Magnolia Gold Home Care

Type of visit: Required - 1 Year

At approximately 09:50 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced for the purpose of conducting a required annual inspection and quarterly Case Management-Legal/Non-compliance (NCC) Inspection and met with caregiver Lorna Valasquez who has Designation of Facility Responsibility (RP). House Manager Gwen Martinez was advise of today's inspection. House Manager arrived at approximately 10:15 AM to further assist with today's inspection. LPA was advised that there were four (4) residents in care, all of which were present during today's inspection. Facility is licensed for six (6) residents, five (5) of which can be non-ambulatory, one (1) bedridden and has a hospice waiver for three (3) residents. This facility was placed on a Non-Compliance Conference (NCC) on 06/26/2024 for a two-year term by Community Care Licensing (CCL); Concerns addressed in that NCC meeting on 06/26/2024 were: Administrator Duties and Qualifications Active Administrator in place for facility oversight per regulation Clearing Plans of Correction (POCs) Reporting Requirements Timely response to CCL when communication is engaged Continued on LIC809C Continued from LIC809 House manager Gwen Martinez was again, for the third time, advised that licensee Triune,INC continues to be in suspended status with the Franchise Tax Board (FTB). In addition LPA advised licensee that the department has not received recent updates on their efforts to get in good standing with the FTB and that this was in violation of the NCC goal of Magnolia Gold Home Care having more, "Timely responses with Community Care Licensing (CCL) when communication is engaged"; a concern that was raised during the last NCC inspection. At approximately 10:45 AM a tour of the facility was conducted and facility was found to be clean and well organized, and a comfortable temperature and without odors. Residents were clean and dressed appropriately. There was an ample supply of hygiene products for residents' care. There was also an ample supply of healthy perishable and non-perishable food as required by Title 22. Water temperature in 2 of 2 bathrooms measured within regulation of 105 -120 F. There was one new fire extinguisher observed to be fully charged. Smoke detectors/carbon monoxide detectors are centrally wired and tested to be functional. The front and back yards are well maintained and the back yard pool is fenced and secured as required by regulation. There is also a covered patio with seating for outdoor activities and visits. There are comfortable couches and chairs in the living room with television and simple games available. Soaps and toxins, as well as sharps were locked securely and inaccessible to residents. A toilet in the back bathroom is noted to rock and be unstable and licensee is advised to make toilet secure so as to provide a stable toilet for residents to use. (Technical Advisory for CCR 87303(a)) The last Emergency/Disaster drill was held on 03/05/2026. At approximately 11:45 AM LPA reviewed four (4) of 4 resident records and all 4 had complete records except resident (R1) was noted to be missing an annual health assessment. A discussion with House Manager had House Manager calling R1's responsible party to request copies of the numerous professional assessments R1 has had over the last year so as to be in compliance with CCR 87463(h)(1) of Resident Records/Incident Report Continued on LIC809-C Continued from LIC809-C At approximately 12:15 PM LPA reviewed six (6) of 6 staff files, including two (2) new staff and found all 6 to have required documentation except staff (S1) although with a clear TB test was missing a health physical and licensee is arranging to get a copy from the staff member not working today. Facility does not handle resident P&I money. At approximately 1:00 PM House Manager and LPA reviewed Medicine Administration and record keeping and found Medicines to be centrally stored and secure. In two (2) out of four (4) records, House manager and LPA observed instances of medicines as having been documented as having been administered but actually had been being termed out by MD order and not in facility, as well as a second instance in which a medicine was ordered every other day and blister packed as such, but was documented as having been given everyday. A type B citation for violation of CCR 87465(c)(2) Incidental Medical and Dental is levied and Plan of Correction (POC) issued. Licensee is asked to provide the following documents by 06/04/2026 to update the facility file including: 1) Updated LIC 308 Designation of Facility Responsibility (1 person per form) 2)Copy of updated Liability Insurance 3)LIC 9020 Resident Roster 4)LIC 500 Updated Personnel roster 5) Updated and signed LIC 610E Emergency Disaster Plan 6)Update Lease Agreement or Deed 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. This report was reviewed RP Lorna Valasquez and Appeal rights were given.the state’s words, verbatim · CDSS document, May 5, 2026

