training was conducted on 1/5/25. {Con't to LIC809-C} Also during this visit, LPA followed-up on an incident that occurred on 1/28/25 were a resident in care (R1) was found on the floor by staff at around 6:03pm. Per incident report, staff on duty heard a loud sound and found R1 on the floor. R1's hospice nurse was notified and instructed staff to call 911. R1 was taken to the emergency. R1 returned to the facility the same day with stiches on the eyebrow area and was prescribed antibiotic for 7 days. Per review of R1's hospice binder, hospice nurse visited R1 the next day at the facility and R1 denies any pain. Per review of the discharge documents, R1 sustained facial injuries including skin tears and nose fracture. Per interview with S1 who was the staff on duty during the incident, S1 was at the kitchen cooking. S1 also indicated that R1 is not a fall risk and that R1 was confused at that time due to a suspected medical condition (M1) which was confirmed and was prescribed antibiotic. S1 added that after receiving antibiotic, R1 was mentally back to normal. At this time, no deficiencies are being cited. An exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 4, 2025

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

On 10/15/24, at 1:43pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct their quarterly case management visit due to a current stipulation order in place. The facility is licensed under a probationary license.. LPA met with the Administrator, Annie Lyn Rodriguez (AD) and stated the purpose of the visit. Present in today's visit were 3 residents in care with 1 staff on duty. Facility is approved for 6 non-ambulatory elderly residents, fire cleared for 1 bedridden resident, and approved for 3 hospice resident. LPA conducted a physical inspection of the facility. LPA observed residents were in their bedroom watching TV. Room temperature was measured at 74*F and hot water temperature was measured at 118*F in one of the bathrooms. 3 of 4 bedrooms were inspected and were observed to be clean and good repair. 1 of 2 bathrooms was inspected and was observed to be maintained and in good repair. Medications, sharp objects and toxic chemicals were observed to be locked and inaccessible to residents in care. Kitchen was observed to be clean at this time. The garage was inspected and was observed to be used as storage only. NO evidence of staff living in the garage. Stipulation was observed in a conspicuous place at the office desk area. During this visit, LPA conducted review of 3 of 3 resident records and 4 staff records. Resident records reviewed have updated Physican's Report and Needs and Services Plan. 4 of 4 staff record reviewed have current 1st Aid/CPR Certificates and ongoing training. Per stipulation, facility conducts monthly staff training. Last training was conducted on 9/27/24. No new admissions since last visit. A reminder was provided to AD that under the stipulation, she cannot accept anyone with prohibited health condition. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held, and a copy of the report was left at the facility with the Administrator.the state’s words, verbatim · CDSS document, Oct 15, 2024

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

On 7/24/24, at 10:09am, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct their quarterly case management visit due to a current stipulation order in place. The facility is licensed under a probationary license. LPA met with the facility administrator, Annie Lyn Rodriguez and stated the purpose of the visit. Present in today's visit were 3 residents in care with 1 staff on duty. At 2pm, LPA conducted a physical inspection of the facility. Facility is located in a residential neighborhood and is approved for 6 non-ambulatory elderly residents, fire cleared for 1 bedridden resident, and approved for 3 hospice resident. LPA observed front and back yard to be maintained and free of obstruction. Fences and gates were observed to be in good repair. Bedrooms and bathroom were observed to be clean and in good repair. Kitchen was observed to be clean and sanitary. Medications, sharp objects and toxins were observed to be locked and inaccessible to residents in care. Refrigerator and freezer temperature were measured within regulatory standard. Room temperature was measured at 74*F. Hot water temperature was measured at 110*F during this visit. LPA conducted review of 3 staff records and 3 resident records. 3 of 3 staff records have current 1st aid/CPR certificates. 1 of 3 staff reviewed was a newly hired and have current health screen and fingerprint cleared. Discussion and advisory with the administrator was conducted to update 3 of 3 residents' Needs and Services Plan. Medication review was conducted for 2 of 3 residents and were observed to be in compliance. {page 1 of 2} Per review of the stipulation order: Current Respondents operate in strict compliance with the regulations and statues governing RCFE: Facility was observed to be in compliance during this visit. Is there full compliance with the regulations and statues governing RCFE: Facility was observed to be in compliance during this visit. Stay of exclusion is valid only for the conduct identified in the second amended accusation and second amended statement of issues: Facility was observed to be in compliance during this visit. Stay of exclusion is valid for respondent Annie Lyn Rodriguez association to facility 1 & 2: Facility was observed to be in compliance during this visit. Respondent completed 18 hrs. of training after 90 days of the Stipulation: Annie Lyn has completed 18 of 18 hours of training. Stipulation is posted in a conspicuous place: Stipulation order was observed to be posted at the office area near the entrance. Has there been incidents to report recently: Recent incidents has occurred and report to be submitted and still within reporting requirements: Advisory was provided to Annie Lyn to ensure verbal reporting of incidents need to be done within the next day of the incident either via phone or email. Respondent cannot retain residents who have prohibited conditions: Annie Lyn has not retained nor accepted residents with prohibited conditions at this time. Within 30 days of this stipulation, respondent have a written plan for obtaining timely medical care for residents? Have training of all staff on procedures: Per review of previous visits, Annie Lyn has submitted a written plan. Within 30 days of this stipulation, respondent have plan in place to for extended absences of the administrator on record? Have training for staff on procedures: Per review of previous visits, Annie Lyn has submitted a written plan. Monthly training of staff provided: Per document review, monthly training was being conducted. Last monthly training was conducted on 6/20/24. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was conducted with Annie Lyn Rodriguez, Administrator, and a copy of this report was provided. {page 2 of 2}the state’s words, verbatim · CDSS document, Jul 24, 2024

