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Type of visit: Case Management - Other

Licensing Program Analyst, LPA Noel Wolf Petersen arrived unannounced to the facility to conduct a case management related to fire clearance. LPA met with administrator Renee Little and maintenance director Juan Valencia, to explain the purpose of the visit. CCLD has the fire clearance from 1997 showing 0 ambulatory/ 32 nonambulatory/ 0 bedridden, LPA has the facility side with a fire clearance from 2025 showing 15 ambulatory/6 nonambulatory/ 11 bedridden. The facility side std 850 does not have a request date, indicating it did not orginate from a ccld change of capacity/fire clearance update request. the 850 on the facility side would appear to be for a pending change of ownership, not the current faciltiy operating in the same building. LPA provided guidance to audit the current population in the facility for the abillity to rotate in bed unassisted, fill out at LIC 200 with a change of capacity request and a facility sketch detailing which kind of ambulatory status and how many will be in that room. Licensing should recive the documents as soon as possible, as there are a lot of clients the LPA is asking for those forms by eod 9/30/26. noel.wolfpetersen@dss.ca.gov Physical inspection was completed, no concerns at this time. there is at least 1 resident who has an inabillity to rotate on thier own. A citation was issued with this visit, an immediate 500$ civil penalty was issued. copy of the report was read and given to the administrator. exit interview was conducted. appeal rights provodedthe state’s words, verbatim · CDSS document, Sep 23, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80020(a)(1) · Plan of correction due date: Sep 24, 2026

80020 Fire Clearance (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. (1) The request for fire clearance shall be made through and maintained by the licensing agency. Not following this requirement is evidenced by: Fire clearance from the licensee side doesnt have a request date, appears to be made though the CAB for the new change of ownership application, not the current facility. in interview with administrator it was learned there is at least one client who would be bedridden. not following this requirement presents a immediate risk to the health and safety and personal rights of clients in care.the state’s words, verbatim · CDSS document, Sep 23, 2026

Plan of correction: LPA asked for a plan for meeting the needs of the currently bedrriden population, basicly if it will be pursued to become bedridden cleared for an approprite ammount of bedrooms or if the plan is for those people to be assisted to a higher level of care. the inital plan should be sent to the lpa by email(noel.wolfpetersen@dss.ca.gov) by eod 9/24/26 and it should be updated after the fire inspector comes out.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Noel Wolf Petersn arrived unannounced to conduct a one year required inspection visit. LPA Wolf Petersen was met by Administrator Renee Little and explained the purpose of the visit to staff. Physical faciltiy inspected/toured the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 32 bed facility with a current census of 29. There is entry door leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. Chemicals and medications are locked to residents in care. No bodies of water were observed at the facility. Hot water temperature was measured in resident bathroom sink, which is within the required range of 105 to 120 degrees Fahrenheit. All necessary Administrator documents were in place, hiv to be sent to LPA via email by 9/23/26. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. LPA observed the facility to have adequate food supply of 7- days non-perishables and 2- days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings. LPA observed, fire extinguishers were dated on 04/01/2026 and current, smoke and carbon monoxide detectors functional, central heating and air functional in the facility. The first aid kit was found in compliance. LPA reviewed 5 staff files. LPA reviewed three resident facility files and was in compliance. LPA needs to review the fire clearance, follow up may be required. facility side clearance says 6 bedridden, per 2025 check by the fire department. No deficiencies cited today during today’s visit, exit interview held and report left.the state’s words, verbatim · CDSS document, Sep 15, 2026

Allegation investigated: Staff member purchased drugs during work hours

On 03/10/2026, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility to conduct a complaint visit. LPA Pascua met with Facility House Manager (HM), Sarah Rico and explained the purpose of the visit. The purpose of the visit was to inform the facility and its representative that a complaint has been filed against it at this time. Current census was 29. A brief interview with HM Rico was conducted. During the course of this visit, this LPA conducted staff interviews, reviewed facility records, and toured the facility. It was alleged that a staff member purchased drugs during work hours. According to the information received, a male staff member was reportedly seen in front of the facility on 03/07/2026 at approximately 10:00 p.m. purchasing drugs from an outside source.Based on interviews conducted with four facility staff members, all denied that any staff left the facility to purchase drugs during their work hours. Unfounded All four staff members also denied personally purchasing drugs while on duty.Additionally, management staff stated that there were no male staff members on site at the facility until 11:00 p.m. on 03/07/2026. LPA Pascua reviewed the facility’s staffing schedule and learned that on 03/07/2026 there were three female staff members working the PM shift from 3:00 p.m. to 10:00 p.m., and three female staff members and one male staff member working the graveyard shift from 11:00 p.m. to 7:00 a.m. This information was confirmed through a review of the facility’s staff time cards.Furthermore, all staff members who were on site beginning at 11:00 p.m. stated that they were aware of each staff member’s whereabouts during their shift and reported that no staff left the facility to purchase drugs. This agency has investigated the complaint alleging that facility staff purchased drugs during work hours. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Mar 10, 2026 · control 27-AS-20260309103642

