TLC Home Care V

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds, including detached storage building. There are 6 private bedrooms--all with private half or full bathrooms and all with direct exits to outside--staff room, shower room, living room, dining room, and kitchen. There are 2 beds in staff room for 3 staff. Clothes washer and dryer are located in one car garage. The backyard is level, fenced and mostly paved. Medications and toxins are secured in locked cabinets in kitchen and hallway, respectively. There are no accessible bodies of water or fire safety hazards observed. Carbon monoxide detector is tested and operable. Hot water temperature is tested at 118 degrees in client bathroom #4. Medications and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. First-aid kit is maintained and complete. Perishable and non-perishable fruits, vegetables and protein are maintained, as well as supplies of bed and bath linens and hygiene products. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Client files are reviewed, including Centrally Stored Medications Records. Joebelle Paymuo and Lilia Mauricio are certified RCFE administrators (x 1/28 & 4/26) that oversee facility operations. The following licensing forms are requested to be completed and submitted to CCLD BY 4/7/26: - Designation of Facility Responsibility (LIC308) - Personnel Report (LIC500) Proof of current liability insurance is given to LPA today. Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. Also, see Technical Advisory Note--1 pagethe state’s words, verbatim · CDSS document, Mar 24, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Mar 25, 2026

STORAGE SPACE & ACCESS ...the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances... other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met. as paint is stored in unlocked storage shed in backyard. Licensee failed to ensure that toxics are inaccessible to clients, which poses an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Mar 24, 2026

Plan of correction: Detached storage shed will be locked and proof of correction to be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: Apr 7, 2026

INCIDENTAL MEDICAL CARE A record of centrally stored Rx medications for each resident shall be maintained and include... pharmacist, drug name, strength and quantity, dates filled, started & expiration, prescription number and instructions. This requirement is not met, as Centrally Stored Medication Records reflect incorrect dates filled, expiration dates, quantities, Rx numbers, and some meds are not recorded on CSMR. Licensee failed to maintain accurate CSMRs, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Mar 24, 2026

Plan of correction: CSMRs for ALL residents shall be maintained accurately and reflect information on Rx labels Proof of correction will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468(b)(1)(A) · Plan of correction due date: Apr 7, 2026

PERSONAL RIGHTS The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record. This requirement is not met, as Personal Rights forms are incomplete or missing for 3 out of 6 clients. Licensee failed to ensure that complete Personal Rights forms are maintained for all clients, which poses a potential health, safety or personal rights risk. Clients #3 and #4, have incomplete Personal Rights forms, and there is no Personal Rights form for client #5.the state’s words, verbatim · CDSS document, Mar 24, 2026

Plan of correction: Completed and signed Personal Rights forms for clients #3, #4, #5 will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69 · Plan of correction due date: Apr 7, 2026

HEALTH AND SAFETY CODE ... the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, & 4 hrs of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met, as staff #2 has not received required 10 hours of medications training, which poses a potential health, safety or presonal rights risk.the state’s words, verbatim · CDSS document, Mar 24, 2026

Plan of correction: Staff #2 shall receive required 10 hours of medications , and proof of correction to be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.69(b) · Plan of correction due date: Apr 7, 2026

HEALTH AND SAFETY CODE Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete 8 hours of in-service training on medication-related issues each...12 month period. This requirement is not met, as staff #3 has received only 4 hours of annual medication training. Licensee failed to ensure that staff receive required 8 hours of annual medication training, which poses a potential health, safety or personal rights risk.the state’s words, verbatim · CDSS document, Mar 24, 2026

Plan of correction: Staff #3 will receive additional 4 hours of medications training and proof of correction to be sent to CCLD BY DUE DATE.

