Maile Aloha Care Home

Allegation investigated: Main exit from a resident's room is partially obstructed The main door handdle does not work properly to exit the facility

Licensing Program Analyst (LPA) Jose De La Cruz conducted an unannounced visit regarding the above mentioned allegations. LPA was greeted by Staff 1 (S1), to whom he identified himself and explained the purpose of the visit. On September 9, 2026, the Reporting Party (RP) alleged that the facility hallway was obstructed, blocking emergency access for a resident. RP also reported that the main door’s exit handle was not working properly. On September 16, 2026, LPA contacted RP, who reiterated the allegations. On the same day, LPA visited the facility, interviewed staff and a resident, and reviewed facility records. LPA toured the facility and observed an Air Conditioning Unit placed in the hallway corner near one resident’s (R1) exit door. LPA also observed two wheelchairs placed near a different exit leading to the outside of the facility. [CONTINUED ON LIC9099-C] Substantiated [CONTINUED FROM LIC9099] LPA informed Staff 2 (S2) that these items may obstruct residents’ exit paths. S2 disagreed but moved R1’s wheelchair out of the room. While touring the facility, LPA attempted to open the main door from the inside, and the handle detached. S2 observed this and explained that it was due to a previous resident who was not permitted to leave the facility unsupervised. Specifically, that the handle had been reversed so that a resident with dementia could not get out of the facility; all other residents and staff were aware of how to operate the lock. Since this, the lock was broken due to individuals attempting to turn it incorrectly. LPA advised that this condition posed an immediate risk to emergency evacuation in the facility. Staff acknowledged the concern and repaired the door handle. Based on record reviews and interviews, the preponderance of evidence standard has been met for both allegations. Two deficiencies were cited in accordance with the California Code of Regulations. Report and Appeal Rights were discussed with and provided to the Licensee. The Licensee’s signature below confirms receipt.the state’s words, verbatim · CDSS document, Sep 16, 2026 · control 08-AS-20260916093319

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Sep 17, 2026

87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. Based on observation, the licensee did not comply with the section cited above in one out of one main entrance door handle, which posed a health and safety risk to eight out of eight persons in care.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: Staff will change the entrance door handle.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: Sep 30, 2026

87307(d)(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. Based on interviews and observations, the licensee did not comply with the section cited above in three out of three items in the hallway, which posed a health and safety risk to eight out of eight persons in care.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: Staff will remove the objects on the hallway.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jose De La Cruz conducted an unannounced visit to conduct a case management visit regarding an unrelated complaint. LPA disclosed the purpose of the visit with staff (S1). During the visit, LPA noticed a lock on the door, which was mentioned to be used to closing the facility over night. Based on today's inspection, deficiencies were cited and a civil penalty was assessed and cited per Title 22, Division 6, Chapter 8, and is listed on the attached LIC 809-D. An exit interview was conducted with staff, to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided. The signature below confirms the documents were received.the state’s words, verbatim · CDSS document, Sep 16, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Sep 17, 2026

87468.1(a)(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents... Based on observation, the licensee did not comply with the section cited above in one out of one main entrance door lock, which posed a health and safety risk to eight out of eight persons in care.the state’s words, verbatim · CDSS document, Sep 16, 2026

Plan of correction: Facility will uninstall the lock from the main door

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jose De La Cruz made an unannounced visit to conduct 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 Licensee Heather Ramirez. The facility's license shows a maximum capacity of fourteen (14) non-ambulatory residents of which three (3) may be bedridden in any bedroom with a direct exit to exterior (2-9). Ambulatory only on the second floor. Waiver granted for hospice care for twelve (12). LPA arrived at 9:15 am to the facility. LPA requested facility, staff and residents files . At 8:53 am, LPA and Licensee toured the interior and exterior of the facility and inspected four bathrooms, and eleven rooms. 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, 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 contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC809] LPA reviewed the medications cabinet. Medications were labeled, as required, and stored in locked areas. No pools, bodies of water or fire places exist on the premises. Per Licensee, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher was serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Water temperatures were measured around the facility with the following readings in Fahrenheit degrees: kitchen sink 109.4, bathroom 1 116.6, bathroom 2 115, bathroom 3 105, bathroom 4 118. LPA interviewed staff, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. No deficiencies were cited per California Code of Regulations. An exit interview was conducted with staff (S1), to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.the state’s words, verbatim · CDSS document, Aug 20, 2026

