Rillera's Guest Home 2

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year Visit and met with Administrator (ADM) Zosima Rillera. During visit, LPA Marrufo toured the inside and outside of the facility. During visit, LPA toured the kitchen area. LPA observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the first aid kit and found it to be complete. LPA toured four out of four bedrooms. Each bedroom had working lights and available bedding and clothing storage areas. LPA tested the smoke/carbon monoxide detectors in the hallways and resident rooms and found them to function properly when tested. LPA toured two out of two resident bathrooms. Each bathroom had working lights and available soap and paper towels. LPA measured the water temperatures in both bathroom sinks and they measured at 109 F. LPA toured the outside area and found both exits to be clear of obstructions. LPA reviewed five out of five resident records. Resident R1 had three medications missing in his/her Centrally Stored Medication and Destruction Records. The rest of the resident records were complete. LPA reviewed five staff records and found them to be complete. See LIC809-C page for more information. Page 1 of 2. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information. LPA Marrufo requests that the following documents be updated and copies sent to the department by 07/17/2026: LIC500 Personnel Report LIC308 Designation of Administrative Responsibility Liability Insurance LIC610E Emergency Disaster Plan This report was reviewed with Elis Pascual and a copy of this report and appeal rights were provided. Page 2 of 2. END REPORTthe state’s words, verbatim · CDSS document, Jul 10, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6)(A)-(F) · Plan of correction due date: Jul 17, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication. This requirement was not met as evidenced by: Licensee did not ensure that resident R1 did not have three medications missing from the Centrally Stored Medication and Destruction Record, which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Jul 10, 2026

Plan of correction: Licensee agrees to audit all resident centrally stored medication and destruction records and submit a statement of understanding of the regulation 87465(h)(6)(A)-(F) to CCL by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Administrator Zosima Rillera. During visit, LPA Marrufo toured the facility inside and out. LPA toured the kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA toured two out of two resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks were 105 F and 106 F. LPA tested the smoke detectors in three out of three resident rooms and in the hallways and each smoke detector functioned properly when tested. Each bedroom had working lights and available bedding and clothing storage areas. LPA toured the outside of the facility and found it to be clear of obstructions. LPA Marrufo reviewed the first aid kit and found it to be complete. LPA reviewed five out of five resident records and found them to be complete. LPA reviewed five out of five resident Centrally Stored Medication and Destruction Records (CSMDRs). Resident R1 had two medications missing from the CSMDR and resident R2 had one medication missing from the CSMDR. LPA reviewed four staff records. Staff S1 was missing a current first aid certification. Staff S2 was missing an LIC503 Health Screening Form. Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information. A civil penalty of $250 was issued due to a repeated deficiency. This report was reviewed with Administrator Zosima Rillera and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jul 2, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management - Annual Continuation Visit and met with Administrator Zosima Rillera. During visit, LPA toured 3 out of 3 resident bathrooms and observed each bathroom had working lights and available soap and paper towels. LPA measured the water temperatures in each bathroom and observed that they measured between 110 F - 118 F. LPA Marrufo reviewed the Centrally Stored Medication and Destruction Records (CSMDR) for residents R1-R6. Residents R2-R4 and R6 had medications that were not recorded in their CSMDRs. LPA Marrufo reviewed the resident records for residents R1-R6. Resident R1's and R3's records were missing Consent Forms. R4's record was missing a Safeguard for Property and Valuables Form. R4's Physician's Report states R4 has dementia and the date of the exam on the most recent Physician's Report was 06/02/2021. R5's record was missing an LIC613 Personal Rights form. R5's Physician's Report states R5 has dementia and the date of R5's most recent exam was 06/19/2018. R6's record was missing a Safeguard for Property and Valuables Form, Consent Form, and LIC613 Personal Rights Form. R6's Physician's Report states R6 has dementia and the date of R6's last exam was on 08/08/2020. LPA reviewed staff records for staff S1-S4. Staff S1 and S4 were missing LIC9052 Employee Rights forms. Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information. Advisory Notes were issued. See LIC9102 Advisory Notes for more information. This report was reviewed with Administrator Zosima Rillera and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 26, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Aug 2, 2024

87705 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 requirement was not met as evidenced by: Licensee did not ensure that residents with dementia R4-R6 had an annual medical assessment, which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Jul 26, 2024

Plan of correction: Licensee agrees to arrange for an annual medical assessment for residents R4-R6 and submit updated copies of their Physician's Reports to CCL by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(b)(16) · Plan of correction due date: Aug 2, 2024

87506 Resident Records (b) Each resident’s record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables. This requirement was not met as evidenced by: Licensee did not ensure that residents R4 and R6 had a Safeguard for Property and Valuables form on file in their resident records, which poses a potential safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 26, 2024

Plan of correction: Licensee agrees to submit completed copies of the Safeguard of Property and Valuables form for residents R4 and R6 by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6)(A)-(F) · Plan of correction due date: Aug 2, 2024

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication. This requirement was not met as evidenced by: Licensee did not ensure that R2-R4 and R6 have medications missing from their centrally stored medication and destruction records, which poses a potential safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 26, 2024

Plan of correction: Licensee agrees to audit all resident centrally stored medication and destruction records and submit a statement of understanding of the regulation 87465(h)(6)(A)-(F) to CCL by POC date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year visit and met with Zosima Rillera, Administrator. During visit, LPA Marrufo toured the facility inside and out. LPA Marrufo toured the kitchen area and food storage areas in the garage. The facility had a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed locked storage areas for sharp objects and cleaning supplies. LPA observed the first aid kit and found it to be complete. LPA toured 4 out of 4 resident bedrooms and observed each bedroom to have available bedding and clothing storage areas and working lights. LPA Marrufo tested the smoke detector system and found it to be functional when tested. LPA toured the outside area and found the exits to be clear of obstructions. Due to time constraints, the annual inspection will need to be completed at a later time. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Administrator Zosima Rillera and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 12, 2024