Type of visit: POC

In response to deficiencies cited on 3/28/25 during annual visit and proof of corrections received on 4/7/25, LPA Jeung reviewed and confirmed corrections and obtained copies of documents. Acknowledgement of corrections is given to administrator--4 pages.the state’s words, verbatim · CDSS document, Apr 22, 2025

Type of visit: Case Management - Deficiencies

LPA Jeung met with administrator to discuss conditions of facility's hospice waiver approved for TWO residents, as well as the Department's initial letter dated 1/14/25 of denial for an increase in the number of hospice residents that facility is allowed to serve. In March 2025, administrator submitted another request for an increase to the existing hospice waiver for two residents. On 4/4/25, this was denied again by the Department. Facility admitted a third hospice client on 3/22/25, despite the in Department's directive in the initial denial letter, which states that "the licensee may resubmit the hospice waiver request after six months of operation in substantial compliance of the regulations for reconsideration," and "for a prospective client to be admitted already receiving hospice care or requiring immediate hospice services, you must request and receive approval for a hospice exception prior to the resident being admitted." Two days after admitting client on hospice care, administrator submitted a letter requesting an exception for the hospice client. Administrator is reminded that failure to comply with conditions of approved hospice waiver for two could result in its revocation. Deficiency of the California Code of Regulations, Title 22 is cited on a following page.the state’s words, verbatim · CDSS document, Apr 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87633(a)(2) · Plan of correction due date: Apr 23, 2025

HOSPICE CARE OF TERMINALLY ILL The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill ... and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met: The licensee remains in substantial compliance with the requirements of this section, with the provisions of the RCFE Act (HSC 1569 et seq.), all other requirements of Chapter 8 of Title 22...CCR governing RCFEs, and with all terms and conditions of the waiver.the state’s words, verbatim · CDSS document, Apr 22, 2025

Plan of correction: Plan of correction to be submitted to CCLD BY DUE DATE to address how licensee will at all times comply with conditions of approved hospice waiver, including adherence to the Department's directives if more than 2 residents require hospice care.

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds, including detached storage building. There are 6 private bedrooms--all with private half or full bathrooms and all with direct exits to outside--staff room, shower room, living room, dining room, and kitchen. There are 3 beds in staff room. Clothes washer and dryer are located in one car garage. The backyard is level, fenced and mostly paved. Medications and toxins are secured in locked cabinets in kitchen and hallway, respectively. There are no accessible bodies of water or fire safety hazards observed. Carbon monoxide detector is tested and operable. Hot water temperature is tested at 106 degrees in client bathroom #3. Medications and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. First-aid kit is maintained and complete. Perishable and non-perishable fruits, vegetables and protein are maintained, as well as supplies of bed and bath linens and hygiene products. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Client files are reviewed. Centrally Stored Medications Records may be reviewed at a later date, due to time constraints. Joebelle Paymuo is a certified RCFE administrator (x 4/26) that oversees facility operations. The following licensing forms are requested to be completed and submitted to CCLD BY 4/11/25: - Personnel Report (LIC500) - Proof of current liability insurance Emergency Disaster Plan (revised 9 page LIC610-E signed and dated on page 9) is given to LPA today. Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. Also, see Technical Advisory Notes--3 pages.the state’s words, verbatim · CDSS document, Mar 28, 2025

Allegation investigated: - Staff did not refund authorized representative after resident's death

The complaint alleging that refund was not issued after resident passed away has been investigated by the Community Care Licensing Division of the CA Department of Social Services, and determined to be unfounded. This means that the allegation could not have happened and/or is without a reasonable basis. Immediately after the death of client on 8/27/24, personal belongings were removed by responsible party and the room was vacated. A refund check was issued on 8/29/24 for 4 days and mailed. However, the address was incorrect, and the envelope was undeliverable; it was returned to licensee on 9/17/24. On 9/17/24, it was confirmed that appropriate refund was received. Unfoundedthe state’s words, verbatim · CDSS document, Dec 16, 2024 · control 14-AS-20240912145409

Allegation investigated: - Staff was unable to meet resident's overall care needs - Resident left in soiled diapers/linens for extended periods of time.

