Madrona Manor

Type of visit: Required - 1 Year

On September 10, 2026 at 12:20 PM Licensing Program Analyst (LPA) LaVette Farlow made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Caregiver, Suryanti Muzakir and was granted entry to the facility. LPA was accompanied by Administrator Gulvarg "Maya" Kaur to conduct a general overall inspection, which included, but was not limited to, the following: The facility has 5 bedrooms 1 of the bedrooms is for staff living quarters, 2 bathrooms, kitchen, 2 dining areas, living room, office area, laundry room, garage and backyard. LPA completed a walk through of facility, review of records and medication audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 107.5, and 105.3 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher, and first aid kit. Posters such as; the personal rights, CCL complaint poster, ombudsman, and license were posted in a common area. Cleaning supplies, toxins, sharps, medications and other dangerous items were kept in secure cabinets inaccessible to residents. Residents/Staff files were observed locked and made inaccessible. There are no bodies of water, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry stocked and up to date. Dishes, cups, and utensils were stored properly. LPA observed the emergency food supply and water stored in the garage. Yards/Outside: One shaded patio, one shed used for storage and a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed two (2) resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed all residents files were maintain and in order. LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. LPA observed 1 out of 3 caregiver had not completed the Criminal Background clearance. LPA notified Licensee S1 would need to be vacate the premises immediately. A Deficiency with a civil penalty cited. Medication was audited and matched with record. Licensee self reported an initial error for the 15th of September. LPA also, observed an initial completed for the PM meds this evening. A Technical Violation issued. LPA reviewed the liability insurance, emergency disaster plan and disaster drills. LPA observed the Emergency Disaster plan and noticed the form needed to be updated and corrected. A technical violation issued. One (1) deficiencies, two (2) technical violation issued during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV, LIC421BG, and appeal rights were discussed and copies were provided to Administrator, Gulvarg Maya Kaur.the state’s words, verbatim · CDSS document, Sep 10, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e) · Plan of correction due date: Sep 11, 2026

87355(e) All individuals subject to a criminal record review... to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by not ensuring S1 completed a Criminal Background Clearance, which poses a immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: LIcensee agrees to immediately remove C1 from the schedule, and C1 will not be allowed to work until the Criminal Background clearance is complete. Licensee will review the regulation cited and submit a statement of understanding regarding the regulation.

Type of visit: Required - 1 Year

On November 12, 2025 at 2:35 PM Licensing Program Analyst (LPA) LaVette Farlow made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Caregiver, Isje Logor and was granted entry to the facility. LPA was accompanied by Administrator Maya to conduct a general overall inspection, which included, but was not limited to, the following: The facility has 5 bedrooms, 2 bathrooms, kitchen, 2 dining areas, living room, office area, laundry room, garage and backyard. LPA completed a walk through of facility, review of records and medication audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 77 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 108.2, and 108.4 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher, and first aid kit. Posters such as; the personal rights, CCL complaint poster, ombudsman, and license were posted in a common area. Cleaning supplies, toxins, sharps, medications and other dangerous items were kept in secure cabinets inaccessible to residents. Residents/Staff files were observed locked and made inaccessible. There are no bodies of water, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry stocked and up to date. Dishes, cups, and utensils were stored properly. LPA observed a sufficient supply of Emergency Food and water for residents and staff. Yards/Outside: One shaded patio, one shed used for storage and a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPA observed all residents files were maintain and in order. LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. All staff file were maintained. Medication was audited and matched with record. LPA reviewed the liability insurance, emergency disaster plan and disaster drills. LPA observed the Emergency Disaster plan was missing the annual signature. A technical violation issued. No deficiencies, one technical violation issued during this visit. An exit interview was conducted where this report LIC809, LIC809C, and technical violation were discussed and copies were provided to Administrator, Gulvarg Maya Kaur.the state’s words, verbatim · CDSS document, Nov 12, 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.

