Family Senior Care Home I

Type of visit: Required - 1 Year

On 01/22/2026, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Janet Salvador and explained the purpose of today's visit. There are currently 4 residents in the facility and 4 staff present. The facility is licensed for 60 and over. 6 may be non-ambulatory and 1 may be bedridden in bedroom number 4. Hospice waiver on file for 4 residents. During today's visit there are no residents on hospice and no residents that are bedidden. During today's visit, LPA toured the inside and outside of the facility. When touring the outside area of the facility, the exits were cleared of obstruction. LPA Rai observed 1 large shed in the backyard which was locked and used for storage belonging to the property owner's that is not used for living space. LPA 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 toured the facilty to include 4 resident rooms, 1 staff room, living room, dining room, kitchen and garage. 4 out of 4 resident bedrooms had available bedding, drawers, and functioning lights, all of which are listed under Title 22 recommendation. The facility bathroom had available soap, paper towels, and trash cans with lids. Water temperature is tested in two bathrooms, one being the common bathroom in the hallway and another in bedroom 4. Both were tested at 120F which poses an immediate health and safety concern for residents in care. Page 2 Fire extinguisher adjacent to the kitchen area observed and inspected on 1/24/2025. The extinguisher is charged and ready for use per indicator observed attached to the extinguisher. Facility smoke detectors and carbon monoxide detectors are in working condition. The last disaster drill was conducted on 01/10/2026 which are for earthquake and fire drill. LPA Vado reviewed resident files and staff files and all are current. LPA also reviewed client P&I money for one client. This is reviewed and is current. Medications are reviewed and are documented as current. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with caregiver, and a copy of the report is provided on this day.the state’s words, verbatim · CDSS document, Jan 22, 2026

Allegation investigated: Staff are not administering medication based on physician's orders Staff are falsifying resident's medication records Staff are not following infection control protocol by using one pair of gloves on mutiple residents, causing a resident to have an e.coli infection Staff did not ensure resident's medications are locked and inaccessible to residents in care

On 07/11/25 Licensing Program Analyst (LPA) Marcela Yanez conducted an unannounced complaint inspection visit to deliver the findings on the above allegations. LPA met with Administrator Elizabeth Bautista and stated the purpose of the visit. On 04/11/2025 the Department received the complaint and on 04/21/2025 LPA conducted an initial complaint investigation visit. LPA attempted to interview 2 residents (R1 and R2). LPA interviewed the administrator (ADM), 1staff (S1), reporting party (RP) and 2 witnesses (W1 and W2). On 5/23/2025, LPA conducted a continuation of the complaint investigation and re-interviewed the administrator and requested for copies of 3 resident records such as but not limited to physician’s report, vital /blood pressure (BP) logs, after visit summary log, centrally stored medication record (CSMDR) appraisal needs and services plan. page 1 of 3 Unsubstantiated page 2 of 3 Staff are not administering medication based on physician’s order. On 4/21/2025 LPA interviewed Staff 1 (S1), Administrator (ADM), witness 2 (W2) and attempted to interview 2 residents (R1, R2) and attempted to interview S2. Based on interview, S1 stated, staff administer medication based on doctor’s orders. ADM stated that the staff logs the vital readings via text message for 3 residents and provided copies and screenshots of vital record logs to LPA. ADM stated that the facility administers medication according to doctors’ order. ADM stated that R3s medication was changing frequently. W2 stated, he/she is not familiar with R2s care because he/she is out of town and have hired Senior Generation Advocate Services to assist and oversee R2s care. Based on document review of the physician’s order, medication will be administered or given when R3’s blood pressure (BP) is too high and no medication for BP given when BP is too low. Staff are falsifying resident's medication records. Based on record review of the facility’s Centrally Stored Medication and Destruction Record (CSMDR), LPA observed that the prescription medication is given per physician’s order and recorded based on the doctor’s instruction. ADM stated the vital record log is used to log the BP medication for R3 and reported to R3s PCP as instructed by the PCP. On 05/29/2025, LPA interviewed W1, who stated that he/she is the one who “noticed that the vital or blood pressure (BP) log looked suspiciously perfect and looked like it’s falsified.” LPA observed that vital / BP record presented by W1, and RP does not have R3s name or another resident’s name on BP log. LPA reviewed 2 out 2 residents’ (R1 and R2) vital / BP record and did not find the “suspiciously perfect and looked like it’s falsified” document. W1 stated, he/she found the vital / BP log on a clip board and took a photo the log was not in R3s file record. The log did not have any name on it and it is unknown who it belonged to. Page 3 of 3 Staff are not following infection control protocol by using one pair of gloves on multiple residents, causing a resident to have an E. coli infection. Based on review of the facility record and observation during the complaint investigation visit, the facility has infection control plan and is adhering to California Code of Regulation (CCR) Title 22 87470 Infection Control Plan Requirement. ADM stated the facility follows infection control procedures when providing care to residents. Staff always wears gloves and layers the gloves each time they attend to the resident and discarded in between completing an interaction with one resident and prior to interaction with another resident. LPA observed hand sanitizers, alcohol, and disinfecting wipes to mitigate any possible contamination between individuals. Staff did not ensure resident's medications are locked and inaccessible to residents in care. During visit LPA observed the medication storage closet was locked and not accessible to residents in care. ADM stated the only time medication door is unlocked is when the staff are preparing and administering the medication. Based on information from interviews conducted and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED. No citations noted at today’s compliant investigation visit. Exit interview conducted with Administrator. This report was provided to review and for signature. A copy of this report was provided to Elizabeth Bautista, Administrator.the state’s words, verbatim · CDSS document, Jul 11, 2025 · control 26-AS-20250411172923