Type of visit: Case Management - Health Checks

On 09/23/2025, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to the community to conduct a Health and Safety check. LPA Campbell met with Administrator Little and explained the purpose of the visit to ensure the health and safety of residents. There are currently 7 staff present and 29 residents. The community is currently licensed to serve 32 ambulatory and nonambulatory clients that are age 60 and over. The community is also approved for 2 hospice residents as well. During a tour of the community, LPA Campbell observed resident bedrooms that were sufficiently furnished with beds that were made. Residents were observed watching TV in their rooms or the common area. LPA Campbell observed an adequate 2 day perishable and 7 day nonperishable food supply. The refrigerator and cabinets were reviewed in the kitchen. Sharps were made inaccessible to residents in locked cabinets. Medications were locked in a closet in the staff office where it can be locked and inaccessible to residents. LPA Campbell conducted a brief interview with R1. R1 was lying in their bed in the room that they share with their roommate watching the single TV present in the room. When questioned about their status, R1 stated that they loved the community and liked their room. They also stated that the only thing they wanted was their TV that had been left. Based on the observations made during this visit, there are no deficiencies being cited. An exit interview was conducted and a copy of this report was provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Sep 23, 2025

Type of visit: Required - 1 Year

On 08/21/2025, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct an annual inspection. LPA Campbell met with Renee Little, Administrator and Sarah Rico, House Manager and explained the purpose of the visit. There are currently 29 people in residence in the facility. The facility is a one story building licensed to serve 32 ambulatory or non-ambulatory clients, age 60 and over. It is also approved for 2 hospice residents. LPA Campbell inspected the physical plant including bedrooms, bathrooms, kitchens and common areas. LPA Campbell observed the community to be well lit, clean, free from odor and in good repair. During a tour of the community, the fire extinguishers were observed to have last been inspected on 05/06/2025 and were fully charged. Staff conducted smoke and carbon monoxide alarm tests and they were found to be functioning. The temperature for the inside of the physical plant was observed to be 70 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The water temperature for the resident bathrooms was measured at 118 degree Fahrenheit. There are no bodies of water present on the premises. Food items were stored in indoor and outdoor settings and a two day supply of perishables and a seven day supply of non-perishables were observed. The refrigerator temperature was observed at 38 degrees Fahrenheit and the freezer at 0 degrees Fahrenheit. LPA Campbell observed that a sign on the front of the refrigerator stated, "Do Not Put Anything in Here Without a Label and a Date". Throughout the physical plant, LPA Campbell observed 'See Something Say Something' posters and contact information for the Long Term Care Ombudsman. LPA Campbell observed resident rooms 10, 11 and 13. They contained the required beds, lamps, closets and chest of drawers. Due to some residents having wheelchairs and/or other personal preferences, residents either had desks or chose to not have a night stand. LPA Campbell observed the first aid supply kit as having scissors, tweezers, thermometers and a first aid manual. Access to knives and cleaning products were found to be inaccessible to residents. Of the 29 residents, LPA Campbell reviewed 3 of their files. For the 24 staff. 3 of their files were reviewed. All files reviewed were found to be complete.the state’s words, verbatim · CDSS document, Aug 21, 2025

Allegation investigated: Staff did not ensure resident's oxygen tanks were secured in a stand

On 02/12/25, Licensing Program Analyst (LPA) Renee Campbell arrived to the facility unannounced to open a complaint. LPA Campbell met with Sarah Rico, House Manager, and explained the purpose of the visit. Regarding the allegation that staff did not ensure resident's oxygen tanks were secured in a stand, LPA Campbell interviewed staff and conducted a search for unsecured oxygen tanks in R1's (R1) room. Staff 1 (S1) stated that R1's oxygen was with them at all times and at night. LPA Campbell also observed R1 with his oxygen in the living room. The tank was a DeVilbiss 5 Liter Oxygen Concentrator which is not an oxygen tank but a method of gathering oxygen from the surroundings and concentrating it for breathing.Emergency oxygen tanks were observed in the locked medicine closet in the office in a stand. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore this allegation is UNSUBSTANTIATED. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6 nothe state’s words, verbatim · CDSS document, Feb 12, 2025 · control 27-AS-20250205120513

