Petit Oasis

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct the required annual visit today. Upon arrival, the LPA was greeted by staff who then contacted the Administrator telephonically. The Administrator, Roberto Ramirez arrived at approximately 10:00am and the reason for the visit was explained. Entrance interview conducted. Beginning at 10:10am, the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The following was observed: Bedrooms: There are three (3) bedrooms for resident use. All (3) bedrooms are designated as shared / double occupancy. Bedrooms were observed to be furnished appropriately and had sufficient lighting. Additional clean linens and towels were observed in a cabinet by the restroom. Restrooms: There are two (2) restroom for resident use. Bathroom was clean and sanitary and in operating condition with non-skid surfaces and grab bars. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 10:14am, the hot water temperature was measured in resident bathrooms, and they measured within the required range of 105 – 120 degrees Fahrenheit at the time of the visit. Common Areas: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed a fire extinguisher to be fully charged with a purchase date of 08/01/2026. Required postings were observed throughout the common space. No hazards/obstructions observed inside or out. Report Continued on LIC 809C... Report Continued from LIC 809... Garage: Washer and dryer were observed inside the garage. Detergents and cleaning supplies were observed locked and inaccessible to residents in care at the time of the visit. The LPA observed a sufficient amount of emergency food and water; adequately stored. Kitchen: The LPA inspected the kitchen/food service area at approximately 10:22am. Knives and sharps were observed in a locked drawer. Cleaning supplies were observed locked and inaccessible under the kitchen sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The hot water temperature was measured in the kitchen sink and it measured 116.1 degrees Fahrenheit. Outdoors: There is an umbrella for shade and adequate furniture for resident use. Emergency passageway was observed to be clear of any obstructions. There is one (1) side gate with latching mechanisms. No bodies of water noted at the time of the visit. Records: Record review began at approximately 10:40am. Two (2) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, consent for treatment form, preplacement appraisals, appraisals, and current needs and services plan. All files were in order. Three (3) personnel files were reviewed for, but not limited to: personnel records, health assessments with negative TB test results, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All personnel files were complete. The Administrator’s certificate is valid until 12/10/2027. Medications: Medication review began at approximately 11:45am. Medications are centrally stored and kept in a locked cabinet by the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appear to be administered as prescribed at the time of the visit. Emergency Disaster Planning: During today’s visit, the LPA reviewed the facility's emergency disaster plan, which was observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; last disaster drill conducted on 07/02/2026. No citations issued at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 4, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today at 9:00 a.m. Upon arrival, there were two (2) staff and two (2) residents present. The LPA was greeted by staff and at this time the reason for the visit was explained. The Administrator, Susan Vincecruz arrived at approximately 9:10 a.m. and the Licensee Representative arrived during the inspection. Entrance interview conducted. Beginning at 9:10 a.m., the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA inspected the kitchen/food service area at approximately 09:15 a.m. Knives and sharps were observed locked and inaccessible in a kitchen drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. Cleaning supplied were observed under the kitchen sink locked and inaccessible at the time of the visit. COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The LPA observed multiple fire extinguishers throughout the facility to be fully charged with a purchase date of 07/31/2025. Required postings were observed throughout the common space. There is a working telephone on premises. The LPA observed an adequate amount of emergency food and water. Washer and dryer were observed. Detergents were observed inaccessible to residents at the time of the visit. No hazards/obstruction observed inside or out. Report Continued on LIC 809C... Report Continued from LIC 809... RESTROOMS: There are two (2) restrooms for resident use. Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 09:20 a.m., the hot water temperature was measured in both bathroom and they measured within the required range of 105 – 120 degrees Fahrenheit. BEDROOMS: There are three (3) total bedrooms in the facility; all bedrooms are approved for double occupancy. Resident rooms were observed to be furnished appropriately. The LPA observed a staff bedroom on premises. BACKYARD: The backyard has a covered patio area with patio furniture for resident use. All passageways were observed to be clear of any obstructions. There is one (1) side gate with latching mechanism. The LPA observed an empty pool locked and inaccessible at the time of the visit. RECORDS: The LPA began record review at approximately 09:33 a.m. Two (2) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were in order. Three (3) personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All files were in order. Administrator’s Certificate is valid until 04/06/2026. During today’s inspection, the LPA conducted interviews with two (2) staff and one (1) resident. No concerns were noted. Report Continued on LIC 809C... Report Continued from LIC 809C... INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. The LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; the last one was conducted on 07/03/2025. MEDICATIONS: Medications review began at approximately 11:00 a.m. Medications are centrally stored in a locked cabinet by the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications were properly documented on the Centrally Stored Medication and Destruction Record (CSMDR). The Medications appear to be given as prescribed at the time of the visit. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 23, 2025

Allegation investigated: Staff did not ensure injections are administered by an appropriately skilled professional. Staff are not documenting medications appropriately. Administrator is not competent to meet the needs of residents.

