Golden Heritage Senior Care IV

Type of visit: Required - 1 Year

On 07/01/2026 Licensing Program Analyst (LPA) Shakaricka Hughes arrived at the facility to conduct an unannounced annual inspection. LPA Hughes met with the facility designated administrator Yelena. The current census is 6 with 1 facility staff present. This facility is a single story building licensed to serve (6) non-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 toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 105.9 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 11/12/2025. LPA observed the facility has a public telephone in the kitchen area and the facility has the required posters posted. Facility thermostat was observed at 72 degrees Fahrenheit. LPA observed toxins located in the kitchen cabinet 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 3 out of 6 residents medications and the medication administration record (MAR) was complete. The first aid kit was checked and contained the required components. LPA requested resident and staff files for review. LPA reviewed 6 out of 6 resident files and they were complete. LPA reviewed 3 staff files, and it was complete. 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 07/02/2026 (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 in compliance with Title 22 Regulations, and a copy of the LIC 809 report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 1, 2026

Allegation investigated: Staff are forging resident documents.

On 06/16/2026, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with facility staff Mereoni and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegation above. The current census is 5. Allegation: Staff are forging resident documents. It was alleged that staff are forging resident documents. This investigation consisted of resident records review. On 02/18/2026 LPA Hughes conducted a visit to the facility and obtained resident LIC 602 Physician’s Reports for 6 out of 6 residents in care. LPA Hughes reviewed the records and verified that 5 out of 6 LIC 602 Physician’s Reports contained physician signatures. LPA contacted the physician’s offices and confirmed that the signatures on the LIC 602 forms were authentic and consistent with the records maintained by the physicians. There is not enough evidence to corroborate that the facility forged or falsified documents. Therefore, this allegation is unsubstantiated Continuation 9099-C Unsubstantiated The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegation is UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 27-AS-20260211112902

Allegation investigated: The facility allowed excluded individuals to work in the facility. The Administrator is not present at the facility for a sufficient amount of time.

On 05/22/2026 Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with the facility administrator Yelena and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 6. Allegation: The facility allowed excluded individuals to work in the facility. It was alleged that the facility allowed excluded individuals to work in the facility. This investigation consisted interviews with facility staff, residents, and records review. On 2/18/2026 LPA Hughes conducted a visit to the facility, LPA spoke with facility staff (S2) who stated that they primarily work in the facility five (5) days per week, and sometimes have relief by other facility staff, stating that she does not know their names. LPA spoke with 5 out of 5 residents in care who stated that (1) facility staff primarily works in the facility, and that they have not seen other staff working in the facility, since (S2) has worked in the facility. Continuation 9099-C Unsubstantiated LPA showed (5) residents a photo of (2) excluded individuals and all residents denied observing the residents working in the facility. LPA reviewed facility records LIC 500 Personnel Report and did not observe the names of the excluded individuals on the staffing schedule. Additionally, LPA reviewed the Guardian facility staff rosters and did not observe the names of the excluded individuals on the staff roster. There is not enough information or evidence present to corroborate this allegation therefore the allegation is unsubstantiated. Allegation: The Administrator is not present at the facility for a sufficient amount of time. It was alleged that the Facility Administrator is not present at the facility for a sufficient amount of time. This investigation consisted of interviews with facility staff, and residents in care. On 2/18/2026 LPA conducted a visit to the facility, during the visit LPA spoke with facility staff (S2) who stated that the facility administrator is continuously present in the facility, stating that the administrator is present inside of the facility 2-3 times per week. LPA spoke with 3 out of 5 residents who stated that the facility administrator is present at least 1-3 times per week. There is not enough information or evidence present to corroborate this allegation therefore the allegation is unsubstantiated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, May 22, 2026 · control 27-AS-20260211112902

