Little Brook Care Home #2

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lavinia Muscan arrived on 05/11/2026 to conduct the annual inspection. During today's annual inspection, the Compliance and Regulatory Enforcement Tool was used. LPA reviewed resident (3) and staff files (2). All resident files contained the required paperwork. All staff files contained the required paperwork. All staff have current first aid and CPR training. Facility was clean and well organized. Facility is current on fire drills. Staff training contained the required initial training. LPA and Administrator toured the facility together to ensure the health and safety of residents in care. The areas toured included resident rooms, bathrooms, kitchen, and common areas and outside area. The food supply is within compliance, 2 days of perishable and 7 days worth of non-perishable food items. Grab bars were present at the toilet and in the shower. All exits were unobstructed. The disaster drill is current. The administrator's certificate is current. There is a side gate for emergency access. LPA checked the kitchen area for the ability to prepare and store food. Knives and Sharp objects found to be locked . LPA observed cleaning products and other toxins to be locked away. LPA observed the area used for medication to be locked and inaccessible to residents. LPA observed smoke detectors and carbon monoxide detector at the care home are operational. Fire extinguisher is ready for emergency use. Water temperature is within compliance. In the areas toured, there were no health or safety violations observed. LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by end of the month. Exit interview conducted. A copy of this report was printed and given to Administrator.the state’s words, verbatim · CDSS document, May 11, 2026

Allegation investigated: Staff are not assisting resident with ambulation Licensee does not ensure that staff receives required training

On November 19, 2025, Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to deliver complaint findings into the allegations listed above and met with Administrator Persida Pop. During the investigation, the Department conducted interviews and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: **Report continued on 9099-C** Unfounded Staff are not assisting resident with ambulation During the investigation the department interviewed residents and completed file reviews. Six (6) out of six (6) resident interviews stated that staff meet resident care needs and respond in a timely manner, including helping them get out of bed when they want or need. Due to the information gathered, the Department finds the allegation to be UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Licensee does not ensure that staff receives required training The Department reviewed records regarding the allegation above. Records revealed that staff have adequate training (on boarding and ongoing) in infection control guidelines and other required topics. Records also show that the facility has adequate supplies of PPE and other care items to take care of residents. Record reviews indicated that the facility has all the required documentation regarding staff training per Title 22 Regulations. Department determined that training provided was current and met regulation standards. Therefore, the Department finds the allegation to be UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview conducted. Report left with facility.the state’s words, verbatim · CDSS document, Nov 19, 2025 · control 59-AS-20250915115843

Type of visit: Required - 1 Year

On July 30, 2025, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct an annual inspection utilizing the CARE tool. LPA met with caregiver and explained the purpose of visit. Caregiver then contacted Administrator who arrived to the facility shortly afterwards. Today's census is five residents in care, with one resident on hospice services. Facility is licensed for six non-ambulatory, hospice waiver of one. LPA and Administrator conducted a tour of the interior and exterior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: six private residents room, bathrooms, laundry room, storage, kitchen, backyard and the common areas. LPA observed active Administrator Certificate #7002556740 posted. LPA observed facility to be cooled at a comfortable temperature of 72*F. LPA observe pool gate to be locked and inaccessible to residents in care. LPA observed medication cart to be locked. LPA observed laundry detergents to be locked in cabinet in the laundry room. LPA observed facility to have ample supply of linens. LPA observed storage room to have at least two days of perishable foods and seven days of non-perishable foods. LPA observed knives to be locked in a secured space. LPA observed fire extinguisher to be recently serviced on December 7, 2024. File review was conducted for three residents and three personnel records. LPA observed files to be complete with the required documents. File review was conducted for facility's Emergency Disaster Plan and Fire Drills. LPA and Administrator discussed requesting a new fire clearance. LPA informed Administrator to submit a new LIC 200 and facility sketch to facility's assigned analyst. Inspection tool was completed and no deficiencies was cited. Exit interview was conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jul 30, 2025

Allegation investigated: Licensee did not follow proper eviction procedures.

On July 29, 2025 (7/1/25), Licensing Program Analyst (LPA) Kevin Mknelly spoke to Persida Pop, administrator to deliver complaint findings for the above allegation. LPA reviewed resident records, facility records and conducted interviews. LPA finds that the allegations cited above are substantiated. On 4/27/25, R1 had an episode of verbal aggression, medication refusal and was on the floor from a, possibly intentional attention seeking, “fall”. Family was called by facility staff to attempt to get R1 from the floor and for R1 to take medication. Family called 9-1-1 for medical assessment. In interview with the Administrator, they stated that staff would not have called 9-1-1. Rather, Administrator stated that they would have followed usual medication refusal and behavioral strategies. On 4/28/25, Hospital records showed, R1 was to be discharged to the home. Hospital records noted R1 to “return to current ALF (assisted living facility)” but that " current facility refusing to take pt (R1) back due to behaviors." R1 was discharged to another facility's memory care unit. Substantiated Facility records and facility staff interviews found that R1 had previously resided in another of the licensee’s homes. While at the other home, R1 at times, exhibited exit seeking, agitation and medication refusals. R1 was transferred to this facility , where behaviors escalated slightly to include property destruction and aggression toward another resident. It was reported that R1 perceived R2 as using R1’s bathroom. In R1’s prior home, R1 had a private bathroom. A review of R1’s behavioral expressions plan (dated as “completed 5/19/25) found that the plan was not reviewed by an appropriately skilled professional and interviews found that staff did not implement the plan consistently. Therefore, while the licensee felt that R1 could possibly benefit from a specialty memory care program, the licensee violated R1’s personal right to be protected from involuntary transfer, discharge, or eviction. The refusal to allow R1’s return resulted in R1 remaining in the hospital longer than their condition required and the hospital used increased medication for behavioral control in the hospital setting. As a result of this investigation, LPA finds allegation to be (S) 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 following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. Report reviewed with . Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 29, 2025 · control 59-AS-20250507110528