Type of visit: Collateral

Licensing Program Analyst (LPA) Arian Golbakhsh conducted a unannounced collateral visit to collect the previous license of the facility as the facility underwent a change of ownership and was issued a new one. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Caregiver Marcela Becerra, and spoke to Administrator Heather Ramirez over the phone. During today's visit, there were five (5) residents in care. LPA collected the physical license belonging to the previous Licensee. No immediate health and/or safety concerns were noted during the visit. No deficiencies were cited during the visit either. An exit interview was conducted with Caregiver Becerra to whom a copy of this report was provided. Their signature below confirms receipt of this document.the state’s words, verbatim · CDSS document, Aug 18, 2025

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Arian Golbakhsh conducted a unannounced Post-Licensing Inspection visit. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Caregivers Marcela Becerra and Abraham Nolasco. LPA spoke with Administrator Heather Ramirez over the phone to inform them of the purpose of the visit. The facility's license shows a maximum capacity of fourteen (14) residents, of which two (2) may be ambulatory, nine (9) non-ambulatory, and three (3) bedridden. Bedridden residents may reside in any bedroom with a direct exit door and ambulatory residents may only reside in bedrooms on the second floor. During today's visit there were five (5) residents in care. LPA and Caregiver Becerra toured the interior and exterior of the facility and inspected each room. Facility sketch was consistent with the current layout of the facility. 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, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: One bathroom sink on the second floor was measured at 107F. 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 contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were locked and inaccessible to residents in care. [Continued on LIC 809-C] When shown the laundry area, LPA observed that laundry chemicals were stored in an unlocked cabinet accessible to residents in care. LPA directed staff to move the items to a locked storage closet. A Deficiency was cited for the accessible chemicals per California Code of Regulations, Title 22, Division 6 on the attached 809D. Centrally stored medication cabinet was locked, per regulation. No pools or bodies of water exist on the premises. Per Caregiver Becerra, no firearms or ammunition are kept at the facility. Carbon monoxide, smoke detectors and emergency lighting were all in working order. Fire extinguishers were serviced within the last 12 months. Required licensing postings were observed in visible areas of the facility. LPA interviewed zero (0) staff and three (3) clients, and interviews did not reveal any licensing or regulatory concerns. LPA reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. One deficiency was cited during the inspection. An exit interview was conducted with Caregiver Becerra to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Aug 25, 2025

87309(a): the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, [. . .] are in locked storage and are not left unattended if outside the locked storage. This requirment is not met as evidenced by: Based on LPA observations and interviews, the licensee did not ensure that laundry chemicals were stored in locked areas, which poses an immediate health and safety risk to 5 out of 5 persons in care.the state’s words, verbatim · CDSS document, Aug 18, 2025

Plan of correction: Staff immediately moved the laundry chemicals to a locked storage closet. Licensee will submit proof of a lock placed on the laundry storage cabinet to LPA by POC due date.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Arian Golbakhsh conducted a scheduled Pre-Licensing Inspection and Component III Training. The facility file and personnel report was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit to Licensee Nitin "Nick" Vermani and Administrator Heather Ramirez. The facility's planned capacity is for fourteen (14) residents, of which two (2) may be ambulatory, nine (9) non-ambulatory, and three (3) bedridden. Bedridden residents may reside in any bedroom with a direct exit door and ambulatory residents may only reside in bedrooms on the second floor. As the facility is undergoing a change in ownership, during today's inspection there were six (6) residents in care. Staff present and providing care under the current/soon to be former licensee were all verified to have valid background clearances. LPA, Licensee Vermani, and Administrator Ramirez toured the interior and exterior of the facility and inspected each room. Facility sketch was consistent with the current layout of the facility. 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, screens, toilets, and showers were in working order. Hot water temperature at taps accessible to clients were all compliant: One bathroom sink on the first floor was measured at 106F and second floor bathroom sink read at 105.3F. 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 contained at least two (2) days of perishable food, and at least seven (7) days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. Knives were locked and inaccessible for residents in care. [Continued on LIC 809-C] [Continued from LIC 809] No toxic chemicals or poisons were accessible to clients. Centrally stored medication cabinet was locked, per regulation. No pools or bodies of water exist on the premises. Per Licensee Vermani, no firearms or ammunition are kept at the facility. Carbon monoxide, smoke detectors and emergency lighting were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA conducted the Component III Training with Licensee Vermani and Administrator Ramirez. LPA also answered additional questions regarding regulations and responsibilities and provided resources for Licensing Forms and best practices. No immediate health and/or safety concerns were observed during today's visit and LPA determined the facility is ready for additional residents. LPA observed residents and chatted with three (3), and interviews did not reveal any licensing or regulatory concerns. The facility's request for licensure will be forwarded to management and the Centralized Application Bureau (CAB) for final review and approval. An exit interview was conducted with Administrator Ramirez to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.the state’s words, verbatim · CDSS document, Aug 1, 2025