Type of visit: Case Management - Health Checks

On 05/22/2026 Licensing Program Analyst (LPA) Shakaricka Hughes conducted announced visit to the facility. The purpose of this visit was to conduct a case management visit. LPA met with the facility administrator Yelena Bigelow. The current census is 6. During the visit LPA spoke with facility staff (S1) who stated that they were leaving the facility as they had been given the day off, however there were no additional staff present at the facility at the time of the visit. S1 stated that the facility administrator had been unable to secure additional staffing to provide care and supervision for the residents. S1 stated they had already contacted an Uber and intended to leave the residents in care of the LPA until the facility administrator arrived. LPA Hughes and LPM Rios advised (S1) that leaving the facility under those circumstances would leave residents without care and supervision resulting in residents being left without any staff present. LPA contacted the facility administrator as staff (S1) was calling an Uber and intended to leave the facility. The facility administrator arrived at the facility shortly before S1 left the facility. The facility was observed not in compliance with Title 22 regulations 87405(a) Administrator Qualifications and Duties and 87464(f)(1)(c) Basic Services. As the facility failed to ensure sufficient care and supervision was maintained for residents at all times after staff indicated they were leaving the facility without relief staff present. A copy of this LIC 809, LIC 809-D and Appeals Rights were provided to the facility at the end of the visit.the state’s words, verbatim · CDSS document, May 22, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: May 26, 2026

87405 Administrator - Qualifications and Duties (a)All facilities shall have a qualified and currently certified administrator...The administrator shall have sufficient...premises a sufficient number of hours to permit adequate attention...administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility This requirement was not met as evidenced by: As the facility did not ensure arrangements were made to maintain staffing and supervision for residents after (S1) indicated they were leaving the facility without relief staff present.the state’s words, verbatim · CDSS document, May 22, 2026

Plan of correction: Licensee agrees that they wil ensure the facility has sufficient staffing at all times. Licensee stated that they secured relief staffing on 05/22/2026- 05/25/2026 while they are in the process of hiring additional staffing for the facility. Licensee will provide an updated LIC 500 Personnel Report of staffing changes in the facility. The licensee agrees that all new staff working inside of the facility will require background clearance, association, and training.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87464(f)(1)(c) · Plan of correction due date: May 26, 2026

87464 Basic Services (f) Basic services shall at a minimum include (1) Care and supervision (c) "Care and supervision" means the facility assumes responsibility for, or provides…which the resident’s physical health, mental health, safety, or welfare would be endangered.... This requirement was not met as evidenced by: Based on interviews and observations during the visit, the facility failed to ensure proper care and supervision at all time. (S1) stated that intended to leave the facility prior to relief staff or facility administrator arriving. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2026

Plan of correction: The licensee will ensure sufficient staffing for the facility by identifying staffing shortages in the facility. The licensee will re-train all staff on Care and Supervision of residents. residents, and send LPA training documents, and sign-in sheet used for training.

Allegation investigated: Staff did not ensure that the resident was assisted with glucose checks.

On 2/18/2026 at 8:40 AM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with facility staff Temo and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegation above. The current census is (6) with (1) facility staff present. Allegation: Staff did not ensure that the resident was assisted with glucose checks It was alleged that staff did not ensure that a resident was assisted with glucose checks. This investigation consisted of interviews with facility staff, residents, and records review. On 2/10/2026 LPA Hughes conducted a visit to the facility, LPA spoke with the facility administrator who reported that facility staff assist the resident with glucose checks and prepare the residents insulin injections. Interview with facility staff (S2) stated that staff assist with checking the resident glucose checks at various times throughout the day, as the resident is unable to check their own glucose due to medical diagnosis. Continuation 9099-C Substantiated Facility staff (S2) stated that the resident can administer their own injections. Interview with resident (R1) stated that the facility uses a glucometer to assist with glucose checks, resident (R1) stated that they can inject themselves, and that the facility assist with drawing their insulin. LPA reviewed facility records provided for resident (R1) which reported the facilities daily tracking of resident (R1) glucose levels. This was observed not in compliance with Title 22 regulation 87628(a) as the facility did not ensure that resident (R1) was able to independently perform blood glucose monitoring. Due to the residents medical diagnosis R1 was unable to safely conduct self- glucose checks without assistance. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Temo and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility.the state’s words, verbatim · CDSS document, Feb 18, 2026 · control 27-AS-20260203093251

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a) · Plan of correction due date: Feb 19, 2026

87628(a)The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing... and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement was not met as evidenced by: The facility did not ensure that resident (R1) was able to independently perform blood glucose monitoring. Due to the residents medical diagnosis R1 was unable to safely conduct self- glucose checks without assistance.the state’s words, verbatim · CDSS document, Feb 18, 2026

Plan of correction: The licensee agrees to remain in compliance with Title 22 regulation 87628 at all times. The licensee agrees to stop accepting and retaining residents whose medical care exceed the facilities scope of care. The licensee agrees to ensure all residents care needs which fall outside of the facilities scope of care... are referred to appropriate services when necessary. The licensee review RCFE Prohibited Health Conditions and Title 22 regulation 87628 and send LPA Hughes a statement of acknowledgement of review of the policy by 1/6/2025.

