Hennelly House

Type of visit: Case Management - Other

On 09/04/2026, Licensing Program Analyst (LPA) conducted an unannounced case management - other visit to make observations regarding facility status and operation. LPA was informed in May 2026 of possible closure. LPA met with caregiver Talica, and explained the purpose of today's visit. There are currently 2 staff present and 5 residents. LPA was informed in May 2026 of possible facility closure but there had been no update or follow up by the licensee. LPA made observations around the facility at random. All residents are in their rooms during today's visit. Based on observations made, all residents look to be taken care of, well groomed, and dressed appropriately. LPA observed food supplies for the residents, and those supplies are in place. Utilities are operating during today's visit. According to staff, a delivery of supplies from CostCo is due to be arriving on this day as well. Per interviews conducted, there are no issues present in regards to obtaining supplies, no shut off utilities, and staff are being paid. Interviews with staff do not report any issues and the facility is operating as it should be. Staff do not know if the facility is planning on closing still but indicate that the facility is fully operating and that the licensee is frequently present for assistance. No citations issued. Report is reviewed with Talica and a copy is provided.the state’s words, verbatim · CDSS document, Sep 4, 2026

Type of visit: Required - 1 Year

On 04/14/2026, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with staff Talica Matainisiga and explained the purpose of today's visit. During today's visit there are 5 residents in care and 3 staff present. This is a single level facility and is licensed to serve 6 residents all of whom may be non-ambulatory. Facility has a hospice waiver on file for 4 residents. There are 2 residents on hospice during today's visit. This is a single level facility. The physical plant is toured inside and outside to ensure the safety of the residents. During today's visit LPA observed 4 of the 5 residents. Two are sleeping in bed, one is awake watching TV in their room, and another is receiving home health care. LPA observed the facility kitchen which is located adjacent to the dining room. Knives are stored within the kitchen in a drawer adjacent to the sink. Medication cabinet is observed as lockable adjacent and above the counter to the sink. Although both have locks, both locks are not operable at this time. Perishable and non-perishable food items are observed as in place in the refrigerator in the kitchen. Additional refrigerator is observed to contain additional food items in the garage. Resident medications are in place and current. The first aid kit is maintained and is complete with required items. LPA observed fire alarm bells throughout the hallway where residents reside, fire extinguishers through out the facility are observed with inspection dates of 05/20/2025, smoke detector/carbon monoxide detectors are in place through out resident rooms and main hallway, and central heating in the facility as in place. Continued on next page. Page 2 - LIC809 PPE is in place according to staff. Laundry room is also observed and is full operational and being used on this day. Chemicals and cleaning supplies are stored beneath kitchen sink and in the garage areas. Both areas are lockable. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Resident rooms are observed and all contained the required furniture as outlined in regulations. Water temperature is tested at 110F in common bathroom in main hallway and in 2 resident rooms. LPA asked about emergency drills being conducted, and was informed a recent drill has not been conducted, and there is no record to show. But in speaking with staff, they are knowledgeable of where to go and how to egress in case of an emergency. This poses a potential health and safety risk to staff and residents. 5 of 5 resident files are reviewed and 3 staff files are reviewed. LPA cannot confirm valid administrator certificates at time of this visit as the administrator certificate on file had expired on 07/26/2019. This item can pose a potential health and safety risk to residents in care. Resident files are reviewed and showed that R4 and R5 do not have documentation of annual doctor visit. Residents R1, R4 and R5 have a diagnosis of dementia and do not have current physicians report or medical assessments done within one year. This poses an immediate health and safety risk to resident's in care. 3 of staff files reviewed showed that all 3 do not have current first aid cards in place and 1 of 3 have current training. This poses a potential health and safety risk to residents in care. The following updated forms are being requested to be received by 04/22/2026: • LIC610D Emergency Disaster Plan • LIC 308 Designation of Administrative Responsibility • LIC 500 Personnel Report • Updated administrator certificate • LIC9020 Client Roster • Certificate of Liability Insurance Per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies are cite on the following LIC809D pages. Report reviewed with staff and a copy is provided on this day.the state’s words, verbatim · CDSS document, Apr 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(h) · Plan of correction due date: Apr 16, 2026

87463(h) Reappraisals - The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This regulation has not been met as evidenced by: Based on file reviews, 3 of 5 residents have not had a recorded annual visit. R1, R4, and R5 have physician's reports that are older than one year with a diagnosis of dementia. This poses an immediate health and safety risk to the residents in care.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Facility shall create a plan of correction in writing indicating that all resident's shall receive an annual routine medical visit, espeically those diagnosed with dementia. Plan to be recieved by date specified.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.695(c) · Plan of correction due date: Apr 17, 2026

§1569.695(c)Emergency Plans - A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This regulation has not been met as evidenced by: Based on file reviews and speaking to staff, the facility does not have a diaster drill log and has not conducted a drill within the last 3 months. This poses a potential health and safety risk to residents and staff in care.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Facility shall create a plan of correction in writing addressing the health and safety code regulation in condcuted drills quarterly. As part of correction, a drill record shall be produced and maintained at the facility to show as evidence of drills being conducted quarterly. Plan to be recieved by date specified.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: Apr 22, 2026

87411(c)(1) Personnel Requirements - General - Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This regulation has not been met as evidenced by: Based on staff files reviewed, 3 of 3 staff do not have current first aid or CPR cards. 2 of 3 expired in March of 2026, and 1 of 3 has an expired card as of 2020. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Facility shall create a plan of correction in writing indicating that all staff shall maintain a first aid card, and or CPR card, on file at all times. Evidence of current first aid cards is to be received.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.625(b)(2) · Plan of correction due date: Apr 24, 2026

I§1569.625(b)(2)Staff training - in addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This regulation has not been met as evidenced by: Based on file reviews conducted, 1 of 3 staff does not have current annual training of 20 hours. S1 last training is indicated back in 2022. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: Facility shall create a plan of correction in writing indicating that all staff will receive the annual 20 hours of training as outlined in health and safety code. Evidence of enrollment and completion of trainng is to be received.