LPA Jeung interviewed staff. Based on information reported by and obtained from facility staff and medical staff, these allegations are substantiated. The preponderance of evidence standard has been met. Former client resided in facility from 1/4/24 to 5/5/24. Upon admission, she was diagnosed with vascular dementia and a hoyer lift was used for transfers; she was incontinent, as well. Starting on 1/8/24, client received home health visits from LVNs and/or RNs approximately 3x/week. On 1/29/24, staff reported that client refused to get out of bed, and that an open wound developed on coccyx. RN assessed the pressure injury as stage 2 on 1/31/24 and staff were instructed on how to care for wound. Despite regular wound care by nurses and staff, coccyx wound worsened. On 3/27/24, RN assessed the coccyx wound as stage 3, and noted a new wound on left hand. Home health nurses noted that on 4 visits, client was soiled; visits were at 10 am, 1pm, 2pm and 3pm. On 4/22/24, insertion of a foley catheter may have been necessitated due to soiled wound dressings and soiled diapers. At the recommendation of client's medical provider, client was relocated to another RCFE. Deficiencies of the California Code of Regulations, Title 22 are cited on a following page. Substantiatedthe state’s words, verbatim · CDSS document, Dec 16, 2024 · control 14-AS-20240529154040

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(h) · Plan of correction due date: Dec 27, 2024

PERSONNEL REQUIREMENTS All services requiring specialized skills shall be performed by personnel qualified by training or experience in accordance with recognized professional standards. This requirement was not met, as non-medical staff provided wound care on C1 pressure ulcer on days when visiting LVNs and RNs did not visit client. Licensee failed to ensure that client received medical care from qualified personnel, which posed a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Dec 16, 2024

Plan of correction: Proof of correction to be sent to CCLD BY DUE DATE, describing how facility will meet the needs of clients who require skilled nursing care.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Dec 27, 2024

MANAGED INCONTINENCE In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for...ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met, as client #1 was observed on at least 4 occasions within a 30-day period to be in a soiled diaper. Licensee failed to ensure that client who needed incontinent care as clean and dry, which posed a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Dec 16, 2024

Plan of correction: Plan of correction to be sent to CCLD BY DUE DATE, which will describe how staff will ensure that incontinent residents are kept clean and dry.

Type of visit: Case Management - Deficiencies

During complaint investigation, deficiencies of the California Code of Regulations, Title 22 were observed and are cited on a following page.the state’s words, verbatim · CDSS document, Dec 16, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Dec 18, 2024

PROHIBITED HEALTH CONDITIONS Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a RCFE: Stage 3 and 4 pressure injuries. This requirement was not met, as former client was assessed to have stage III pressure injury on 3/27/24, which was being treated by home health. Licensee failed to relocate client to higher level of care or request exception from CCLD, which posed an immediate health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Dec 16, 2024

Plan of correction: Plan of correction to be submitted to CCLD BY DUE DATE, describing how this situation will not recur

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87609(b)(3) · Plan of correction due date: Dec 27, 2024

ALLOWABLE HEALTH CONDITIONS & USE OF HOME HEALTH AGENCIES Incidental medical care may be provided to residents through a licensed HH agency provided...the licensee informs the HH agency of any duties the regulations prohibit facility staff from performing, and of any regulations that address the resident’s specific condition(s). This requirement was not met, as staff did not inform HH that they were not qualified to perform wound care nor that stage III pressure ulcers were prohibited, which posed a potential health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Dec 16, 2024

Plan of correction: Licensee to submit plan to CCLD BY DUE DATE for ensuring that HH agencies are informed about limitations of facility staff duties and regulations pertaining to clients' specific health conditions.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87609(b)(4)(B) · Plan of correction due date: Dec 27, 2024

ALLOWABLE HEALTH CONDITIONS & USE OF HOME HEALTH AGENCIES The licensee & HH agency agree in writing on the responsibilities of the HH agency, & ...of the licensee in caring for the resident’s medical condition(s)... shall include day & evening contact information for the HH agency, & the method of communication between the agency & the facility, which may include ... logbook. This requirement was not met, as facility failed to maintain written record from HH of client's condition, which posed a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Dec 16, 2024

