Elk Vista Residential Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sommer Hayes arrived unannounced on 09/30/25 to conduct a Required - 1 Year annual inspection visit. LPA met with Fabiola Nunez and explained the purpose of the visit. LPA Hayes returned on 11/14/25 to continue this visit due to a system error on 09/30/25. LPA observed residents during this visit sleeping, watching tv and sitting at the table in the dining area. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed kitchen, dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The temperature inside the facility was observed to be at 73*F which is within the required range of 68-85*F. The hot water temperature was measured at 105.2*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and a guide. LPA reviewed 2 staff and 2 resident files during this visit. Continued on 809C Administrator Certification for Fabiola Nunez expires 03/09/26. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.the state’s words, verbatim · CDSS document, Sep 30, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 10/31/24 at 8:30AM to conduct a Required - 1 Year annual inspection visit. LPA met with Fabiola Nunez and explained the purpose of the visit. Hospice approved for 2 residents of which there are 2 residents receiving hospice services and 0 bedridden residents during this visit. Licensing fees are current. Administrator certificate expires 3/9/26 for Fabiola Nunez. The facility is licensed for a capacity of 6 non-ambulatory residents of which 1 maybe bedridden in room #2 and 2 may receive hospice care services. LPA observed residents during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed kitchen, dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The temperature inside the facility was observed to be at 74*F which is within the required range of 68-85*F. The hot water temperature was measured at 112.0*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 2 staff and 3 resident files during this visit. Upon a file review the following items were discussed to be submitted with any changes annually: Licensing fees-Current Criminal Record Clearances LIS536-Current Administrative Organization LIC309-Current Designation of Administrative Responsibility LIC308-Submit Personnel Report LIC500-Submit Affidavit Regarding Client/Resident Cash Resources LIC400-NA Surety Bond LIC402-NA Facility Floor Plan/Plot Plan LIC999-Current Fire Clearance (consistent with terms and limitations of license)-NA Qualifications of Administrator/Facility Manager-Submit Articles of Incorporation/Organization, Constitution and bylaws-NA Partnership Agreement-NA Control of Property-Submit Emergency Disaster Plan LIC610-Submit Plan of Operation (Restricted Health Care Plan)-NA Admission Policies and Procedures-NA Health Screening Report-Facility Personnel LIC503-NA Bacteriological Analysis of Private Water Supply-NA In-service Training Program-NA Medication Procedures-NA Transportation Procedures-NA Job Description/Personnel Policies-NA Exemptions/Waivers and Exceptions-Current First aid/CPR certificates-Current Liability Insurance-(if applicable)Submit Infection Control Plan-Submit if applicable Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.the state’s words, verbatim · CDSS document, Oct 31, 2024

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 1/24/24 at 8:30AM to conduct a Post Licensing visit. LPA met with Fabiola Nunez and explained the purpose of the visit. Licensing Fees are current. Administrator Certificate expires on 3/8/24. LPA observed a LIC308 Designation of Facility Responsibility on file. The facility is licensed for a capacity of 6 Non-ambulatory residents of which 1 may be bedridden in room #2. Facility has approval for 2 residents to receive hospice care services. There is 0 residents receiving hospice care services and 0 bedridden at this time. LPA observed residents eating breakfast during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed kitchen, dining area, bedrooms and bathrooms, storage areas, laundry and lighting throughout the facility. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The temperature inside the facility was observed to be at 68*F which is within the required range of 68-85*F. The hot water temperature was measured at 119.5*F which is within the required range of 105-120*F. LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. Per the California Code of Regulations, Title 22, Division 6, Chapter 8 no deficiencies cited. Exit interview held, copy of report giventhe state’s words, verbatim · CDSS document, Jan 24, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 11/30/23 at 1:00pm and met with Applicant Fabiola Nunez and stated the purpose of the visit. This visit is to conduct a Pre-Licensing Inspection for a change of ownership. LPA was allowed entry into the home that will be licensed for a capacity of 6 non-ambulatory residents of which 1 may be bedridden in bedroom #2 only. Bedroom #7 shall be for staff only. Administrator certificate expires 3/8/2024. LPA and Fabiola Nunez toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed the kitchen area, dining area, bedrooms, bathroom, storage areas, back yard, and laundry rooms. LPA observed knives/sharps area to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature measured at 105.0 *F which is within the required range of 105-120*F. The temperature inside the facility measured at 74*F which is within the required range of 68-85*F. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution, and guide. LPA observed area for centrally stored medications to be locked. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s) and exit alarms on every door in the home. The facility has central heating and air. LPA observed the staff and resident files locked and readily available for review. LPA reviewed 2 resident and 2 staff files during this visit. Component III conducted - There are no objections to licensure at this time. -Licensure pending. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 30, 2023

Type of visit: Office

Successful Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 4 COMP II Participants: Fabiola Nunez, Licensee/Administrator Interview Method: Teams Meeting On 11/15/2023, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Nov 15, 2023