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Sexual abuse

At approximately 09:50 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced to deliver findings of a complaint recieved by Community Care Licensing (CCL) on 12/03/2025. LPA was met by caregiver Lorna Velasquez who has Designation of Facility Responsibilty (RP). RP called Administrator Madonna Martinez who arrived at approximately 11:30 AM to assist with today's report findings. During the investigation, the Department requested and reviewed documents, conducted interviews and made observations. An alligation of sexual abuse of Resident (R1) by staff member (S1) was received, in which it was alleged that S1 had exposing themselves alongside the bed of R1 and within direct view of R1. A medical professional witness (W1) observed on 12/01/2025 between 8:30 AM and 9:15 AM, staff (S1) facing R1 with their pants down below their buttocks. W1 informed the department, it appeared S1 was stroking their gentital area, W1 was able to gain the attention of S1 who pulled up their pants. W1 exited the faciltiy and reported the incident to their manager. Based on the departments interviews, record review and obtained police report, there is a preponderance of evidence that S1 exposed their genitals to R1 and the allgation of sexual abuse is SUBSTANTIATED. Continued on LIC9099-C Substantiated Continued from LIC9099 A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. A Plan of Correction (POC) is being issued today for a Type A violation of Health and Safety Code (HSC) 1569.269(a)(10) Enumerated Rights. Exit interview conducted with Administrator, whose signature on form confirms receipt of documents. Copy of report and appeal rights provided to Administrator.the state’s words, verbatim · CDSS document, Feb 3, 2026 · control 21-AS-20251203135942

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(10) · Plan of correction due date: Feb 5, 2026

HSC:1569.269 Enumerated Rights;severabiltiy (a) Residents of RCFE shall have all the following rights: (10) To be free from neglect, finacial exploitation, involuntary seculsion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement has not been met by evidence by: Based on interviews wtih residents and care partners a prepondrance of evidence has deemed that R1 was subject to sexual abuse.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Licensee agrees to review regulation Health and Safety Code (HSC) 1569.269(a)(1) by 02/05/2026 and conduct a training with the staff on current LIC500 personel roster and submit self-certification that the training has been completed by 02/13/2026

Type of visit: Case Management - Legal/Non-compliance

At approximately 09:50 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced for the purpose of conducting a quarterly Case Management-Legal/Non-compliance (NCC) Inspection and met with caregiver Lorna Valasquez who has Designation of Facility Responsibility (RP). Administrator Madonna Martinez was called to advise of today's inspection. Administrator Madonna Martinez arrived at approximately 11:15 AM to assist with today's inspection Licensing received copy of a valid Administrator's Certificate #7020245740 on 01/28/2026 with expiration date of 06/20/2027 LPA was advised that there were five (5) residents in care, two (2) of which are on hospice. Facility is licensed for six (6) residents, five (5) of which can be non-ambulatory, one (1) bedridden and has a hospice waiver for three (3) residents. Facility was found to be a warm, comfortable temperature and without odors in each of the resident's rooms. This facility was placed on a non-compliance (NCC) on 06/26/2024 for a two-year term by Community Care Licensing (CCL); Concerns addressed in that NCC meeting on 06/26/2024 were: Administrator Duties and Qualifications Active Administrator in place for facility oversight per regulation Clearing Plans of Correction (POCs) Reporting Requirements Timely response to CCL when communication is engaged Continued on LIC809C Continued from LIC809 Administrator was again advised that licensee Triune,INC continues to be in suspended status with the Franchise Tax Board (FTB). In addition LPA advised licensee that the department has not received recent responses from the licensee regarding their efforts to get in good standing with the FTB and that this was in violation of the NCC goal of Magnolia Gold Home Care having more, "Timely responses with Community Care Licensing (CCL) when communication is engaged" At approximately 11:15 AM four(4) of 4 staff files were reviewed and had all required documentation including evidence of 40 hours of training within their 1st four weeks of employment. At approximately 12:45 AM, five (5) of 5 resident files were reviewed and new resident R2 was noted to be missing signed Admissions Agreement, Pre-placement Appraisal and Consent for Emergency Medical Treatment with facility working with niece to secure. Longer term resident R1 was noted to need facility Appraisal Needs and Service and Pre-placement appraisal. A Type B citation for Violation of CCR 87506(a) Resident Records is being issued today. 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. This report was reviewed Licensee Madonna Martinez by phone and and Appeal rights were given.the state’s words, verbatim · CDSS document, Feb 3, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Feb 13, 2026