Allegation investigated: Staff abandoned resident Staff yells at resident Staff are not providing adequate food service to resident

Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced visit to the facility to conclude the investigation and deliver the findings to the above-mentioned complaint. LPA was greeted and granted entry by Caregiver, Esperenza Duro, LPA informed Esperenza of the purpose of the visit and askd that she inform the administrator of my arrival. LPA later met with Administrator Gulvarg "Maya" Kaur during the visit. The investigation consisted of a tour, observations, interviews with residents and staff and record reviews. Allegation 1: Staff abandoned resident. LPA interviewed 4 out of 4 residents in care and based on the interviews 4 out of 4 residents stated they have not felt abandoned and that their needs are being met by staff. LPA interviewed 2 out of 2 staff and based on the interviews with staff it was revealed that staff have not abandoned residents in care. LPA interviews with R1, and W1, it was revealed the Administrator made comments that made R1 and W1 believed R1 would not have placement while in the hospital. R1 was unable to give examples or express what was said due to illness. LPA, observed staff assisting other residents in care during visit. ***Continued LIC9099C*** Unsubstantiated Allegation 2: Staff yelled at residents. LPA interviewed four (4) residents in care. Four (4) out of four (4) residents stated that the staff were nice and they did not experience staff or administrators yelling at them. R1 and W1 stated the administrator yelled at them while R1 was in the hospital and trying to recover. It was reported the administrator made reference to R1 spending too much time in the hospital and she needs to move and administrator stated she already have someone ready to take R1 place. Allegation 3: Staff are not providing adequate food service to residents. LPA Farlow interviewed four (4) out of four (4) residents in care. Four out of four residents stated the food was good and they were satisfied with the meals. Interviews with R2, R3 stated they enjoy the hot dogs, and hamburger meals. R1 stated they only provide coffee and muffins for breakfast, not a well-balanced meal. During today’s visit LPA observed the facility menu and sufficient food supply, for the number of residents in care per regulations. Based on the information above, the allegations is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted. This report was reviewed, discussed, then provided to Administrator Gulvarg "Maya" Kaur.the state’s words, verbatim · CDSS document, Aug 2, 2025 · control 56-AS-20240912145733

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michelle Echeverria made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Caregiver, Esther Sinsu and was granted entry to the facility. LPA was accompanied by Esther to conduct a general overall inspection, which included, but was not limited to, the following: The facility has 5 bedrooms, 2 bathrooms, kitchen, 2 dining areas, living room, office area, laundry room, garage and backyard. LPA completed a walk through of facility, review of records and medication audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 78 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 106.2 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, charged fire extinguisher, and first aid kit. Posters such as; the personal rights, CCL complaint poster, ombudsman, and license were posted in a common area. Cleaning supplies, toxins, sharps, medications and other dangerous items were kept in secure cabinets inaccessible to residents. Residents/Staff files were observed locked and made inaccessible. There are no bodies of water, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: LPA observed 2 days of perishables and 7 days non-perishables food, pantry stocked and up to date. Dishes, cups, and utensils were stored properly. Yards/Outside: One shaded patio, one shed used for storage and a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medication was audited and matched with record. LPA reviewed the liability insurance, emergency disaster plan and disaster drills. No deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, and LIC809C were discussed and copies were provided to Administrator, Gulvarg Kaur who arrived in the middle of the tour.the state’s words, verbatim · CDSS document, Nov 21, 2024

Allegation investigated: Staff are illegally evicting the resident from the facility.

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Madrona Manor, Residential Care Facility for the Elderly to initiate a complaint investigation into the allegation listed above. LPA introduced self and stated the purpose of the visit. LPA was greeted and granted entry by Administrator Gulvarg Kaur. During today's visit, LPA interviewed staff and residents, completed a walkthrough of the facility, reviewed and collected pertinent documents. Staff interview revealed that the resident was never given a legal eviction notice. The notice was provided to the resident and his medical care plan as a request for relocation due to the resident's behaviors. LPA and Administrator discussed the difference between a legal eviction and a request of relocations. Resident interview revealed that the documentation provided was thought to be an eviction. LPA and resident discussed what an eviction is and complaince with the facility's house rules. Please see LIC9099-C Unsubstantiated Based on information above, the allegation is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted. This report was reviewed, discussed, then provided to Facility Representative.the state’s words, verbatim · CDSS document, Nov 30, 2023 · control 56-AS-20231127141748