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(20) · Plan of correction due date: Jul 30, 2025

Additional Personal Rights of Residents in Privately Operated Facilities (a) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions. This requirement was not met based on records and interviews. This posed an immediate risk to R1’s personal rightsand welbeing.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Licensee will submit a statement of understanding of resident rights as well as eviction procedures by the POC date of 7/30/25.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required annual. LPA met with Persida Pop, Administrator, and explained purpose of inspection. Also present were caregivers, Jayana Casas and Simone Viorica. LPA observed (1) resident working with a physical therapist who had just arrived. LPA observed (5) other residents throughout the home. Currently no residents are under hospice care. LPA and Administrator toured the interior and exterior of the facility including the common areas, (6) resident bedrooms, (3) resident bathrooms, kitchen, laundry area and office. LPA observed the facility to be clean, in good repair and to have sufficient furniture and lighting throughout. Both bathrooms have the necessary grab bars, non-skid flooring. Administrator to ensure there are paper towels in any shared bathrooms and hand-washing posters are near each sink. There is sufficient 2+day perishable and 7+day non-perishable supply of food and locked sharps in the kitchen. There are locked toxins in the laundry room, and a lock will be installed under the kitchen sink to allow toxins to be stored. Medications are stored and locked in a medication cart. The inside temperature measured at 75*F, and the hot water measured 115*F in a resident bathroom. The water heater shows the hot water set at 120*F maximum. Fire extinguisher was last serviced on 12/8/23, and the smoke/monoxide alarms are in working order. Quarterly fire drills are conducted. Residents use a call button to inform staff they need assistance. All exit doors have alarms. There are sufficient towels/linens/blankets. PPE supplies will be brought over from a related facility. There is a gated and locked pool and a covered patio with seating. There are (2) unlocked exits. LPA reviewed (3) resident files and found them to be organized, complete and contain current documentation. Medications were reviewed for (2) residents- orders matched medications being given. The facility uses an Assisted Living software program to manage medications. Discussed how start dates should be noted on each bubble pack or medication bottle, as they are noted on the Centrally Stored Medication Record (LIC622).cont on 809C... 809C-1. LPA reviewed (4) staff files. All staff is cleared/associated and has current First Aid/CPR documentation. Also, staff is regularly completing required initial/annual training, through an approved on-line vendor. Documentation was on file. RCFE Administrator certificate #7002556740- exp 11/12/25. Administrator stated she is signed up for the Administrator Portal where completed continuing educational units are uploaded to the Department's website. Administrator is also using the Department's Guardian system and is managing staff rosters. Email address of record is current as well as the land phone line. LPA obtained updated mobile phone number. Annual fees are current and were paid on-line. LPA obtained an updated copy of insurance and requested updated copy of LIC308 and LIC500- due by 7/24/24. There are no deficiencies issued; however, (2) Technical Advisory Notes are being issued on separate reports. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Jul 17, 2024

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a required post-licensing insepction. LPA met Persida Pop, Administrator, and explained purpose of inspection. Also present were caregivers, Stephanie Ferroni and Tyiesha Leslie. The facility was licensed on/around 7/3/23 for (6) non-ambulatory residents and has an approved hospice waiver for (4). Currently, there are (6) residents and (1) resident receives hospice care. LPA and Administrator toured the interior and exterior of the facility and observed it to be clean, in good repair, to have sufficient furniture and lighting, and the bathrooms to have the necessary grab bars, non-skid flooring, and hand-washing posters. LPA observed sufficient 2+day perishable and 7+day non-perishable supply of food. Sharps are locked in the kitchen, medications in the medication cart and toxins in the laundry area. LPA observed the inside temperature to be 72*F. Fire extinguisher was last serviced on 12/14/22 and doors have alarms. LPA observed a complete First Aid kit. PPE and paper supplies. All smoke/monoxide alarms are functioning. Water temperature measured 110*F in the bathroom. Complete First Aid kit on site. LPA observed various required postings. Administrator to post Theft & Loss Policy. (4) resident binders were reviewed and found to be organized and contain current documentation. (4) staff files were also reviewed and found to be organized, complete and contain current training documentation, including First Aid/CPR. Staff to ensure they have completed all required training as part of initial or ongoing training. All staff are fingerprint cleared and associated. A copy of liability insurance policy was previously provided to the Department. Exit interview. Copy of report provided to the Administrator.the state’s words, verbatim · CDSS document, Nov 30, 2023