Allegation investigated: Staff are not safeguarding resident belongings. Staff do not treat resident with dignity and respect.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to open this complaint investigation. LPA Moleski met with facility administrator Lyenna Bigelow and explained the purpose of the visit. LPA Moleski received a video taken by a resident of this facility (R1). In this video, R1 was heard raising concerns to a staff member (S1). R1 accused S1 of calling them names, such as a "drama queen." In response to these concerns, S1 said "oh, you're just miserable, that's all." R1 continued to raise their concerns. S1 then began to raise their voice considerably, and told R1 that they were being abusive toward them. S1 said that R1 was harassing them, and said they could call the police on R1 as a result. S1 suggested they may call the police on R1 multiple times. LPA Moleski met S1 in person during today's visit, and verified their identity. S1 confirmed that R1 had been taking videos of them, but said that they remained quiet and did their work, and only responded to say that R1 was being disrespectful. [continued on 9099-C] Substantiated The department has determined the following as it relates to the allegation staff are not allowing resident to use restroom closest to their bedroom: Based on interviews, the above allegation is UNSUBSTANTIATED, which means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiencies were cited regarding this allegation. An exit interview was held and a copy of this report was left with Bigelow. In an interview, R1 said several personal items have gone missing since they moved in. R1's admission agreement indicates they moved in on 9/10/25. In an interview, S1 said they started working at this facility about two weeks ago. S1 was associated to this facility as of 10/14/25. S1 said that, when they started, R1 informed them that a hat and a bluetooth speaker were both missing. S1 said that the speaker was back in R1's possession as of 10/22/25, although their hat was found previously. In an interview, R1 said their bluetooth speaker went missing about three weeks prior to this visit, and they found it about two days ago. LPA Moleski reviewed R1's file. LPA Moleski observed no documentation regarding any loss of R1's property. In an interview, R1 said their iPad also went missing the day before yesterday. R1 alleged that it was stolen. In an interview, Bigelow and S1 both said they were notified of this alleged theft on the morning of 10/22/25. HSC Section 1569.153(i) requires that licensees make a police report within 36 hours when they have reason to believe a theft has occurred involving property worth $100 or more. As it has been less than 36 hours since this report was made to Bigelow, this subsection has not been violated. R1 told LPA Moleski that they reported this alleged theft to local law enforcement during this visit. Officers arrived and met with R1. HSC Section 1569.153(c) requires the following: "Documentation of lost and stolen resident property with a value of twenty-five dollars ($25) or more within 72 hours of the discovery of the loss or theft ... The documentation shall include, but not be limited to, the following: (1) A description of the article. (2) Its estimated value. (3) The date and time the theft or loss was discovered. (4) If determinable, the date and time the loss or theft occurred. (5) The action taken." LPA Moleski observed no such documentation in R1's file regarding their missing bluetooth speaker. 22 CCR Section 87218(a)(2) states that "The licensee shall be presumed to have made reasonable efforts to safeguard resident property if there is clear and convincing evidence of efforts to meet each requirement specified in Section 1569.153." A failure to document property loss, as required by HSC Section 1569.153, even if that property was later found, means that the licensee is presumed not to have made reasonable efforts to safeguard resident property. LPA Moleski reviewed R1's personal property inventory and observed that no inventory was made of R1's property. A cross was drawn through the property inventory form. R1 and Bigelow both signed the form. HSC Section 1569.153(d) states that "The facility shall not be liable for items which have not been requested to be included in the inventory..." [continued on 9099-C] The department has determined the following as it relates to the allegations that staff are not safeguarding resident belongings, and that staff do not treat resident with dignity and respect: Based on interviews and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met. This facility is hereby cited per HSC Section 1569.153(c) and 22 CCR Section 87468.1(a)(1). An exit interview was held with Bigelow. Appeal rights and a copy of this report were left with Bigelow.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 27-AS-20251020081614

