Sima Court RCFE

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angelica Boyles conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Administrator DJ Mase and Caregiver Raymart Baracena. According to the facility’s license, the facility serves residents age 60 and over and has a maximum capacity of 4 residents. Four residents may be non-ambulatory, of which 2 may be bedridden in bedroom #2. LPA, accompanied by Administrator, 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. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. 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 residents. 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 Caregiver, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. The reviewed files contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited on today's visit. An exit interview was conducted with Caregiver Raymart Baracena, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jul 1, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Debbie Correia conducted an unannounced required annual visit. LPA was greeted by Caregiver Porcoincula, identified herself, and was granted entry into the facility. LPA then met with Licensee Dominique Mase who was informed the purpose of the visit was to ensure that the facility is in compliance with the California Code of Regulations, Title 22, Division 6. During today's visit, LPA Correia conducted facility, staff, and client records reviews that were observed to be accurate and complete. The facility has current liability insurance and surety bond. Administrator certification was current, fire extinguishers were last inspected on 02/09/2025, smoke alarms and carbon monoxide detectors were present and operable. LPA accompanied by Licensee Mase toured the facility inside and outside, client bedrooms were observed to be clean; required furnishings were present, and safeguards were present in the clients’ bathroom. Toilets were found to be in working order, lidded trash cans were present. Hot water temperature in client bathroom measured at 108.9 degrees F. The facility was found to be sanitary and in good repair. LPA did not observe any obstructions of pathways. The facility's ambient temperature was 77 degrees F during the visit. Hazardous and/or toxic chemicals were stored and secured in locked cabinets that are inaccessible to clients. Client medications were also centrally stored in locked cabinets. There was a first aid kit and manual present in the facility. The facility had sufficient space in which to conduct activities. No pools or bodies of water were observed near or on the premises. According to the Licensee, no firearms and/or ammunition present or will be stored in the facility. Sufficient and appropriate storage was present to store perishable and non-perishable food items. Required postings were present and posted in a visible area of the facility. No deficiencies were observed or cited during today's post- licensing/annual inspection. An exit interview was conducted with Licensee Dominique Mase to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/) were provided during the visit.the state’s words, verbatim · CDSS document, Jul 30, 2025

Allegation investigated: Licensee falsified information during the licensing application process. Licensee did not confirm adequate food for residents in care.

Licensing Program Analyst (LPA), Debbie Correia, conducted an unannounced visit to conclude a complaint investigation at the facility. LPA was greeted at the front entrance by Licensee Dominique Mase, identified herself, was granted entry, and explained the purpose of the visit. The Department's investigation included a facility file and outside source records reviews, interviews conducted with the Licensee and an Outside Source, and a brief tour of the facility. It was alleged the Licensee submitted false information on the facility license application regarding the percentage of ownership not being equal (50%, each) between two applicants. Based on a file review the facility's ownership was processed at 50% percent per the two (2) applicants. It was also alleged the Licensee did not ensure residents in care received adequate food. Unfounded An interview conducted with Licensee and facility tour confirmed the facility has not had any new admissions since Licensure was granted on August 16, 2024. Further review of facility files revealed the complaint was inadvertently filed on the wrong facility and will be redirected to the appropriate facility location. Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained the allegations were found to be unfounded. An unfounded determination means that the allegations were false, could not have happened and/or are without a reasonable basis. An exit interview was conducted with Licensee Mase and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 21, 2025 · control 08-AS-20250314165800

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Debbie Correia conducted an announced Pre-Licensing visit. LPA was joined by Applicant, Dominique Mase, and granted entry into the facility. The purpose of the visit was to inspect the facility to ensure that the facility is in compliance with California Code of Regulations, Title 22, Division 6. The Fire Department granted fire clearance on February 6, 2024. During today's visit, LPA Correia, accompanied by applicant Mase, toured the facility inside and outside and inspected every room. The facility was found to be in good repair with no pathway obstructions. Clients' bedrooms were observed to be clean; required furnishings were present. The facility's ambient temperature was 66 degrees F during the visit. Toilets were found to be in working order. Hot water temperature in client bathroom measured at 105.4 degrees F. Hazardous and/or toxic chemicals will be stored and secured in locked cabinets that are inaccessible to clients. Locked cabinets will be used for storage of medications and client and staff records. There was a first aid kit and manual present in the facility. The facility has sufficient space in which to conduct activities. Smoke and carbon monoxide detectors were present and were recently inspected by the local fire authority. No pools or bodies of water were observed near or on the premises. According to the applicant, no firearms and/or ammunition present or will be stored in the facility. Sufficient and appropriate storage was present to store perishable and non-perishable food items. Required postings were present and posted in a visible area of the facility. Component III was conducted during today’s visit. This report was discussed with the applicant. Applicant will be provided a copy of the report at the conclusion of the visit. Signature below confirms receipt of the report. LPA left the facility for an hour lunch break during the visit.the state’s words, verbatim · CDSS document, Jun 21, 2024