87506 Resident Records (a) The licensee shall ensure that seperate complete, and current record is maintained for each resident in the facility...available to facility staff...and licensing. This requirement is not met as evidence by: Based on interview and record review, the licensee did not comply in 2 out of 5 resident records.which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: Licensee to read regulation 87506 and to submit a Pre-Placement Appraisal (LIC603) and Appraisal Needs and Service Plan (LIC625) for R1 and a Admissions Agreement, Pre-Placement appraisal & Consent for Emergecy Medical Treatment for R2 by POC date 02/13/2026

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Case Management - Legal/Non-compliance

At approximately 11:30 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced for the purpose of conducting a quarterly Case Management-Legal/Non-compliance (NCC) Inspection and met with caregiver Martha Reyes who has Designation of Facility Responsibility (DFR). Administrator Madonna Martinez was called to advise of NCC inspection, but was not able to attend as she was at a sister facility. LPA was advised that there were five (4) residents in care, one (1) of which is on hospice. This facility was placed on a non-compliance (NCC) on 06/26/2024 for a two-year term by Community Care Licensing (CCL); Concerns addressed in NCC meeting on 06/26/2024 were: Administrator Duties and Qualifications Active Administrator in place for facility oversight per regulation Clearing Plans of Correction (POCs) Reporting Requirements Timely response to CCL when communication is engaged DFR was advised that on 08/27/2025 and again on 10/13/2025, LPA left voice mail messages with licensee that an update was needed as to the status of Triune, INC with the Franchise Tax Board (FTB). LPA advised DFR that Triune,INC is currently indicated as in suspended status with the FTB. In addition LPA advised DFR That this LPA did not receive a update response from the licensee regarding their efforts with the FTB and that this was in violation of the NCC goal of Magnolia Gold Home Care having more, "Timely responses with CCL when communication is engaged" Continued on LIC809C Continued from LIC809 At approximately 12:00 PM, five (5) staff files were reviewed and one staff member (S1) of five (5) were found to have just ten (10) hours of the required 40 hours of education and shadow training required for all caregivers within the first four (4) weeks of work at a Residential Community For the Elderly (RCFE) (Type B violation was issued and Plan of Correction (POC) developed.) Licensee was given a copy of educational requirements for staff and volunteers at RCFEs. Five (5) of 5 Resident files were reviewed and 5 of 5 were found to have all required documentation including recently attained Consents for Emergency Medical Treatment (LIC627C) At approximately 1:00 PM LPA and caregiver/DFR conducted a wellness and safety walk-through of facility, finding it at a comfortable temperature, clean, odor free, exits free from obstructions and well organized. Residents were clean and dressed appropriately. There was an ample supply of hygiene products for residents' care. There was also an ample supply of healthy perishable and non-perishable food as required by Title 22. Left-over foods were observed to be labeled appropriately. A new fire extinguisher in the kitchen purchased 08/10/2025 was observed to be fully charged, Smoke detectors/carbon monoxide detectors are centrally wired and tested to be functional. The front and back yards are well maintained and the back yard pool is fenced and secured as required by regulation. There is also a covered patio with seating for outdoor activities and visits. There are comfortable couches and chairs in the living room with television and simple games available. Soaps and toxins, as well as sharps were locked securely and inaccessible to residents. Medications were kept secured in a closet in hallway. LPA obtained copy of letter indicating the 2022 Income Tax Return for Triune, INC was submitted to the IRS. 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. This report was reviewed with Martha Reyes (DFR) in person and Licensee Madonna Martinez by phone and and Appeal rights were given.the state’s words, verbatim · CDSS document, Nov 4, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(1) · Plan of correction due date: Nov 14, 2025