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

On 4/11/2024, at 10:30am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct a quarterly case management visit. LPA Villanueva initially met with the staff on duty and explained the purpose of the visit. The Administrator on record Annie Rodriguez was notified of the visit and arrived shortly after. Upon arrival to this facility, LPA observed 5 resident in care with 1 staff on duty. At 10:46am, LPA Villanueva conducted a facility observation to ensure compliance with Title 22 regulations. LPA observed the stipulation order is posted in a conspicuous place located at the office area of the facility. During this visit, LPA observed a hospice personnel arrived to conduct a faith/religious session with the resident that was sitting in the living room. During the observation of the outside area, LPA observed the side gate located at the right side of the facility sketch has been repaired as advised during their annual visit. LPA observed both side gates to be working properly and both are self-latching. LPA observed the inside of the facility to be clean, safe, sanitary and in good repair. Medications, sharps, and toxic products were observed to be properly stored, kept in safe and locked place, and are inaccessible to residents in care. LPA observed required staff monthly training completed in March 2024 with the following topics: observation of change in condition of residents, duty to obtain timely medical care, prevention of pressure sore, prohibited conditions, stages of pressure injuries, and how to call 911. LPA reviewed three resident files and two staff files. LPA did not observe residents with prohibited health conditions during resident file review. Also during resident file review, LPA observed one resident with an incident report that was submitted to the Department. Staff working in the home were observed to be fingerprint cleared. Also staff that were reviewed have current first aid/CPR certificate. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held with Annie Lyn Rodriguez, and a copy of the report was providedthe state’s words, verbatim · CDSS document, Apr 11, 2024

