Adom Manor Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Eva Karikari arrived later, certificate #7014764740 expires 1/26/28 At approximately 1:45pm LPA and licensee toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Extra food stored in garage along with canned goods. Closet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sinks accessible to residents in care measured at 106.7 degrees F in the kitchen, 113.4 degrees F in room #5, 112.1 degrees F in the main bath and 109.4 degrees F in kitchen, and 108.9 degrees F in the back hall bathroom which are all within the allowable range of 105 to 120 degrees F. Room #6 has a pump feature that enables hot water accessibility. Room #6 is located in a part of the house that was an addition to the facility so that is why the hot water from the hot water heater does not reach room #6 in a timely manner. Pump ensures hot water delivery in a timely manner. Licensee demonstrated pump to LPA. LPA asked resident to explain hot water procedure. Resident was able to communicate a clear understanding of how to turn on hot water. LPA observed it to be in working order. Water temperature in room #6 was 109.4 degrees F. Continued on 809C... Continued from 809... Fire extinguishers were last inspected 3/2/25. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drills were conducted 5/8/26. Facility has a backup generator for use during a power outage. At approximately 2:30pm LPA conducted a review of six (6) resident records. Resident (R3) did not have a current Appraisal, Needs, and Services Plan (deficiency cited, see 809D). At approximately 3:15pm LPA conducted review of five (5) staff records. LPA discussed with licensee updating her forms to ensure all hands-on shadowing forms for training list the date of training and hour duration of training. No deficiencies cited. LPA discussed with licensee training requirements per Health and Safety Codes: 1569.625, 1569.696, and 1569.69. At approximately 3:45pm LPA and licensee conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. LPA discussed with licensee the need to have all directions for administration listed on the Centrally Stored Medication Log (CSML). LPA discussed with licensee PRN MAR requirement. LPA observed PRN Authorization letters in resident files, but forms were blank. LPA advised if residents can both clearly determine and communicate their need for PRNs then a PRN MAR is not required. 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 licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, Jun 30, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver, but Administrator Eva Karikari arrived later. At approximately 9:30am LPA toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Extra food stored in garage along with canned goods. Kitchen cabinet containing cleaning supplies was locked. Kitchen drawer with sharp knives locked. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathroom had required bath mat and grab bar. Water temperature in sinks accessible to residents in care measured at 107 degrees F in bathroom by living room, 105.7 degrees F in kitchen, and 108.9 degrees F in the back hall bathroom which are all within the allowable range of 105 to 120 degrees F. Room #6 has a pump feature that enables hot water accessibility. Room #6 is located in a part of the house that was an addition to the facility so that is why the hot water from the hot water heater does not reach room #6 in a timely manner. Pump ensures hot water delivery in a timely manner. Caregiver demonstrated pump to LPA. LPA observed it to be in working order. Fire extinguishers were last inspected 3/2/25. Smoke/Carbon Monoxide detectors located throughout the facility were operational. Facility’s last quarterly disaster drills were conducted 4/25/25. Facility has a backup generator for use during a power outage. Continued on 809C... Continued from 809... At approximately 10:00am LPA conducted a review of 6 resident records. All required documentation present. While conducting physical plant inspection, LPA interviewed resident (R1) with caregiver present. R1 indicated their legs were hurting because they had been in their wheelchair for an extended period of time. R1 requested to be transferred but R1 is a two-person assist and only one caregiver was present at facility, as Admin had taken another resident to a doctor appointment. LPA and Admin discussed ensuring adequate staffing to meet residents' needs. At approximately 11:00am LPA conducted review of 5 staff records. All required documentation present. Training verified on Community Care Options website. At approximately 12:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. Eva Karikari Administrator Certificate 7014764740 expires 1/26/26. LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report Liability Insurance 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, Jul 1, 2025

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Christi Coppo and Jacky Macias arrived unannounced to conduct a required Annual inspection and was greeted by staff. Administrator Eva Karikari arrived shortly after. At approximately 09:30am LPAs and Admin toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPAs observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen drawer with sharp knives locked. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sink accessible to residents in care measured at 118, 113.2, 118.4, 119.4 and 118.5 degrees F which is within the allowable range of 105 to 120 degrees F. LPAs discussed with Admin about adjusting water heater temperature slightly as to avoid going over 120 degree threshold. Fire extinguishers were last inspected 5/15/2024. Smoke/Carbon Monoxide detectors located throughout the facility were present. Facility’s last quarterly disaster drills were conducted 4/12/2024. Facility has a backup generator for use during a power outage. At approximately 10:00am LPAs conducted review of 5 staff records. S2, S3, S4, S5 have did not have current annual training in the amount of hours required. S1 has no current First Aid/CPR Certification (deficiencies cited, see 809D). At approximately 11:00am LPAs conducted a review of 5 resident records. All required documentation present. Continued on 809C... Continued from 809... At approximately 12:00pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies. Administrator Eva Karikari 6046713740 Certificate expires 1/26/2024. Licensee/Admin provided proof of renewal payment. LPAs verified payment by viewing check issued. LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance 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 Licensee. 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 18, 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.