HSC 1569.625(b)(1) The department shall...require 40 hours of training....staff...shall complete 20 hours...including 6 hours of dementia care...4 hours of postural supports, restricted health conditions, hospice care...the remaining 20 hours shall include 6 hours dementia care within 4 weeks. This requirement is not met as evidenced by:Based on record review, the licensee did not comply with the section cited above in 1 out of 5 staff members which poses a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Nov 4, 2025

Plan of correction: Licensee to provide evidence of 30 hours of required training from an outside provider in a classroom setting or on-line, as well as documented shadow training for S1 by 12/04/2025

Type of visit: Case Management - Legal/Non-compliance

At approximately 9:45 AM Licensing Program Analyst (LPA) Stevenson arrived unannounced for the purpose of conducting a Case Management-Legal/Non-compliance (NCC) Inspection and met with caregiver Martha Reyes who has Designation of Facility Responsibility (DFR). Administrator Madonna Martinez was called to advise of NCC inspection, but was not able to attend as she was at a sister facility. This facility was placed on a non-compliance (NCC) on 06/26/2024 for a two-year term by Community Care Licensing (CCL); Concerns addressed in NCC meeting on 06/26/2024 were: Administrator Duties and Qualifications Active Administrator in place for facility oversight per regulation Clearing Plans of Correction (POCs) Reporting Requirements Timely response to CCL when communication is engaged LPA was advised that there were five (5) residents in care, one (1) of which is on hospice. At approximately 10:05 AM LPA and caregiver/DFR conducted a wellness and safety walk-through of facility, finding it at a comfortable temperature, clean, odor free, exits free from obstructions and well organized. Residents were clean and dressed appropriately. There was an ample supply of hygiene products for residents' care. There was also an ample supply of healthy perishable and non-perishable food as required by Title 22. DFR was reminded of the mandate to label foods in airtight containers with the date they are removed from commercial packaging. A fire extinguisher in the kitchen was last serviced on 2/16/2024 and observed to be fully charged, DRF was advised to have the device re-inspected or have a new device purchased with the receipt taped to the new extinguisher. Smoke detectors/carbon monoxide detectors are centrally wired and tested to be functional. The front and back yards are well maintained and the back yard pool is fenced and secured as required by regulation. Continued on LIC809C Continued for LIC809 There is also a covered patio with seating for outdoor activities and visits. There are comfortable couches and chairs in the living room with television and simple games available. Soaps and toxins, as well as sharps were locked securely and inaccessible to residents. Medications were kept secured in a closet in hallway. At approximately 11:00 AM, five (5) staff files were reviewed and two (2) of five (5) were found incomplete with S1 having expired 1st aid (and CPR), S2 missing a MD health screening (LIC503) and S3 missing evidence of current 1st aid (and CPR) training. Type B violation issued with a plan of correction to attain missing documents by Friday 08/29/2025 Five (5) of 5 Resident files were reviewed and 5 of 5 were found to have all required documentation including recently attained Consents for Emergency Medical Treatment (LIC627C) DRF advised LPA that a non-hospice resident expired May 16, 2025 but Community Care Licensing (CCL) has no evidence of an incident report submitted to CCL for the hospital admission on May 14th, 2025 or for the death and death report. Licensee was advised via phone that these two documents should be submitted to CCL along with a death certificate once received. In addition, licensee was advised by phone that not a single incident report is documented at CCL for items like hospital admissions, notification of hospice services, non-payment of resident fees etc. Finally licensee was contacted by phone to make her aware that Triune, INC (4299104) not good standing with the Franchise Tax Board (FTB). Licensee indicated she had made efforts without success to reach out to FTB. Licensee was made aware that that CCL will need evidence of her efforts (email or letter or payment plan etc) of Triune, INC resuming good standing with FTB by Wednesday August 6th, 2025 by end of business day or face the potential of citation and financial penalties from CCL. In addition, licensee was notified that licensing fees of $742.00 are due and the PIN number was given to DRF/caregiver during today's inspection. In addition, FTB was provided Technical Support Program support brochure to share with licensee. Updated Liability insurance was obtained by LPA today. 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. This report was reviewed with Martha Reyes (DFR) in person and Licensee Madonna Martinez by phone and and Appeal rights were given.the state’s words, verbatim · CDSS document, Jul 29, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a) · Plan of correction due date: Aug 29, 2025

