Lsa - Home #1

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Cheryll Lagunilla. During the visit, LPA observed 4 residents and 3 staff. LPA explained the purpose of the visit. This facility is vendorized by San Andreas Regional Center and is a level 7 LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 5 residents bedrooms. There was no obstruction to block the walkways. The staff area of the facility was also inspected. The front yard and backyard were inspected. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 118 degrees F in resident bathrooms. Fire extinguisher was serviced in April 22, 2026. The facility was equipped with smoke and carbon monoxide detectors. ADM stated the sprinkler system was last inspected on October 2025. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on May 20, 2026. LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. LPA reviewed 3 resident P&I records. LPA requested a copy of the following updated documents for the year 2026: 1. LIC500, Personnel Summary 2. LIC308, Designation of Administrative Responsibility 3. LIC400, Affidavit Regarding Client/Resident Cash Resources 4. Emergency disaster Plan No deficiencies cited during today's visit. This report was reviewed with Administrator Cheryll Lagunilla and a copy of the signed report was provided.the state’s words, verbatim · CDSS document, May 27, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit. LPA Rai met with Administrator, Cheryll Lagunilla and stated the purpose of today's visit. LPA Rai observed 3 staff 5 residents at the facility. The facility is vendorized by San Andreas Regional Center and is a level 4I facility. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the facility to include 5 resident rooms, living room, dining room and kitchen. 5 Out of 5 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The hot water temperature in the bathroom and kitchen sink ranged from 105.5 - 118.8 degrees F. Fire extinguisher was observed and inspected on 10/27/2024. Facility's sprinkler system was last inspected on 4/2/2025. The last disaster drills were conducted on 3/4/2025 and 4/15/2025. LPA Rai observed a complete first aid kit at the facility. LPA Rai reviewed facility records for 2 staff and 2 residents. LPA Rai reviewed resident medications and central stored medication records. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Cheryll Lagunilla and a copy of the report was provided. LIC 858 and LIC 859 were provided.the state’s words, verbatim · CDSS document, May 13, 2025

Type of visit: Case Management - Other

On January 29, 2025 at 11:00 AM, Licensing Program Analysts (LPAs) Kenneth Madrigal and Simi Rai arrived at the facility unannounced to conduct a case management – other visit. LPAs met with Justin Williams, Staff Training & Development Coordinator . LPAs observed two staff members and three residents at the facility. Two out of the five residents were out of the facility during the visit. The purpose of the visit is to hand deliver an immediate exclusion letter for an individual (S1) who the Department determined engaged in conduct inimical as a staff in the facility. The letter was handed to the Staff Training & Development Coordinator. The Staff Training & Development Coordinator states S1 was never hired, does not work for the facility, and is not in their Human Resources (HR) system. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Staff Training & Development Coordinator, Justin Williams and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 29, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Cheryll Lagunilla. LPA Rai observed 3 staff and 5 residents at the facility. The facility has 5 elderly developmentally disabled residents who are overseen by San Andreas Regional Center. During visit, LPA Rai toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai toured the facility kitchen and observed food supply of at least 2 days of perishable food and at least 7 days of nonperishable food. Sharps and medications were locked in secured areas. LPA observed additional food supply areas and secured areas for cleaning supplies and laundry detergents. LPA Rai toured the resident bedrooms. 5 out of 5 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. The water temperature in the bathroom sinks ranged from 105.1 degrees F - 114.1 degrees F. During tour, LPA Rai observed Clorox disinfecting wipes in multiple areas of the facility, such as the kitchen and resident room, which was accessible to residents at the facility. LPA Rai observed 2 resident which were non-ambulatory and were using a walker around the facility. LPA Rai reviewed facility records for 3 staff and 3 residents. LPA Rai observed 2 out of 3 residents did not have a signed Appraisal/Needs and Services Plan by Licensee and Resident/Resident's Responsible Party on file. Continuation on LIC 809-C, Page 1 of 2. Page 2 of 2. LPA Rai reviewed resident medications and central stored medication records for 3 residents. LPA Rai observed 1 out of 3 resident (R3) has medication discrepancies wherein 5 out of 7 medication tablets in the bottle did not match the Central Stored Medication Record. Medication #1 should have 52 tablets in the bottle, LPA and Staff S1 observed 58 tablets, which meant there were 6 extra tablets in the bottle. Medication #2 should have 187 tablets in the bottle, LPA and Staff S1 observed 196 tablets, which meant there were 9 extra tablets in the bottle. Medication #3 should have 65 tablets in the bottle, LPA and Staff S1 observed 44 tablets, which meant there were 12 extra tablets in the bottle. Medication #6 should have 47 tablets in the bottle, LPA and Staff S1 observed 58 tablets, which meant there were 11 extra tablets in the bottle. Medication #7 should have 30 tablets in the bottle, LPA and Staff S1 observed 43 tablets, which meant there were 13 extra tablets in the bottle. LPA and S1 reviewed R3's Medication Administration Record (MARs) and staff initialed each dose, stating the resident was administered the medication and resident was not away from the facility. Fire extinguisher was observed and inspected on 10/3/2023. Facility smoke detectors and carbon monoxide detector are in working condition. The last disaster drill was conducted on 4/18/2024. 87411 Personnel Requirements - General is being cited during today's visit. LPA Rai would like to clarify the facility personnel being in sufficient in numbers is not the concern, however the facility personnel's actions and documentation are observed to be not competent to provide the services necessary to meet the resident's needs. Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. This report was reviewed with Administrator (ADM) Cheryll Lagunilla and a copy of the report was provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, May 21, 2024