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management for annual continuation from 1/23/2025. LPA Rai met with Administrator, Elizabeth Bautista and stated the purpose of today's visit. The hot water temperature in the bathroom sink ranged from 105.1 - 105.3 degrees F. Fire extinguisher was observed and inspected on 1/24/2025. Facility smoke detectors and carbon monoxide detectors were in working condition. The last disaster drills were conducted on 1/7/2025 and 1/9/2025. LPA Rai reviewed facility records for 2 staff and 2 residents. LPA Rai observed resident R2 with a full bed rail. ADM stated R2 was not receiving Hospice care at this time. LPA Rai reviewed R2's facility file and R2 did not have a written physician's order for full bed rail or half bed rail. ADM stated she will work with R2's physician to obtain a written physician's order for half bed rail and remove the full bed rail from R2's bed. LPA Rai observed R3, R4, and R5 with half bed rails who are not receiving Hospice care at this time. LPA Rai reviewed R3, R4 & R5's facility file and they did not have a written order from physician for using a half-bed rail for mobility use. ADM stated she will work with the resident's physician's to obtain a written physician's order for half-bed rails. LPA Rai reviewed R5's facility file and reviewed a medical assessment conducted on 6/13/2023 and ADM stated R5 was not recently seen by physician. ADM will work with R5's responsible party and physician for R5 to receive an annual routine visit with physician. Continuation on LIC 809-D, Page 1 of 2. Page 2 of 2. LPA Rai reviewed R5's Appraisal/Needs and Services Plan was not signed by R5's responsible party. ADM stated to work with R5's responsible party and a signed copy of the document will be added to R5's file. LPA Rai observed 2 bottles of OTC medications in R2's room and 1 bottle of prescription medication in R4's room. LPA Rai reviewed Physician's Report for R2 and R4 and both residents cannot store medications on their own and require medications to be centrally stored at the facility. ADM removed the items during the visit and placed medications in the medication cabinet. LPA Rai reviewed resident medications and central stored medication records. Deficiencies were cited per California Code of Regulations, Title 22. See LIC 809-D. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Administrator Elizabeth Bautista and a copy of the report was provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jan 24, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Jan 31, 2025

87608 Postural Supports (a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care... This requirement is not met as evidenced by: Based on record review and observation, R2 has a bed rail that extended the entire length of the bed and R2 is not receiving hospice care at this time which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 24, 2025

Plan of correction: Administrator stated to submit a written plan of action of understanding regulation and remove the full bed rail and ask for written physician’s order for half-bed rail and place a half-bed rail on R2’s bed by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(3) · Plan of correction due date: Jan 31, 2025

87608 Postural Supports (a)(3)A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.... This requirement is not met as evidenced by: Based on observation and record review, 3 out of 5 residents used a half bed rail and did not have a written order from a physician on file which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 24, 2025

Plan of correction: Adminstrator stated to submit a written plan of action of understanding reglulation and obtain a written order from resident's physician for half-bed rail to be used for mobility by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jan 31, 2025

87465 Incidental Medical and Dental Care (h) (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on observation and record review, 3 medication bottles were not kept in a safe and locked place which is not accessible to persons other than employees which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 24, 2025

Plan of correction: Administrator stated to submit a written plan of action of understanding regulation and provide staff training to ensure centrally stored medications are kept in a safe and locked place inaccessible to residents by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(h) · Plan of correction due date: Jan 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 is not met as evidenced by: Based on record review, R5's file contained a medical assessment completed on 6/13/2023 and there was no other documentation of R5 receiving an annual routine visit with R5's physician which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 24, 2025

Plan of correction: Administrator stated to submit a written plan of action of understanding regulation and schedule an appointment with R5's physician to complete an updated medical assessment by POC due date.