87412(a) - Personnel Records The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement is not met as evidence by: Based on observation and record review the licensee did not comply with section cited in 3 out of 5 personnel records as evidence of messing 1st aid training and health screening which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 29, 2025

Plan of correction: Licensee to submit evidence of 1st aid (CPR) training for S1 and S3 and evidence of a health screening (LIC503) for S2 by 08/29/2025

Type of visit: Required - 1 Year

At approximately 9:35 AM Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required Annual Inspection and required quarterly NCC visit. LPA was met by caregivers Martha Reyes and Lorna Valasquez. There are 6 residents in care with 2 on hospice. At approximately 10:00 AM a tour was conducted and facility was found to be clean and well organized, and a comfortable temperature. Residents were clean and dressed appropriately. There was an ample supply of hygiene products for residents' care. There was also an ample supply of healthy perishable and non-perishable food as required by Title 22. Water temperature in 2 of 2 bathrooms measured 117.1F and 118.4FF and within regulation of 105 -120 F. There was one fire extinguisher that was last serviced on 2/16/2024 and observed to be fully charged. Smoke detectors/carbon monoxide detectors are centrally wired and tested to be functional. The front and back yards are well-maintained and the back yard pool is fenced and secured as required by regulation. There is also a covered patio with seating for outdoor activities and visits. There are comfortable couches and chairs in the living room with television and simple games available. Soaps and toxins, as well as sharps were locked securely and inaccessible to residents. Medications were kept secured in a closet in hallway. The last fire drill was held on 2/16/2025 by verbal report. Caregivers were told of the requirement to conduct and document quarterly emergency drills. (Technical Violation issued) At approximately 11:00 AM five (5) staff files were evaluated and 3 of 5 were found complete and 2 of 5 files observed that S1 needs evidence of MD assessment and TB clearance and S2 needs evidence of 1st Aid Training (technical violation issued) Designated caregiver was asked to ensure that personel files be completed with records TB clearance and 1st aid training. (technical violation issued) Five (5) of six (6) Resident files were reviewed and 5 of 5 were found to have all required documentation including signed POLST forms by their responsible parties, but were missing Consent for Emergency Medical Treatment forms (LIC627C) (Technical Violation issued) Continued on 809C Continued from 809 LPA requested the following updated forms to be submitted to Community Care Licensing by 05/20/25: 1) updated LIC 308 Designation of Facility Responsibility (1 person per form); 2) LIC 500 Personnel Report; 3) Copy of updated Liability Insurance; 4) Updated and signed LIC 610E Emergency Disaster Plan; There were no deficiency citations issued during this inspection.the state’s words, verbatim · CDSS document, Apr 22, 2025

The state marks this report as 6 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Office

A non-compliance conference was conducted today in the Santa Rosa Regional Office. Present in the meeting: Regional Manager, Carla Nuti-Martinez, Licensing Program Manager, Bethany Moellers, Licensing Program Analyst, Julie Florio, and Facility Licensee/Administrator, Madonna Martinez. An informal office meeting was conducted on 6/12/2024, to discuss areas of non compliance. Licensee was requested to submit documents by close of business 6/14/2024, and failed to do so. The purpose of today's meeting is to review ongoing compliance concerns. This non-compliance conference is being conducted to discuss concerns identified by community care licensing in regards to the operation of Zealcare Home, 286804025 and Magnolia Gold Home Care, 486803895. Areas of noncompliance not limited to below were discussed: Administrator Duties and Qualifications Active Administrator in place for facility oversight per regulation Clearing POCs Reporting Requirements Timely response to CCL when communication is engaged LIcensee was informed of Technical support program and agrees to engage in services. No deficiencies sited during this noncompliance conference.the state’s words, verbatim · CDSS document, Jun 26, 2024

Allegation investigated: Staff did not provide resident medical attention in a timely manner.

