Serra Mesa Guests Home II

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced visit to continue a required Annual Inspection. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Caregiver Victoria Dones. Licensee Evelyn Salazar arrived shortly after. According to the facility’s license, the facility has a maximum capacity of six (6) residents, of whom all may be ambulatory or non-ambulatory, but none may be bedridden. During today’s inspection, there were a total of two residents in care who are ambulatory. The facility’s license does not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present. LPA, accompanied by Evelyn, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was comfortable and compliant. Hot water temperature at taps accessible to clients were all compliant. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809C] [CONTINUED FROM LIC 809] No pools or bodies of water were observed on the premises. Per Evelyn Salazar, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) and emergency flashlights were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs interviewed staff and clients. LPA reviewed staff and client records/files. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance and surety bond. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Luis, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.the state’s words, verbatim · CDSS document, Nov 21, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Liliana Silveira conducted an unannounced visit to commence a Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with Victoria Diones. Licensee Evelyn Salazar arrived shortly after. During today’s visit, LPA toured the facility, briefly spoke to residents and discussed elements of the inspection with Licensee Evelyn Salazar. No deficiencies were cited during today’s visit. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection. An exit interview was conducted with Evelyn, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Nov 18, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to conduct a Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Celina Samonte. LPA then met with Licensee Evelyn Salazar, who arrived later during the visit. According to the facility’s license, the facility has a maximum capacity of six (6) residents, of whom all may be ambulatory or non-ambulatory, but none may be bedridden. According to care records, staff interviews, and LPA observation: During today’s inspection, there was a total of one (1) resident in care, Resident #1 (R1), who was non-ambulatory. [See LIC811 Confidential Names list for a description of select person identifiers used in this report.] The facility’s license does not include endorsements for delayed-egress doors or secured perimeter, and neither of these were present. During today’s visit, LPA performed a welfare check, interviewing R1 and multiple staff. LPA reviewed R1’s care records and personnel files for multiple staff. LPA, accompanied by the Licensee, also toured the interior and exterior of the facility, and inspected all common areas and bedrooms. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens, hygiene supplies, and Personal Protective Equipment (PPE) were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Inside the facility was a cabinet which contained centrally stored medications. At the time of LPA’s arrival, the doors of this cabinet were closed but not locked. (This cabinet was subsequently locked by staff during LPA’s visit.) Inside the facility’s garage refrigerator, LPA observed, unlocked/accessible, three (3) packages of suppositories. [CONTINUED ON LIC 809-C, 1 of 2] [CONTINUED FROM LIC 809] Interview of facility manager showed that the suppositories belonged to a former resident. (The suppositories were subsequently removed and handed to Licensee for destruction.) In the facility’s backyard, LPA observed two (2) former juice bottles which had been re-purposed to hold liquid cleaning chemicals; one was purple in color, and one was clear. Staff interviews confirmed these bottles contained cleaning chemicals, to include bleach. The original juice labels were still on these bottles, and the bottles were left in the open and accessible. (These chemicals were subsequently removed and handed to staff to be correctly labeled and locked away). According to their latest LIC602 Physician’s Report (dated 10/24/2024), R1’s physician wrote that R1 had Alzheimer’s Disease and Dementia, that they were confused/disoriented, and that they required staff assistance to store and take their prescribed medications. The facility’s ambient internal temperature was complaint at 71 F. Hot water at taps accessible to clients were initially too hot, when compared to the temperature range described in regulation: Kitchen Sink was 129.4 F, Bathroom #1 Sink was 131.9 F, Bathroom #2 Sink was 133.2 F, and Bathroom #3 Sink was 133.6 F. (During today’s visit, adjustments were made to the facility’s water heater to bring all these taps back into the compliant temperature range). Appliances to preserve perishable food were compliant in temperature: Kitchen and Garage Refrigerators were both below 40 F. Kitchen and Garage Freezers were both 0 F or colder. There were at least (2) days of perishable food and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. Confidential records were stored in locked areas. Per the Licensee, no firearms or ammunition were kept at the facility. No pools or bodies of water observed on the premises. The facility's fireplace was screened. There were no open-faced heaters accessible to residents. Smoke detectors, carbon monoxide detector, emergency lighting, night lights, and facility telephone were all working. The facility’s fire extinguishers were serviced within the last twelve (12) months. Required licensing postings were observed in visible areas of the facility. Licensee presented proof of current business liability insurance. During a review of training records, LPA observed, and manager interview confirmed: Licensee did not have proof that active Staff #1 (S1) through Staff #5 (S5) had received training on the facility’s written Emergency Disaster Plan within the last year, as was required. Also, Licensee did not have proof that S1 through S5 had received training on Personal Protective Equipment (PPE) within the last year, as was required. [CONTINUED ON LIC 809-C, 2 of 2] [CONTINUED FROM LIC 809-C, 1 of 2] Four (4) deficiencies was cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the LIC 809-D pages). Plans of Correction were jointly developed with the Licensee. LPA also issued one (1) Technical Violation (TV) regarding tight-fitting covers on trash cans (refer to the LIC9102-TV page). An exit interview was conducted with Licensee Evelyn Salazar, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TV page, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee during today's visit.the state’s words, verbatim · CDSS document, Nov 7, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Dawn Segura conducted an unannounced Required Annual Inspection. LPA identified herself, was granted entry into the facility, and met with Evelyn Salazar, Administrator, who arrived at the facility a short time later. LPA disclosed the purpose of the visit. According to the facility’s license, the facility is licensed for six (6) residents, all of whom may be non-ambulatory. During today’s inspection, there were five (5) residents in care. The facility does not feature a secured perimeter or delayed egress doors. LPA, accompanied by administrator, toured the interior and exterior of the facility. The facility was clean and in good repair. Pathways were free of obstruction and slip hazards. Non-skid mats were present in resident bathrooms. Equipment inspected was in working order. Hygiene supplies and Personal Protective Equipment were present. The facility had sufficient space and equipment to facilitate visitation, meetings, and resident activities. The facility’s internal temperature was 72 degrees F. Hot water temperature in bathroom sink accessible to residents was 120 degrees F. There were no sharp objects, fireplaces, or open-faced heaters accessible to residents; however, AJAX powder was observed in an unlocked cabinet below the sink in a bathroom accessible to a resident who has a diagnosis of dementia. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguishers were serviced within the last 12 months. First aid kit was complete and readily accessible. LPA interviewed staff and residents. LPA also reviewed staff and resident records/files. LPA observed that Resident 2 (R2) was admitted into the facility in May 2023; however, R2’s admission agreement was not signed by R2 or R2’s responsible party. Confidential records were stored in a locked file cabinet, and required licensing postings were observed in visible areas of the facility. Deficiencies are cited per California Code of Regulations, Title 22, on the attached LIC 809-D. Technical advisories were also provided to the administrator. Plans of Correction were jointly developed with the administrator. An exit interview was conducted with Evelyn Salazar, to whom a copy of this report, the LIC 809-D, LIC 9102TAs, the LIC 811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the end of the visit.the state’s words, verbatim · CDSS document, Nov 29, 2023