Type of visit: Required - 1 Year

On 5/14/2025 LPA Grace Donatoconducted an unannounced annual visit to the facility. LPA met with the administrator Kesa Vodonaivalu and explained the purpose of the visit. LPA toured the facility inside and outside. While touring the facility it was observed that the temperature was at 69 deg F. Hot water was also tested and temperature was 106 deg F. Two residents currently residing in the facility. One resident having lunch at the dining area. All personal belongings are intact. Carbon monoxide monitor is working properly. All fire extinguishers have been checked. Bathrooms were observed to be in good repair equipped with non-skid mats and grab bars. There is also adequate amount of food. 2 days for perishables and & 7 days non-perishable. Sharps and toxic materials are locked. Emergency drills are done quarterly. Medication review was done and all medications are accounted for and centrally stored medication records are updated. Two staff records and two resident record was reviewed. All staff has criminal record clearance and are associated with the facility. Resident records are checked and all are complete and updated. Licensee to submit Liability Insurance to LPA. No deficiencies cited today. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, May 14, 2025

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with co-administrator/staff Kesa Vodonaivalu and explained the purpose of today's visit. LPA asked about the the listed administrator, Suzi Stefanac, and she indicated she is not present on this day but visits the facility multiple times a week. LPA was allowed entry to the facility. This is a single level facility and is licensed to serve 6 residents all of whom may be non-ambulatory. Facility has a hospice waiver on file for 4 residents. There are no residents on hospice during today's visit according to Kesa. Annual Fees are current. The physical plant is toured inside and outside to ensure the safety of the residents. During today's visit LPA observed 3 of the 4 residents, one of which was still sleeping in bed, and one is at the main dining table having breakfast. LPA observed the facility kitchen which is located adjacent to the dining room. Knives are stored within the kitchen in a drawer adjacent to the sink. Medication cabinet is observed as lockable adjacent and above the counter to the sink. It is unlocked at time of inspection due to staff distributing medications as observed by LPA. Perishable and non-perishable food items are observed as in place in the refrigerator in the kitchen. Additional refrigerator is observed to contain additional food items in the garage. Resident medications are in place and current. The first aid kit is maintained and is complete with required items. Continued on LIC809C... Page 2 - LIC809 LPA observed fire alarm bells throughout the hallway where residents reside,fire extinguishers through out the facility are observed with inspection dates of 10/04/2023, smoke detector/carbon monoxide detectors are in place through out resident rooms and main hallway, and central heating in the facility as in place. PPE is observed in the garage. Laundry room is also observed and is full operational and being used on this day. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Resident rooms were observed and all contained the required furniture as outlined in regulations. Water temperature is tested at 108F in common bathroom in main hallway. The facility does not handle resident money. Current administrator certificate for Suzi Stefanac is current expiring on 07/15/2024. 2 of 4 resident files are reviewed and 3 staff files are reviewed. LPA cannot confirm valid administrator certificates at time of this visit as the administrator certificate on file had expired on 07/26/2019. This item can pose a potential health and safety risk to residents in care. Resident files reviewed showed that R1 and R2 have a diagnosis of dementia and do not have current physicians report or medical assessments done within one year. This can pose an immediate health and safety risk to resident's in care. The following updated forms are being requested to be received by 04/26/2024: • LIC610D Emergency Disaster Plan • LIC 308 Designation of Administrative Responsibility • LIC 500 Personnel Report • Updated administrator certificate • LIC9020 Client Roster • Certificate of Liability Insurance Per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies are cite on the following LIC809D pages. Report reviewed with Kesa Vodonaivalu.the state’s words, verbatim · CDSS document, Apr 19, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(5) · Plan of correction due date: Apr 20, 2024

87705(c)(5) Care of Persons with Dementia - (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: 5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This regulation has not been met as evidenced by: Based on records reviewed on 2 of 4 resident files, LPA observed that R1 and R2 both are diagnosed with dementia and do not have current medical assessments. R1's physicians report is dated 10/12/2020 and R2's physicians report is dated 06/10/2022. This can pose an immediate health and safety risk to resident's in care.the state’s words, verbatim · CDSS document, Apr 19, 2024

Plan of correction: Facility shall create a plan of correction in writing indicating that resident's diagnosed with dementia shall receive yearly medical assessments and physician's reports. Plan to be recieved by date specified.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87406(g) · Plan of correction due date: Apr 26, 2024

87406(g) Administrator Certification Requirements - (g) Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements. This regulation has not been met as evidenced by: Based on record reviews conducted, administrator certificate for S1 has expired as of 07/26/2019. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 19, 2024

Plan of correction: The facility shall submit evidence of renewal of administrator certificates for all administrators at the facility to the Department by the specified date.