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. During the course of this investigation, statements were taken from witnesses and staff, documents were obtained and reviewed and site visits made to the facility. The following determinations are made: Resident (R1) died at the facility on 03/25/2024 of cardiopulmonary arrest; R1 was elderly and suffered numerous serious medical conditions; Records indicate that staff on duty 03/25/2024 had received required training and responded appropriately when R1 became non responsive; Available records suggest that the staff provided a timely response when R1 became non responsive and that they took appropriate action by initiating CPR and calling 911; R1's Conservator has stated that Conservator believes the staff have taken good care of R1 and that the staff took timely action in response to R1's medical episode. Although the allegation may be true, based on records and statements, there is not a preponderance of evidence to prove, or disprove, the allegation. Therefore, the allegation is UNSUBSTANTIATED. Report left. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 12, 2024 · control 21-AS-20240418140944

Type of visit: Office

An informal meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Regional Office Manager Carla Nuti-Martinez, Licensing Program Managers, Bethany Moellers and Kimberley Mota, Licensing Program Analysts, Julie Florio, David Leibert, and Jill Nakagawa, and Administrator, Madonna Martinez and Gwen Martinez, Licensee for Magnolia Gold. The purpose of the informal meeting was to discuss citations for deficiencies and for failure to correct Plan of Corrections (POC) by the due date, as well as citation issued on this date for Administrator's Qualifications. The following areas of concern were discussed: - Administrator to ensure clearing POCs and responding to Community Care Licensing (CCL) communication requests and reporting requirements. Administrator to have a plan for qualified personnel to be the facility's designated responsible party in the absence of the Administrator. Documents requested during informal meeting to be submitted to CCL by close of business June 14, 2024: Continued on 809-C Continued from 809.... -Licensee submit an updated LIC500 indicating staff coverage in all areas of facilities -Licensee to submit LIC308: Designation of Facility Responsibility -Licensee to submit copy of Administrator's Certificate for current Administrator -Administrator to self-certify that they have read regulation 87405 by 6/14/2024. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Jun 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(a)(1) · Plan of correction due date: Jun 12, 2024

87405(d)(a)(1)- (d)The administrator shall have the qualifications specified... (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not met as evidenced by: inspection, the licensee diLPAs interviews, observations and records reviewed which show that Adminstrator has not been present a sufficent number of hours to properly meet the responsibilities of operating the facility. This is an immediate risk to the health and safety of all residents in care.the state’s words, verbatim · CDSS document, Jun 12, 2024

Plan of correction: Licensee to ensure that the facility has a qualified, certified RCFE Administrator on-site as required by regulation. Licensee will also have a plan to designate designated person listed on LIC308 to ensure continuity of care and operating regulations are met in the absence of Administrator. Submit the following documents to CCL by COB 6/14/2024: LIC500, LIC308, copy of Administrator's Certificate. Attn: LPA Florio

Type of visit: POC

Licensing Program Analyst Leibert arrived unannounced for the purpose of POC visit. LPA was met by Madonna Martinez and the Acting Administrator, Romeo Cade. LPA had, prior to the visit, verified Mr. Cade's current Administrator's Certificate. The citation issued 4/23/2024 is cleared.the state’s words, verbatim · CDSS document, May 14, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jill Nakagawa arrived at the facility on 5/3/24 to conduct a case management inspection. Based on LPA's review of documents, no Incident Reports were filed by the facility to the Department. LPA found evidence that Licensee did not submit required incident report for Resident R1 when hospitalized on 7/29/23 and Resident R2 when taken out of the facility by ambulance to the hospital on 1/18/2024. Per regulation 87211(a), licensee shall submit a report to licensing agency within 7 days of an occurrence of any incident that threatens the welfare, safety, or health of any resident. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, May 3, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: May 3, 2024