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Oct 24, 2025

"(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons." This requirement was not met as evidenced by: Based on interviews and record review, S1 did not treat R1 with dignity, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Oct 23, 2025

Plan of correction: Licensee agrees to provide LPA Moleski with a training plan by POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.153(c) · Plan of correction due date: Oct 30, 2025

"(c) Documentation of lost and stolen resident property with a value of twenty-five dollars ($25) or more within 72 hours of the discovery of the loss or theft ... The documentation shall include, but not be limited to, the following..." This requirement was not met as evidenced by: Based on interviews and record review, documentation was not maintaned as required by Health and Safety Code.the state’s words, verbatim · CDSS document, Oct 23, 2025

Plan of correction: Licensee agrees to review the applicable sections of HSC and to provide LPA Moleski with an acknowledgement. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski spoke with facility administrator Lyenna Bigelow over the phone and explained the purpose of the visit. LPA Moleski received a police report from a local law enforcement agency. According to the report, a former resident of this facility, R1, eloped on 6/16/25. R1 was later found by a responding officer at a supermarket about a mile away. R1 told officers they had taken a bus to the supermarket. R1 has a dementia diagnosis and was not permitted to be in the community unattended as a result. This facility was licensed as of 7/7/25, meaning that R1 was not under the supervision of the current licensee at the time of the above described incident. The former licenseholder's license was revoked, and they do not currently hold any licenses issued by the California Department of Social Services. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Ravuoco.the state’s words, verbatim · CDSS document, Sep 30, 2025

Allegation investigated: Staff did not administer medication as prescribed to a resident in care. Staff did not prevent the facility from being malodorous. Staff are not providing activities for the residents in care.

Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to follow up on this complaint investigation. LPA Moleski spoke with facility administrator Lyenna Bigelow over the phone and explained the purpose of the visit. On 8/24/25, LPA Moleski received an incident report from Bigelow which described a resident's (R1's) family member (R1's RP) raising concerns over medication administration. In an interview, R1's placement agent said they had conducted an audit of R1's medications along with R1's RP on 8/17/25 and observed inconsistencies. LPA Moleski conducted an audit of R1's medications on 8/28/25. LPA Moleski observed discrepancies with R1's medications, including a prostate medication. LPA Moleski observed two bottles of the medication, containing 200 capsules total. The bottles were started on 8/16/25. R1 was ordered to take two capsules every evening. LPA Moleski observed 24 doses signed off on their MARs between the start date and the date of the audit, which should have left 176 capsules remaining. LPA Moleski counted out 98 and 75 capsules between the two bottles, for a total of 173 capsules. [continued on 9099-C] Substantiated LPA Moleski performed this count in front of a staff member (S1) to ensure accuracy. S1 raised no concerns regarding the accuracy of the count. LPA Moleski performed a similar count for one of R1's painkillers, and observed another discrepancy. LPA Moleski observed a start date of 6/8/25. R1 was ordered to take one tablet daily. R1's centrally stored medication records indicated the medication was started on 6/8/25. LPA Moleski observed 81 doses administered between that date and the date of the audit, which should leave 19 tablets remaining in the bottle. LPA Moleski counted out 20 tablets in the bottle. S1 observed this count as well and similarly did not voice concerns over the methods used or the accuracy of the count. An antidepressant prescribed for R1 did not have a start date recorded, making an audit impossible. LPA Moleski received an incident report from Bigelow on 8/25/25. According to the incident report, a resident (R2) refused personal care, and "the strong odor associated with the resident's refusal of hygiene care became noticeable in the common areas and was causing discomfort for other resident." The incident report stated that staff continued to "make efforts to support" R2, but no description was provided of efforts to eliminate or reduce the odor. During LPA Moleski's visit on 8/28/25 and on LPA Moleski's visit on 9/9/25, fairly mild incontinence odors were observed to be present in R2's room. In an interview, R1's placement agent said they had smelled strong incontinence odors on multiple occasions. In interviews, R1 and R3 said that they had sometimes smelled odors coming from R2. LPAs Moleski and Lindstrom spent several hours at this facility during today's visit. LPAs Moleski and Lindstrom observed no activities being offered to residents. LPA Moleski observed no activities being offered during his visit on 8/28/25 either. In interviews, R1's placement agent, as well as R1-R5, said that there are no activities offered to residents. R3 and R5 said there are games at the facility, but they are not used. The department has determined the following as it relates to the allegations that staff did not administer medication as prescribed to a resident in care, that staff did not prevent the facility from being malodorous, and that staff are not providing activities for the residents in care: Based on interviews, observation, and record review, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Sections 87465(a)(4), 87625(b)(3), and 87219(a). An exit interview was held with Bigelow. Bigelow said staff member Aisake Jemesa could sign this report in her absence. Appeal rights and a copy of this report were left with Jemesa.the state’s words, verbatim · CDSS document, Sep 9, 2025 · control 27-AS-20250819031608