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct an annual inspection. LPA Campbell met with Renee Little, Administrator and Sarah Rico, House Manager and explained the purpose of the visit. Residents were observed throughout the facility socializing with peers and staff and eating. The facility was clear of debris and passages were unobstructed. LPA Campbell toured the facility and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas to ensure there are no safety hazards for residents. Furnishings were sufficient to meet the needs of residents. In each bedroom was a bed, tables, lamps and chair. No changes have been made to the floor plan in comparison to the facility sketch provided. All bedrooms are designed to be shared with two residents. Of the 20 staff files available, LPA Campbell was able to review 4 staff files and found them to be complete. Of the 27 client files, LPA Campbell was able to view 3 client files and the required documents were found to be included. All active staff were found to be cleared in Guardian. LPA Campbell reviewed the certificate for Administrator Renee Little that expired on 09/17/2024 and proof of renewal. In the physical plant, the temperature for a freezer is to be no higher then 0 degrees Fahrenheit. Of the 1 freezer found in the facility, the temperature was -1 degrees Fahrenheit. Refrigerator temperatures are to be no higher than 45 degrees Fahrenheit. Of the two refrigerators found on the premises, both had a temperature of 40 degrees Fahrenheit. Hot water must be between 105 and 120 degrees Fahrenheit. The temperature for the hot water in the resident bathroom was 116 degrees Fahrenheit. The facility temperature was 72 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The backyard was toured by LPA Campbell and pathways and exits were found to be clear. Staff parking is in the back of the facility along with a locked tool storage, locked refrigerator and food pantry shed. LPA Campbell observed first aid supplies, a fully-charged and up-to-date fire extinguisher that was last checked on 03/08/2024 and working carbon monoxide/smoke detectors that were tested by staff during the visit. LPA Campbell observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Campbell observed locked closets and cabinets for the storage of medication and P&I. LPA Campbell also observed locked storage areas for cleaning solutions in the staff bathroom. Per California Code of Regulations (CCR's) - Title 22, Division 6, Chapter 6, no deficiencies are being cited. An exit interview was conducted with Renee Little and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 25, 2024

Type of visit: Case Management - Incident

On 1/10/23 at 1:15pm, Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct two case management visits regarding a resident fall incident report on 01/04/2023 and a peer to peer altercation which occurred on 01/03/2024. LPA met with Renee Little, Administrator and explained the purpose of the visit. LPA reviewed an incident report dated 01/04/2023 and conducted a brief interview with Sarah Rico, House Manager. Based on an incident report, on 01/04/2023 resident 1 (R1) became agitated after their routine was disrupted by another peer (R2). An altercation resulted in which R1 pinched R2 on the stomach. R2 responded by punching R1 in the eye, resulting in a black eye. Based on an incident report and interview, R2 had no noticeable injuries but was taken to the hospital for X rays due to an older injury. The incident was reported to the licensing department, the service coordinators for both R1 and R2, and R1’s father within regulatory time frames. A team meeting for staff was held on 01/04/2023. The House Manager discussed factors that may be contributing to R1’s aggression such as the loss of her mother in addition to the holidays. Staff were urged to identify moments in R1’s routine when she is most likely to be triggered. Staff would then redirect R1 by supporting them in being patient when other residents disrupt the schedule and/or help R1 to make better behavioral choices The incident for R3 occurred on 01/04/2023. R3 uses a walker and usually showers while staff monitors them. The House Manager stated that R3 self reported that he had gotten into the shower on his own without staff monitoring him and had fallen and gotten himself up. R3 was unable to recount when the fall occurred other than “a few days ago”. None of the staff reported observing R3 fall during a shower. R3 reported he was sore and in pain on 01/04/23 and was asked if he wanted to go to the ER but declined. The next day, House Manager Sarah Rico inquired about his arm and R3 reported that it was “a little sore” per the House Manager. R3 is now scheduled to be seen by a Nurse Practitioner for a home visit on 01/15/2023 instead. This is the first incident of falling in the shower with R3. R3’s Service Coordinator Juanita Cardona was informed of the fall. Staff urged R3 to inform them if he wanted a shower in the future. A review of R3’s 602 shows that he is non-ambulatory and uses a walker and that he must be monitored when showering. This is the first known incident when R3 tried to get in the shower on his own. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 ,and California Health and Safety Code. Failure to correct deficiencies may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 10, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 80078(a) · Plan of correction due date: Jan 17, 2023

80078 Responsibility for Providing Care and Supervision a) The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by: Based on observation and record review, the facility did not provide supervision as necessary to meet the client’s needs. Which poses a potential Health, Safety or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 10, 2024

Plan of correction: Licensee agrees provide reassessment for R3 with updated 602 and will submit a plan outlinining procedures on maintaining awareness of residents whereabouts. Plan to be submitted to LPA by POC due date.