87211(a)(1)(D):Reporting Requirements:(a) Each licensee shall furnish to the licensing agency...(1)A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident.. This requirement is not met as evidenced by: *Based on records reviewed the Licensee did not comply with the section cited above and did not submit reports to CCL as required. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 3, 2024

Plan of correction: Licensee to provide training to all care staff reviewing the Regulation: 87211 Reporting Requirements and how to properly fill out the LIC 624 form. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures by POC due date of 05/10/2024.In addition, Licensee to submit past due Incident Reports.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an Annual Inspection. There were 2 care staff and 3 residents at the time of inspection. Facility was found to be clean and well organized, and a comfortable temperature of 72 F. Residents were clean and dressed appropriately. There was an ample supply of hygiene supplies for residents' care. There was also an ample supply of perishable and non-perishable food as required by Title 22. Water temperature in 2 of 2 bathrooms measured 117.4 -117.9 F., within regulation of 105 -120 F. There was one fire extinguisher that was last serviced on 2/16/2024, fully charged. There were three smoke detectors/carbon monxide detectors which were tested and functional. The last fire drill was held on 2/16/2024. The front and back yards are well-maintained and the back yard pool is fenced and secured as required by regulation. There is also a covered patio with seating for outdoor activities and visits. There are a variety of games and activities. Soaps and toxins, as well as sharps were locked securely and inaccessible to residents. Medications were kept secured in closet in hallway. LPA requested the following updated forms to be submitted to Community Care Licensing by 04/30/24: 1) LIC 308 Designation of Facility Responsibility (1 person per form); 2) LIC 500 Personnel Report; Continued on 9099-C Continued from 9099...... 3) Copy of Liability Insurance; 4) LIC 610E Emergency Disaster Plan; 5) LIC 9020 Register of Facility Residents; 6)Copy of Administrator's Certificate; 7) Copy of current Lease/Rental Agreement or Property Tax document showing control of property 8)Copy of Updated 602's 9)Copy of First Aid/CPR certificates for staff There were no citations issued during this inspection.the state’s words, verbatim · CDSS document, Apr 16, 2024

Allegation investigated: Resident has unexplained injuries

Licensing Program Analysts (LPAs) Nakagawa and Mutialu arrived unannounced to complete an investigation and deliver findings on the above allegation. LPAs conducted interviews, reviewed documents, and made observations. Complaint alleges that Resident (R1) has a burn on left leg and one healing on right leg. LPA Nakagawa conducted interview with R1 who was unable to recall how the injury occurred. Department reviewed R1’s medical records and photos of the injuries and was unable to determine that R1 sustained any burns. Continued on 9099-C............ Unsubstantiated Continued from 9099... A review of medical documents and care notes indicate that R1 has a condition that can produce blisters. LPA was unable to find any evidence that R1 had received any burns .Although the allegations may be valid, or true, based upon the statements made and lack of critical documents, there is not a preponderance of evidence to prove the allegations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED. Report left at facility. No citations issued regarding this investigation.the state’s words, verbatim · CDSS document, Apr 9, 2024 · control 21-AS-20231127103820

Allegation investigated: Facility doesn’t have an administrator on the premises

*****This is an amended version of the original report************ The findings on this complaint are amended from UNSUBSTANTIATED to SUBSTANTIATED. A new LIC9099 (Complaint Investigation Report) now supersedes this document. Substantiatedthe state’s words, verbatim · CDSS document, Apr 9, 2024 · control 21-AS-20240322152816

