M. S. Care Home

Type of visit: Case Management - Deficiencies

On 04/15/2026, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - deficiencies visit while at the sister facility Hennely House located at 301 31st Avenue, in San Mateo, CA due to this facility now being closed and vacant. LPA discussed the purpose of this report with staff person Talica Matainisiga. According to the licensee, this facility has been closed since December 2025 and all resident were moved to the licensee other facility Hennely House. LPA interviewed the licensee regarding this via telephone on March 3, 2026 and she confirmed the closure and its details. LPA provided regulations to the the licensee over telephone and email as she agreed to receive the information in that manner during the interview but did not hear back from the licensee since. LPA conducted a visit on 04/13/2026 to this facilty, and spoke with the husband of the licensee and he confirmed its closure. LPA observed the resident rooms as vacant and observed that the facility is undergoing repairs and the property will be sold, not the facility/business. Due to the licensee of the facility failing to inform the Department in writing, or communicating with the Department in any manner, to inform the closure and moving of residents to the sister facility citations are being issued on this day. Further citations and civil penalties may be issued. Per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies are cite on the following LIC809D page. 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: HSC 1569.682(a) · Plan of correction due date: Apr 16, 2026

§1569.682 Transfer of resident upon forfeiture of license or change in use of facility; duties of licensee; closure plan; duty of department upon licensee’s failure to comply; civil penalties - (a) A licensee of a licensed residential care facility for the elderly shall, prior to transferring a resident of the facility to another facility or to an independent living arrangement as a result of the forfeiture of a license, as described in subdivision (a), (b), or (f) of Section 1569.19, or a change of use of the facility pursuant to the department’s regulations, take all reasonable steps to transfer affected residents safely and to minimize possible transfer trauma, and shall, at a minimum, do all of the following... This regulation has not been met as evidenced by: Based on facility observations and interviews conduted, the licensee failed to notify the department of closure of this facility and the moving of the residents to another licensed facility where the licensee also owns and operates a licensed residential care facility for the elderly. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 15, 2026

Plan of correction: The licensee shall inform the Department of the closure of this facility in writing regarding the closure of the facility by the due date indicated of 04/16/2026, abiding by the health and safety code and the items within the code.

Type of visit: Case Management - Other

On 04/13/2026, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - other visit. LPA met with the husband of the licensee Frank Hennelly. LPA explained the purpose of today's visit is in regards to the status and closure of the facility. According to Frank they are having to close the facility and sell the home, not the business. LPA toured the facility with Frank and observed all resident rooms. All rooms are vacant. No resident belongings are in place besides hospital beds that were left behind. He says they are in the process of returning the beds to the appropriate companies. He says that all 4 residents that resided at this location moved to the other facility Hennelly House and they have hospital beds there as well. LPA observed various construction materials, tools, and paint as they are renovating the home and touching up spaces to put the home on the market. He confirmed with LPA that this facility is no longer in operation and all residents are at Hennelly House receiving care and supervision.the state’s words, verbatim · CDSS document, Apr 13, 2026

Type of visit: Required - 1 Year

On 07/24/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection. LPA met with caregiver Talica Matainsiga and explained the purpose of today's visit. There are 2 staff present and 4 residents in the facility during today's inspection. This is a single level facility. Annual fees are current. The facility is licensed for residents 59 and over which all may be non-ambulatory. Two residents are on hospice during today's visit. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in the kitchen in a drawer. Medications are also locked in an upper cabinet. Perishable and non-perishable food items are observed as in place. There are additional refrigerators and freezers in the garage areas which also carry additional food supplies. First aid kit is observed as complete with required items. LPA observed fire extinguishers in place inspected 05/20/2025, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system. Facility also has a hardwired fire alarm system and pull stations at the front and rear of the facility. Continued on next page... Page 2 PPE and additional food supplies are observed as in place. Laundry area is also observed as fully operational located beneath the facility. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 110F. Shower floor uses non-skid mat when shower is in use. LPA observed rooms at random and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place. Per staff, the facility conducted a disaster drill in March of 2025 but did not document this drill and the facility does not maintain a disaster training log. LPA reviewed 4 resident files and reviewed 3 staff files on this day. Per resident files reviewed, some files are not current. R1 with dementia does not have a current appraisal on file, last appraisal was in February 2024. R3 and R4 both do not have current appraisals or updated LIC602 since 2023. Per staff files reviewed all files were current with training and CPR/First Aid for the staff persons inspected. The file for the administrator is not current with outdated items dating back to 2017 and needs to be updated with current items such as administrator certificate and first aid card. LPA cannot locate a current administrator certificate, recertification documents, or first aid training on record for the administrator during today's visit. The following updated forms are requested to be submitted to CCLD by 07/31/2025: • Copy of updated Administrator Certificate • Copy of facility's certificate of liability insurance • LIC308 Designation of responsible staff person • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property Citations issued on attached LIC809D and technical violation issued on attached LIC9102TV. Report is reviewed with Caregiver - Talica Matainisiga and a copy is provided.the state’s words, verbatim · CDSS document, Jul 24, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463 · Plan of correction due date: Jul 31, 2025