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 10, 2025

"(4) The licensee shall assist residents with self-administered medications as needed." This requirement was not met as evidenced by: Based on interviews, observation, and record review, at least one resident's medications were mismanaged, which poses an immediate health, safety, and personal rights risk.the state’s words, verbatim · CDSS document, Sep 9, 2025

Plan of correction: Licensee agrees to provide a plan regarding staff training by POC due date. After completing trainings, licensee shall provide LPA Moleski with training sign-in sheets. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Sep 16, 2025

"(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: ... (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence." This requirement was not met as evidenced by: Based on interviews, observation and record review, the facility contained strong incontinence odors on at least one occasion, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Sep 9, 2025

Plan of correction: Licensee agrees to provide a written plan by POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a) · Plan of correction due date: Sep 16, 2025

"(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:" This requirement was not met as evidenced by: Based on interviews and observation, activities were not provided to residents in care, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Sep 9, 2025

Plan of correction: Licensee agrees to provide LPA Moleski with a written plan to implement activities as of POC due date. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Vincent Moleski and Triel Lindstrom arrived unannounced to follow up on a complaint investigation but discovered an unrelated deficiency. LPA Moleski spoke with facility administrator Lyenna Bigelow over the phone and explained the purpose of the visit. Bigelow sent LPA Moleski a handwritten incident report on 9/9/25. The incident report stated that on 8/17/25 "diet orders were not followed" for a resident (R1). Bigelow said that R1 was served a large amount of rice, despite having dietary restrictions on carbohydrates. "Staff did not follow proportions correctly," Bigelow said. LPA Moleski reviewed R1's LIC 602 and observed they had a physician-ordered diabetic diet. In an interview, R1's placement agent said they had witnessed improper foods being served to R1 inconsistent with a diabetic diet. This facility is hereby cited per 22 CCR Section 87555(b)(7). An exit interview was held with Bigelow. Bigelow said staff member Aisake Jemesa could sign this report in her absence. Appeal rights and a copy of this report were left with Jemesa.the state’s words, verbatim · CDSS document, Sep 9, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(7) · Plan of correction due date: Sep 10, 2025

"(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided." This requirement was not met as evidenced by: Based on record review and interviews, a resident's physician-ordered diet was not adhered to on at least one occasion, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Sep 9, 2025

Plan of correction: Licensee previously provided staff training regarding restricted diets. Licensee agrees to provide LPA Moleski with training sign-in sheets by POC due date. vincent.moleski@dss.ca.gov

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Vincent Moleski arrived announced to conduct a prelicensing inspection. LPA Moleski met with applicant Lyenna Bigelow and explained the purpose of the visit. LPA Moleski conducted Component III orientation with Bigelow. LPA Moleski reviewed one resident file and one staff file. LPA Moleski toured the property with Bigelow and inspected the common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were appropriate for residents in care. The facility's water temperature measured 110 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed fully-charged and up-to-date fire extinguisher and working carbon monoxide/smoke detectors. LPA Moleski observed locked cabinets for the storage of medication and locked cabinets for the storage of cleaning solutions and knives. LPA Moleski observed the minimum two-day supply of perishable foods and the minimum seven-day supply of nonperishable foods. LPA Moleski has no objections to licensure. This applicant has passed their prelicensing inspection. An exit interview was conducted and a copy of this report was left with Bigelow.the state’s words, verbatim · CDSS document, Jul 3, 2025

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 5 COMP II Participant: Yelena Bigelow, Managing Member/Administrator Interview Method: Telephone interview On 7/3/25, applicant/administrator participated in COMP II. Identification of the applicant/administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant/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, Jul 3, 2025