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Jill Nakagawa and Stefanie Mutialu arrived unannounced to conduct an investigation. There were 2 care staff and 3 residents at the time of inspection. Facility was found to be clean and well organized. It was a comfortable temperature. Residents were clean and dressed appropriately. There was an ample supply of hygiene supplies for residents' care. There was also an ample supply of perishable and non-perishable food as required by Title 22. Staff were reminded to seal and date food to safeguard quality and freshness. LPAs reviewed resident records and found no current orders for hospital beds, bed rails or gait belts for 2 of 3 residents. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and a copy of this report along with appeal rights were emailed to the Administrator due to printer issues.the state’s words, verbatim · CDSS document, Apr 9, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(3) · Plan of correction due date: Apr 9, 2024

Based on the individual's pre-admission appraisal....(3) a written order from a physician...order. This is evidenced by: Based on review of residents' records there was no written order by physician for 1/2 bed rail which poses a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Apr 9, 2024

Plan of correction: Administrator to supply Dept. with proof of doctors' orders for residents use of bedrails by 4/10/24, end of business day.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an investigation. There were 2 care staff and 4 residents at the time of inspection. Facility was found to be clean and well organized. It was a comfortable temperature. Residents were clean and dressed appropriately. There was an ample supply of hygiene supplies for residents' care. There was also an ample supply of perishable and non-perishable food as required by Title 22. During investigation it was found that Administrator's Certificate has expired. LPA checked the list of pending and active certificates and Administrator's name was not found. In addition, LPA reviewed resident records and found no current orders for 1/2 bed rails for 3 of 3 residents with bed rails. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and a copy of this report along with appeal rights were emailed to the Administrator due to printer issues.the state’s words, verbatim · CDSS document, Jan 26, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Jan 26, 2024

87608 Postural Supports (a) Based on the individual's pre-admission appraisal....(3) a written order from a physician...order. This is evidenced by: Based on review of residents' records there was no written order by physician for 1/2 bed rail which poses a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jan 26, 2024

Plan of correction: Administrator to supply Dept. with proof of doctors' orders for residents use of bedrails by 1/29/24, end of business day.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Jan 26, 2024

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. licensee and the administrator may be one and the same person. The administrator...This is evidenced by: Based on observation of expired Administrator's Certificate dated 6/30/23 and no renewal on file with the Dept. which poses a potential risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Jan 26, 2024

Plan of correction: Administrator to apply for a renewal of Administrator's Certificate and supply Dept. with proof of registration by 1/29/24, end of business day.

Allegation investigated: Neglect/Lack of Care and Supervision resulting in severe and unexplained injuries

On 12/8/2023, Licensing Program Analyst (LPA) Nakagawa arrived unannounced for the purpose of delivering complaint investigation findings and a was greeted by Carestaff. During the course of the investigation, the facility was toured, staff and outside parties were interviewed, resident and facility records were reviewed, and observations made. Investigation was conducted and completed by Community Care Licensing Investigations Branch (IB) investigator and the following was reported. Continued on 9099-C Unsubstantiated Continued from 9099... On 7/29/2023, Resident (R1) was transported to Kaiser Permanente Vacaville for bruising on the chest/right side. R1 was diagnosed with rib fractures to the left side that were in the healing stage. Medical records note the R1 sustained fractures to the left eighth, ninth and tenth ribs, bruising to the right side and hematoma on the right-side chest wall. R1’s physician reported that the injuries sustained could have been a result of trauma such as a fall. R1’s physician reported the injury pattern was not suspicious for physical abuse. Staff interviewed reported that R1 was non-ambulatory and required two person assist to and from bed. R1 was unable to walk and could only stand with assistance. Facility staff reported that R1 never had a witnessed or unwitnessed fall while living at the facility. Due to a lack of corroborating evidence to determine how the bruising, fractures and hematoma developed or as a result of physical abuse, the allegation is found to be unsubstantiated. Allegation, neglect/lack of care and supervision resulting in severe and unexplained injuries is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Appeal Rights given. No deficiencies cited during today's visit.the state’s words, verbatim · CDSS document, Dec 8, 2023 · control 21-AS-20230801082339