87463 Reappraisals: (h) 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 requirement has not been met as evidenced by: Based on resident file review conducted, 3 of 4 resident files are observed to not have current appraisals. R1 with dementia does not have a current appraisal on file, last appraisal was in February 2024. R3 and R4 both do not have current appraisals or updated LIC602 since 2023.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: The facility shall create a plan in writing to address having the residents indicated have a new assessment or new physicians report. The plan shall indicate intention of having this done and the dates of when these reappraisals will be conducted. The plan shall be sent to the Department by the due date indicated.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1565(c) · Plan of correction due date: Jul 31, 2025

(c) 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 individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by: Based on interview and documentation reviewed, the facility has conducted a drill but does not record each drill. LPA does not have any documentation to review indicating drills are taking place quarterly.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: The facility shall conduct a disaster drill and create a disaster drill log to be maintained and updated each time a drill is conducted quarterly to meet health and safety code requirements. The log shall be sent to the Department by the due date indicated.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(d) · Plan of correction due date: Jul 31, 2025

87412 Personnel Records - (d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. This regulation has not been met as evidenced by: Based on file revies conducted, the file for the administrator is not complete showing she holds a current administrator certificate or recertification requirements. The file is incomplete with documents dating back to 2017.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: The facility shall submit evidence of a current administrator certificate, evidence of recertification, or renewal items to the Department by the due date indicated.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c)(1) · Plan of correction due date: Jul 31, 2025

87411 Personnel Requirements - General (c)(1) - 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 file reviews conducted, the file for the administrator is not current with outdated items dating back to 2017. LPA cannot locate a current first aid training on file for the administrator.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: The facility shall submit evidence of current first aid training for the administrator on file with the facility, Suzi Stefanac or submit a written plan indicating that first aid training will be obtained with projected dates of attainment.

Type of visit: Required - 1 Year

On 07/03/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection. LPA met with administrator Noralee Reyes and explained the purpose of today's visit. There is 2 staff present and 5 residents present. LPA was allowed entry into the facility. This is a single level facility. Annual fees are current. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in the kitchen in a drawer. Medications are also locked in an upper cabinet. Perishable and non-perishable food items are observed as in place. There are additional refrigerators and freezers in the garage areas which also carry additional food supplies. First aid kit is observed as complete with required items. LPA observed fire extinguishers in place inspected 10/04/2023, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system. Facility also has a hardwired fire alarm system and pull stations at the front and rear of the facility. PPE and additional food supplies are observed as in place. Laundry area is also observed as fully operational located beneath the facility. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 107F. Shower floor uses non-skid mat when shower is in use. LPA observed rooms at random and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place. Continued on next page... Page 2 LPA reviewed 2 client files and also reviewed 3 staff files on this day. Per resident files reviewed they are current. Per staff files reviewed all files were current with training and CPR/First Aid for the staff persons inspected. The file for the administrator is not current with outdated items and needs to be updated with current items such as administrator certificate and first aid card. LPA is aware that the licensee has those items currently but the file this facility has not been updated. P&I is not handled by the facility. Client medications are inspected and are current. S2's file is present but is not associated to the facility and does not have active fingerprints clearances in place. This poses an immediate health and safety risk to residents in care. As a result civil penalties are being assessed on this day at $100 x 2 = $200. $100 for each regulation violated. The following updated forms are requested to be submitted to CCLD by 07/10/2024: • Copy of updated Administrator Certificates • Copy of facility's certificate of liability insurance • LIC308 Designation of responsible staff person • LIC400 Affidavit Regarding Client/Resident Cash Resources • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property Citations issued on attached LIC809D. Report is reviewed with Caregiver - Talica Matainisiga and a copy is provided.the state’s words, verbatim · CDSS document, Jul 3, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Jul 4, 2024

87355(e)(2) Criminal Record Clearance - All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by: Based on records review, licensee failed to request a transfer of criminal record clearance for S2 which poses an immediate health and safety risk to clients in care. It is confirmed that S2 is not associated to the facility on this day 07/03/2024.the state’s words, verbatim · CDSS document, Jul 3, 2024

Plan of correction: The facility shall ensure to submit a criminal record clearance transfer request to the licensing office for S1 and S2 by the POC due date. Also submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date. Immediate civil penalty of $100 for S2 is being assessed on this day.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(1) · Plan of correction due date: Jul 4, 2024

87355(e)(1) Criminal Record Clearance - (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as evidenced by: Based on records review, licensee failed to obtain a criminal record clearance for S2 which poses an immediate health and safety risk to clients in care. It is confirmed that S2 does not have a criminal record clearance on this day 07/03/2024the state’s words, verbatim · CDSS document, Jul 3, 2024

Plan of correction: Administrator shall ensure to submit proof of fingerprinting of S2 and proof of clearance to the licensing office for S2 by the POC due date. Also submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date. Immediate civil penalty of $100 for S2 is being assessed on this day.