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

87463 Reappraisals (f) The licensee shall ...communicate with the resident and,... the resident's representative, about any significant change in condition and the recommendation... Documentation of such communication shall be added to the resident’s record. This requirement is met as evidenced by: Based on record review of R5's Appraisal/Needs and Services Plan was not signed by R5's responsible party which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 24, 2025

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and to follow up with R5's responsible party to sign the Appraisal/Needs and Services Plan by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Elizabeth Bautisa. LPA Rai observed 2 staff who have obtained a Criminal Record Clearance. LPA Rai observed 5 residents at the 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 observed 1 shed in the backyard which was locked and used for storage and not habitual space. 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 facilty to include 4 resident rooms, 1 staff room, living room, dining room, kitchen and garage. 4 Out of 4 resident bedrooms had available bedding, drawers, and functioning lights. The facility bathroom had available soap, paper towels, and trash cans with lids. This annual inspection will be completed at a later date. This report was reviewed with Administrator (ADM) Elizabeth Bautisa. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 23, 2025

Allegation investigated: Facility food does not meet the recommended dietary allowance. Facility staff restricting resident from voicing concern.

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Lead Staff, Jose Cruz and stated the purpose of today’s visit. Administrator Elizabeth Bautisita was not able to be present during visit, so LPA Rai spoke with Administrator over the phone and stated the purpose of today's visit On 5/17/2024, the Department received a complaint with the above allegations. On 5/24/2024, the Department conducted an initial investigation at the facility. Continuation on LIC 9099-C, Page 1 of 3. Unfounded Page 2 of 3. Facility food does not meet the recommended dietary allowance. On 5/24/2024, the Department interviewed 3 staff (S1-S3). Three out of three staff prepare the meals and snacks to the residents. All three staff stated the meals and snacks provided are nutritious and cooked fresh before served. S3 stated R1 is provided protein shakes, requested fruits and consumes all meals served to R1 since R1 has a good appetite. S3 stated R1’s family will provide snacks such as dried fruits and snacks and they are always available for R1 in the resident’s room. On 5/24/2024, the Department interviewed 4 residents (R1-R4). Four out of four residents refused to answer LPA Rai’s questions and refused to be interviewed. During 5/24/2024 visit, LPA Rai observed 2 days of perishable foods and 7 days of non-perishable foods in the kitchen, pantry, and garage. The foods observed was a variety of frozen and cooked protein, vegetables, carbs, and canned foods. LPA Rai observed snacks in R1’s room which included dried fruit, nuts, and packaged items. Based on review of R1’s Admission Agreement dated 5/6/2024, the facility staff is to provide basic services which include food services to include 3 nutritious meals daily and snacks and special diets if prescribed by a doctor. Based on facility house rules, all residents received 3 meals a day in the dining room and Snacks are available at all times. Based on review of R1’s Physician’s Report dated 6/1/2023, R1 has a special diet due to resident has a diagnosis of End-Stage Renal Disease (ESRD) and R1 is not able to feed self. Based on review of R1’s Appraisal/Needs and Services Plan dated 12/30/2023, R1 goes to dialysis 3 times a week and R1 needs assistance with feeding and requires a regular diet with low sugar. Based on review of text messages between Administrator and facility staff, facility staff were aware of R1 needed more protein in diet and more food intake due to R1 losing weight. ADM instructed facility staff to ask R1’s preference and to include it with grocery shopping. Based on review of R1’s Progress notes from 2/26/2024 to 5/6/2024, facility staff documented the resident would come back from dialysis hungry and thirsty and some meals were provided to the resident were documented. Based on review of staff training from January 2024 to June 2024, staff have completed training in the following topics which include Dehydration and Proper Nutrition and Activities of Daily Living. Page 3 of 3. Facility staff restricting resident from voicing concern. On 5/24/2024, the Department interviewed 3 staff (S1-S3). Three out of three staff they have not seen or heard staff restricted resident R1 from talking or communicating R1’s needs. All three staff have provided direct care to resident R1. Three out of three staff stated R1 is able to communicate to staff for assistance and express concerns directly to the Administrator. S3 stated R1 will yell of the tv in the next room is loud and staff have told R1 to “quiet down" after the issue has been resolved but they do not tell R1 to not restrict R1 from voicing any concerns about R1's care or about the facility. On 5/24/2024, the Department interviewed 4 residents (R1-R4). Four out of four residents refused to answer LPA Rai’s questions and refused to be interviewed. Based on review of staff training from January 2024 to June 2024, staff have completed training in the following topics which include Discrimination and Harassment and Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Lead Staff Jose Cruz and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 21, 2024 · control 26-AS-20240517154107