Type of visit: Required - 1 Year

On 4/4/24 at 10am Licensing Program Analyst (LPA) Arvin Villanueva conducted an unannounced annual required visit. LPA initially met with a staff on duty and explained the purpose of today's visit. The facility Administrator, Annie Lyn Rodriguez, arrived shortly after. Present during this visit, there were five residents in care with one staff on duty. At 10:15am, LPA and Administrator inspected the facility’s physical plant including but not limited to the kitchen, dining room, resident bedrooms, resident bathroom, laundry room, living area, common TV area, and outside of the facility to ensure compliance with Title 22 regulations. The facility is a one-story structure located in a residential neighborhood. There were no bodies of water on the premises at this time. Outside of the facility was observed to be clean and clear of obstructions. Additionally, LPA observed outdoor furniture for clients’ use. During the inspection outside, LPA observed the side gate door to require force to open. LPA also observed the bolt securing the gate to the wall of the house was damaged causing the door to be stuck. Per interview, the door was damaged by ambulance personnel. Per Administrator, they will have it repair. Other entrances, exits and hallways were observed to be clear of obstructions. LPA observed three (3) resident bedrooms (all shared), and two (2) bathrooms for resident use. There is one staff room in the facility. LPA observed beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage for the client’s personal belongings. Bed linens, comforters, and bath towels were adequately stocked during the visit. Bathroom is observed to be operational and adequately supplied, including with grab bars and non-skid flooring. LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were locked and not accessible to residents in care. The kitchen was inspected, and sufficient 2-day perishable and 7-day non-perishable food was maintained adequately. Room temperature was maintained in the facility at 75 degrees F. Water temperature in the bathroom was measured at 107 degrees F. One fire extinguisher was last serviced on 3/12/24. Smoke detectors/ carbon monoxide combo were tested and found to be operable during this visit. {Con't to LIC809-C} Medication storage area was observed to be locked and inaccessible to residents in care. Medications were reviewed for accuracy for two residents. First aid kit was observed to have adequate supplies and accessible to staff. The facility maintains for each client Centrally Stored Medication, Destruction Record and PRN Log. LPA observed the facility's infection control practices. All mandated inspection control posters were posted. LPA observed personal rights poster. Facility has appropriate internet access available for resident use. LPA observed sufficient equipment and supplies to meet activity program needs of residents in care. During this visit, one resident was watching TV in the common area. Other residents were in their bedrooms. During this inspection, LPA conducted an audit of facility files, five (5) resident files, and four (4) staff files for regulatory compliance. All four staff have criminal background clearances and are associated to this facility. All four staff files reviewed contained required contents including health screening, TB results, current first aid/CPR, and initial and ongoing required training. During resident file review, LPA discovered that 1 of 5 resident file does not contain the following required forms: admission agreement and pre-admission appraisal. Further review of resident files revealed that 1 of 5 resident have a restricted health condition. Additional review revealed that facility does not have a plan of care and staff training was not completed prior to working with the resident with restricted health condition. Facility’s liability insurance is current per regulatory requirements. LPA reviewed facility’s disaster plan to ensure regulatory compliance. LPA observed that facility conducts quarterly fire drills. LPA was provided updated copy of LIC 308, LIC 500, 1 and liability insurance. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in civil penalties. An exit interview was conducted with Administrator Annie Lyn Rodriguez, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 4, 2024

The state marks this report as 10 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Health Checks

On 1/11/2024, at 2pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct a quarterly case management visit. LPA Villanueva met with Administrator on record Annie Rodriguez and explained the purpose of the visit. During this visit, LPA observed 5 resident in care with 2 staff on duty. LPA and Administrator Annie toured the facility to ensure compliance with Title 22 regulations. LPA observed 1 resident in care who was watching TV in the living room and 4 resident was in their bedrooms. The facility has an approved hospice waiver for 3 residents, and there is currently 2 residents in care on hospice. Common areas and resident bedrooms were observed to be clean, organized, and free from obstructions. Facility was observed to have emergency water and a fully stocked pantry. Room temperature was observed at 75 degrees F. Hot water temperature was measured at 108 degree F. Fridge and freezer temperatures were observed to be within regulatory standard. LPA observed the current stipulation order place in a conspicuous place in the front area of the home at the office desk. Staff working in the home were observed to be fingerprint cleared. LPA observed staff training from June 2023 to December 2023 with topics that align with the stipulation order. LPA also reviewed 2 staff files and 2 resident files. Technical advisory was provided to the administrator to obtain PRN authorization letter from the residents' physician. During resident file review, LPA observed files do not contain PRN Authorization for each resident in care. A technical violation was given to licensee/administrator regarding hospice resident who is also have a bedridden status. During resident file review, LPA observed a medical assessment, dated 9/29/23, of 1 of 5 resident is diagnosed as bedridden. Per licensee/administrator, the nurse who assessed the resident might have assessed the resident ambulatory status by mistake. LPA reviewed previous medical assessments of the resident and revealed that the said resident was assessed as non-ambulatory. LPA provided assistant to licensee /administrator to have the resident reassess to proper ambulatory status. Note that the facility is licensed to have 1 bedridden resident in bedroom #3 of the facility sketch, but the resident is in a bedroom not cleared for bedridden. The licensee/administrator has completed 18 out of 18 hours of training related to observation change in residents, duty to obtain timely medical care, prohibited health conditions and prevention of pressure injuries. LPA also reviewed current LIC308. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit. An exit interview was held with Annie Lyn Rodriguez, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 11, 2024