Adelaide Home II

Type of visit: Case Management - Incident

At approximately 9:50 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced to conduct a Case Management visit to follow up on a Special Incident Report received by the department on 02/10/2026, as well as an SOC341 received by the department on 02/11/2026. LPA made observations, conducted interviews and obtained documents. No deficiencies or citations were sited.the state’s words, verbatim · CDSS document, Feb 17, 2026

Type of visit: Required - 1 Year

At approximately 09:00 AM, Licensing Program Analyst (LPA) Stevenson arrived unannounced to conduct a required 1-year annual inspection and was greeted by LVN caregiver Pam Deleon who has Designation of Facility Responsibility (RP). Administrator Jasmine Aliscad was called and informed of inspection and arrived later at 09:50 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with four (4) residents in care. Two residents were present and one was away with Administrator at an assessment and another resident was away at day program. Facility has a Dementia Care Plan, is approved for all non-ambulatory residents and has a hospice waiver for one (1) and is vendorized with North Bay Regional Center (NBRC). At approximately 9:30 AM, LPA initiated a tour of the facility with RP and observed the following: Facility is a one story home, was a comfortable temperature, free from odors, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, and hygiene products, incontinent care supplies, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency food and water supply. In addition each resident has a dedicated emergency go-bag. There is a shaded seating area with a electronic retractable awning in the backyard with outdoor space and stainless steel Bar-B-Que for use. In addition, facility has wide wheelchair ramps in front and back of the home. LPA observed 1 locked shed in the backyard which LPA inspected and observed the contents to consist of PPE supplies, extra resident care equipment, holiday decorations, and a large emergency generator. Continued on LIC809-C... Continued from LIC809C... LPA observed an activity schedule and were informed that the residents play bingo, play indoor bowling, watch movies, and engage in sensory activities. Facility also hosts holiday parties for the residents and throws a large Halloween, Thanksgiving, Christmas, and 4th of July party in a central location where all five (5) care homes attend. Facility has internet access and provides a designated internet access device for resident use. Facility has a telephone which was tested during inspection. Facility's fire extinguisher was observed charged and was last serviced 10/2025. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Centralized Fire system was tested and all fire doors closed automatically. Facility conducts monthly disaster drills, and the most recent drill was conducted 12/2025. LPAs observed the facility's infection control plan, first aid kit, PPE, and emergency supplies. LPAs reviewed facility's emergency disaster plan last updated 1/2025. At approximately 10:30 AM, LPA conducted file review. Four (4) staff files and four (4) resident files were reviewed. One (1) staff member hired 10/14/2025 was noted to have evidence of initial 40 hours of training and orientation within the 1st four (4) weeks of hire, but did not have evidence of the full 14 hours of dementia training or the full 8 hours of postural supports/restricted conditions, hospice care training in those 40 hours and a Technical Violation was issued. Four (4) of four (4) resident files reviewed contained all the required documentation per regulation. Administrator states they coordinate residents' medical and dental appointments and transportation to and from visits. Medications and P&I were reviewed and observed managed and maintained within regulation. Updated copies of the following documents were obtained during this visit: LIC500 - Personnel Report (updated) LIC610D Emergency Disaster Plan (updated) Proof of Liability Insurance LIC 9020 Register of Facility Clients/Residents Technical Violation is cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), may result in a civil penalty assessment. Exit interview conducted with Administrator and Appeal rights were given. Signature on form confirms receipt.the state’s words, verbatim · CDSS document, Dec 23, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At approximately 11:00 AM, Licensing Program Analysts (LPAs) Julie Florio and Robert Frank arrived unannounced to conduct a required 1-year annual inspection and were greeted by Jasmine Aliscad, Administrator. Facility is a Residential Care Facility for the Elderly (RCFE) with four (4) residents in care. Residents 2 (R2), Resident 3 (R3) and Resident 4 (R4) were present during inspection and LPAs were informed that Resident 1 (R1) was away at their day program. Facility has a Dementia Care Plan, is approved for all non-ambulatory residents, and is vendorized with North Bay Regional Center (NBRC). At approximately 11:45 AM, LPAs initiated a tour of the facility with Administrator and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPAs observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. However, LPAs observed the key used to unlock said cabinets hanging on a hook in the kitchen where accessible to residents in care, (see LIC809D). Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency Food and water supply. Medications were centrally stored and locked. There is a shaded seating area in the backyard with outdoor space for activities. LPAs observed 1 locked shed in the backyard which LPAs inspected and observed the contents to consist of PPE supplies, extra resident care equipment, holiday decorations, and an emergency generator. LPAs observed an activity schedule and were informed that the residents play bingo, go bowling, watch movies, and engage in sensory activities. Facility also hosts holiday parties for the residents and throws a large Halloween, Thanksgiving, Christmas, and 4th of July party in a central location where all five (5) care homes attend. Facility has internet access and provides a designated internet access device for resident use. Facility has a telephone which was tested during inspection. Continued on LIC809-C... Continued from LIC809C... Facility's fire extinguisher was observed charged and was last serviced 10/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Centralized Fire system was tested and all fire doors closed automatically. Facility conducts monthly disaster drills, and the most recent drill was conducted 12/2024. LPAs observed the facility's infection control plan, first aid kit, PPE, and emergency supplies. LPAs reviewed facility's emergency disaster plan last updated 1/2024. At approximately 12:45 PM, LPAs conducted file review. Four (4) staff files and four (4) resident files were reviewed. All staff files reviewed have all of the required paperwork including the required CPR and First Aid training certificates and documentation of all required initial and annual training hours. Four (4) of four (4) resident files reviewed contained all the required documentation per regulation. Administrator states they coordinate residents' medical and dental appointments and transportation to and from visits. Medications and P&I were reviewed and observed managed and maintained within regulation. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: LIC500 - Personnel Report (updated) LIC610D Emergency Disaster Plan (updated) Proof of Liability Insurance (updated) Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted with Administrator and Appeal rights were given. Signature on form confirms receipt.the state’s words, verbatim · CDSS document, Dec 19, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 01/30/2024 at 12:45 PM Licensing Program Analyst (LPA) Jill Nakagawa arrived at the facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator-in-Training Jasmine Aliscad (JA). LPA and JA toured the facility together to ensure the health and safety of residents in care. Areas toured include but are not limited to four (4) resident rooms, two (2) bathrooms, common areas, kitchen, storage areas, garage and yard. The facility was found to be well-maintained, clean, sanitary and well-organized. Bedrooms of residents are decorated to highlight their interests, and had required furnishings. The kitchen was clean and in good repair. Cooking/dining equipment and utensils were present. Food was found to be stored properly. Facility has required (7) seven-day non-perishable and (2) day perishable supply of food. The common area was clean and decorated for Valentine's Day and had plenty of space for activities, meals, and socialization. Staff and resident files were reviewed. Medications were also reviewed. Medication is locked in a locked closet. Facility also utilizes a medication cart and a treatment cart, which are locked. The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Two (2) fire extinguishers were fully charged and serviced on 10/6/2023. Smoke detectors and fire alarm system passed inspection on 10/6/2023. Carbon monoxide detectors tested and found to be operational. Hot water temperature measured within required Title 22 regulations of 105 degrees F and 120 degrees F. ( Continued on 809-C) Continued from 809 All employees requiring background checks are cleared. All required postings are displayed within facility. No pools/bodies of water are on the premises. No firearms are on premises. The last disaster drill was conducted and documented on 12/22/2023; the facility has been conducting drills every month. No deficiencies found at the time of inspection. No citations issued. Exit interview conducted with Administrator-in-Training and copy of report was provided to administrator.the state’s words, verbatim · CDSS document, Jan 30, 2024