Plan of correction: Licensee to submit plan to CCLD BY DUE DATE for ensuring that HH notes are maintained whenever clients receive HH nursing care

Type of visit: Prelicensing

LPA Jeung reviewed modifications made as per pre-licensing visit of 2/16/24. LPA observed the following: 1. Complaint information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints (PUB475), is posted prominently in area accessible to residents, representatives, and the public. (87468 Personal Rights) 2. Admission agreement, modifications and attachments, or notice of their availability, is conspicuously posted in a location accessible to public view in the facility. (87507 Admission Agreements) 3. An internet access device dedicated for resident use--such as a computer, smart phone, tablet, or other device that can support real-time interactive applications, equipped with videoconferencing technology, including microphone and camera functions--is acquired and maintained. (HSC 1569.319) 4. A spare set of keys--including all resident units, facility vehicles, all exit doors, all cabinets, cupboards or files that contain elements of the emergency and disaster plan, including, but not limited to, food supplies and protective shelter supplies--is available to staff on each shift for use during an emergency evacuation. (1569.695) Facility meets physical plant requirements for RCFE licensure for 6 non-ambulatory elderly clients over age 59 in 6 rooms. Fire clearance has been approved. Immediate licensure is recommended, pending final approval from Central Applications Unit.the state’s words, verbatim · CDSS document, Mar 6, 2024

Type of visit: Prelicensing

Applicant Lilia Mauricio has applied for RCFE licensure for 6 non-ambulatory elderly clients over age 59 in 6 rooms. Fire clearance has been approved. Facility is currently licensed and operating under the name Apple Tree Home Care 2 #415600744, which is reflected on application (LIC200). There are 6 residents present; two residents receive hospice care. LPA Jeung toured facility and grounds of this one level facility. There are 6 private bedrooms--all with private half or full bathrooms and all with direct exits to outside--staff room, shower room, living room, dining room, and kitchen. There are 3 beds in staff room. Clothes washer and dryer are located in one car garage. The backyard is level, fenced and mostly paved, and supplies and paint are stored in detached storage shed, which is locked. Medications and toxins are secured in locked cabinets in kitchen and hallway, respectively. Food preparation and service items are present, as well as perishable and non-perishable fruits vegetables and protein. Supplies of bed and bath linens and hygiene products are observed. The following items are observed and must be addressed prior to licensure: 1. Complaint information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints (PUB475), shall be posted prominently in area accessible to residents, representatives, and the public. (87468 Personal Rights) 2. Admission agreement, modifications and attachments, or notice of their availability, must be conspicuously posted in a location accessible to public view in the facility. (87507 Admission Agreements) 3. An internet access device dedicated for resident use--such as a computer, smart phone, tablet, or other device that can support real-time interactive applications, equipped with videoconferencing technology, including microphone and camera functions--must be maintained. (HSC 1569.319) 4. A set of keys--including all resident units, facility vehicles, all exit doors, all cabinets, cupboards or files that contain elements of the emergency and disaster plan, including, but not limited to, food supplies and protective shelter supplies--must be available to staff on each shift for use during an evacuation. (1569.695) LPA to be contacted upon completion of the above 4 items. Revised Emergency Disaster Plan (LIC610E) is provided to LPA, which includes corrected utility shut off and fire extinguisher locations. Facility phone number is verified: 650/699-4010. Component III RCFE orientation is reviewed with licensee/administrator Lilia Mauricio and assistant administrator Joebelle Payumo. RCFE licensure is pending at this time.the state’s words, verbatim · CDSS document, Feb 16, 2024

Type of visit: Office

Facility Type: Residential Care Facility for the Elderly Application Type: Change of Ownership Capacity: 6 Census (if any clients in care): 6 COMP II Participants: Lilia Mauricio Interview Method: Telephone interview On January 25, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jan 25, 2024