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted a case management visit for an exemption request for staff (S1) that cannot be completed due to incomplete information and incorrect form used. LPA met with Administrator (ADM) Elizabeth Bautista and stated the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) that serves individuals who are age 60 and over, approved for 6 non-ambulatory of which 1 may be bedridden and hospice waiver for 4. LPA observed 5 out of 6 residents and 2 staff (S2 and S3), at the facility. 1 Out of 5 resident was in the living room watching TV, 1 Out of 5 is under hospice care, 3 out of 5 are in bed and resting. 1 out of 5 is out of the facility for medical appointment. LPA checked Guardian S2 and S3 are both associated with the facility. LPA interviewed S2 and S3. and 4 out of 5 residents (R1 to R4). LPA reviewed staff record and found that S1 worked at the facility since 5/7/2023 and no exemption transfer request was submitted to CDSS CPMB (Care Provider Management Branch). Based on interview with S1, S2, and residents (R2 and R5) S1 works at the facility and provides care to residents. ADM stated that S1 has been working as a part time for the facility since 5/7/2023, and had an exemption from the old license that was closed on 8/23/2022. The exemption transfer approval for S1 was not transferred to the new license. ADM stated that he/she assumed that the exemption transfer approval of S1 from the old license is still effective after the closure of the old license. Continuation on LIC 809-C, page 1 of 2 LPA discussed with ADM Title 22 CCR 87355 (e)(3) Criminal Record Clearance wherein, (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: (3) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r) unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility LPA discussed with ADM the importance of Title 22 CCR 87405 - Administrator Qualification (d)The administrator shall have the qualification as specified in Section 87405(d)(1) through (7). (2) Knowledge of and the ability to conform to the applicable laws, rules and regulations. During visit, ADM started to work on the exemption transfer request for S1, filled the LIC 9188 and faxed the request to CPMB. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC 809-D. A civil penalty is being assessed for the amount of $500 for S1 working in the facility for more than 5 days without receiving criminal record exemption transfer approval. The civil penalty will be for $500 ($100 per day x 5 days = $500). See LIC421BG. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Administrator Elizabeth Bautista and a copy of the report and Appeal Rights were provided. end of report page 2 of 2the state’s words, verbatim · CDSS document, Jun 7, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Jun 8, 2024

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review ... prior to working, residing or volunteering in a licensed facility:(3)Request and be approved for a transfer of a criminal record exemption. This requirement is not met as evidenced by: Based on interview and record review, S3 did not have an approved transfer of a criminal record exemption. S3 provides care and supervision to the residents at the facility which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 7, 2024

Plan of correction: ADM completed the LIC 9188 while LPA was in the facility and ADM stated that as soon as exemption transfer approval is received ADM will email or fax proof to LPA. ADM will fax the proof of application by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(d)(2) · Plan of correction due date: Jun 8, 2024

87405 - Administrator Qualification (d) The administrator shall have the qualification as specified in Section 87405(d)(1) through (7). (2) Knowledge of and the ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by. Based on interview, ADM did not exhibit understanding of the applicable laws, rules and regulations by assuming that the exemption transfer approval from the old license automatically transfer to the new license.the state’s words, verbatim · CDSS document, Jun 7, 2024

Plan of correction: ADM stated he/she will reference Title 22 at all times to ensure that ADM is complying with the regularions as applicable to the program. ADM will email LPA of the plan of correction by due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Simi Rai is conducting a case management visit as a result of finding information during today's complaint investigation. LPA Rai met with Administrator (ADM) Elizabeth Bautista. LPA Rai observed 5 residents and 2 staff at the facility. During today's visit, LPA Rai observed Staff (S3) leave the facility as his/her shift was ended. S3 was not associated to the facility. During LPA's investigation interviews with S1 and S2, S1 and S2 were not associated to the facility. S1 and S2 stated they both started working on Saturday, May 18th, 2024. S1 and S2 stated they provide care and supervision to the residents, such as but not limited to assisting residents with feeding, bathing, grooming, and incontinence care. LPA Rai verified S1 and S3 do have a California criminal record clearance but are not associated to the facility. ADM stated S2 does not have California criminal record clearance because S2 is shadowing the care staff and will be leaving the facility tomorrow. ADM stated S1 and S3 are care staff and provide care and supervision to the residents at the facility. LPA Rai educated ADM on Title 22 CCR 87355 Criminal Record Clearance wherein all individuals prior to working, residing or volunteering at the facility need to have a California criminal record clearance and ensure they are associated to the facility. During visit, Administrator signed up on Guardian to set up an account to be able to associate and disassociate individuals who are working, residing or volunteering at the facility. Continuation on LIC 809-C, page 1 of 2. Page 2 of 2. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC 809-D. A civil penalty is being assessed for the amount of $1500. For S2 working in the facility for more than 5 days without receiving a California criminal record clearance, the civil penalty will be for $500 ($100 per day x 5 days = $500). For S1 and S3 working at the facility without associate and California criminal record clearance transfer, the civil penalty will be $1000 ($100 per day x 5 days = $500 for two individuals). See LIC421BG. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Administrator Elizabeth Bautista and a copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, May 24, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: May 25, 2024

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review ... 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 is not met as evidenced by: Based on observation, interview and record review, staff S2 did not have a California Criminal Record Clearance and S2 was providing care and supervision to the residents at the facility which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 24, 2024

Plan of correction: Administrator stated staff S2 will be removed from the facility and will return after obtaining a Claifornia criminal record clearance. Administrator stated to submit a written plan of action and understanding regulations by POC dute date. Administrator agreed and understood.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(2) · Plan of correction due date: May 25, 2024

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review ... prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance. This requirement is not met as evidenced by: Based on observation, interview and record review, staff S1 and S3 did have a California Criminal Record Clearance but was not assosicated to the facility, which poses/posed an immediate Health, Safety or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, May 24, 2024

Plan of correction: Administrator stated she will ensure staff S1 and S3 will ensure the California criminal record clearance is transferred and associated to the facility. Administrator stated to submit a written plan of action and understanding regulations by POC dute date. Administrator agreed and understood.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Simi Rai arrived unannounced to conduct a continuation of the annual inspection from 1/27/2024. LPA Rai met with Administrator (ADM) Elizabeth Bautista and stated the purpose of today's visit. LPA Rai observed 2 staff, including ADM and 4 residents at the facility. On 1/27/2024, LPA Rai reviewed resident (R1)'s Centrally Stored Medication log and R1's medications. LPA Rai observed discrepancy in R1's medication administration record (MAR) for January 2024. 2 Of 13 medications were not administered to R1 as per physician's orders. LPA Rai and S1 counted medication #5 and 2 tablets were not administered to R1. LPA Rai and S1 counted medication #6 and 0.5 tablet was not administered to R1. Based on R1's MAR, R1 did not refuse medication and R1 was not admitted to the hospital after the medication bottles were opened. During visit, LPA Rai reviewed facility records for 2 staff and 2 residents. During review of 2 of 2 resident files (R1-R2), files did not contain weight log observing resident's weight. ADM stated the facilty is not monitoring resident's weight. Based on record review, R1 has been admitted to the facility for 6 months and did not have any recorded weight log. ADM understood if the resident was not able to use weight machine to record weight, ADM can measure resident's arm and note under observation. Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. 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. Technical Violation was given. This report was reviewed with Administrator (ADM) Elizabeth Bautista. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jan 30, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jan 31, 2024

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on record review, interview and observation R1's 2 out of 13 meds not administered to R1 as prescribed by the R1's physician which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2024

Plan of correction: Administrator stated to submit a written plan on understanding regulations and schedule in-service training to staff by POC due date. Administrator agreed and understood.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87207 · Plan of correction due date: Jan 31, 2024

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: Based on record review, interview and observation, R1's MARs noted medications were given to R1 but medication was not administered based on medications counted in bottle which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2024

Plan of correction: Administrator stated to submit a written plan on understanding regulations and schedule in-service training to staff by POC due date. Administrator agreed and understood.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Required 1 Year visit and met with Administrator (ADM) Elizabeth Bautisa. LPA Rai observed 2 staff and 4 residents at the 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 Rai toured the resident bedrooms. 4 out of 4 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 105.1F - 105.4F. The water temperature in the kitchen sink was 107.1F. Fire extinguisher was observed and inspected on 6/2/2023. This annual inspection will be completed at a later date. This report was reviewed with Administrator (ADM) Elizabeth Bautisa. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 27, 2024