Licensing Program Analyst (LPA), Martha Arroyo conducted an initial complaint investigation visit for the above allegations. Upon arrival, the LPA met with Administrator, Susan Vincecruz and explained the reason for the visit. The Licensee Representative, Roberto Ramirez arrived shortly after. Entrance interview conducted. During today's visit, the LPA conducted interviews with three staff and two residents between 10:07am and 11:45am, conducted a medication review at 10:30am, and conducted a file review and obtained copies of pertinent documents relevant to the investigation. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that staff did not ensure injections are administered by an appropriately skilled professional. It was reported that Resident #1 (R1) is prescribed four units of Lantus every 12 hours, administered via an injection pen. However, R1 is unable to administer the injection independently. Interviews conducted with staff and R1 revealed that R1 is responsible for self-administering their medication. R1 stated that facility staff assist by bringing the injection pen to them but confirmed that they perform the injection themselves. During interview, R1 demonstrated to the LPA where and how they administer the injection. Additionally, a review of R1’s physician’s report dated 10/10/2024, lists R1’s primary diagnoses as mild cognitive impairment (MCI) and diabetes. Regarding the diabetes management, the report states that R1 is capable of managing their own treatment, medication, and equipment. Based on record review and interviews conducted, the Department has insufficient evidence to support the allegation or that a violation occurred. Therefore, allegation, “staff did not ensure injections are administered by an appropriately skilled professional” is deemed Unsubstantiated at this time. It was also alleged that staff are not documenting medications appropriately. It was reported that the medication Lispro is supposed to be administered; however, it is not being documented as administered by facility staff. A review of R1’s medications, the Centrally Stored Medication and Destruction Record (CSMDR), and Medication Administration Records (MARs) revealed that Insulin Lispro, administered via injection pen, is being administered four (4) times per day. Staff interviews confirmed that R1’s blood glucose levels are being checked four times daily and that R1 self-administers their insulin injections. Staff also stated that the MARs are updated shortly after medications are distributed to all residents in the facility. Furthermore, at the time of the visit, the medications appeared to be properly documented on the CSMDR. Based on medication review and record review, the Department has insufficient evidence to support the allegation or that a violation occurred. Therefore, allegation “staff are not documenting medications appropriately” is deemed Unsubstantiated at this time. Report Continued on LIC 9099C... Report Continued from LIC 9099C... It was further alleged that Administrator is not competent to meet the needs of residents. It was reported that the Administrator is not properly trained to care for the residents. Interviews conducted with both facility staff and residents revealed that the Administrator is effectively meeting residents’ needs and providing assistance within the facility as needed. Residents stated that the Administrator checks on them daily and also assists with providing care and supervision throughout the day. Additionally, residents did not express any concerns regarding the Administrator's ability to meet their needs during interviews. Furthermore, record review of the Administrator’s personnel file revealed that the required annual training is up to date and that the Administrator’s certificate is valid through 04/06/2026. Based on the information obtained through record review and interviews, the Department has insufficient evidence to support the allegation or that a violation occurred. Therefore, allegation “Administrator is not competent to meet the needs of residents” is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and copy provided. Report Continued from LIC 9099... It was alleged that staff did not ensure glucose checks are administered by an appropriately skilled professional. It was reported that R1 is supposed to have their blood glucose levels checked four times a day and at bedtime and the glucose levels are not being documented consistently. Interviews conducted with staff indicated that they assist R1 by bringing the necessary tools to perform glucose testing. Staff reported that R1 pricks their own finger and that they only provide the blood glucose meter for R1 to place the blood sample. Staff also stated that they document the glucose readings each time they are checked. However, during an interview, R1 confirmed that their blood glucose levels are checked at least four times a day but stated that facility staff perform the entire process by bringing the meter, pricking their finger, and documenting the results. At this time, R1 also noted that staff inform them of the glucose readings after each test. Furthermore, record review of R1’s physician’s report dated 10/10/2024, indicates under mental condition that R1 is not confused or disoriented. Based on the information obtained and reviewed, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation “staff did not ensure glucose checks are administered by an appropriately skilled professional” is deemed Substantiated at this time. It was also alleged that resident missed medication due to staff not ordering medication. It was reported that a medication list was emailed to the Administrator; however, the medication had not been ordered by the facility. A review of R1’s medications, Centrally Stored Medication and Destruction Record (CSMDR), and Medication Administration Records (MARs) revealed that R1 has not been receiving their medication as prescribed, as the medication ran out before a refill was received from the pharmacy. Interviews conducted with staff revealed that they notify the Administrator before medications run out; however, the refills do not always arrive on time from the pharmacy. As a result of not having the medication refills available, R1 has had missed doses. Based on record review and interviews conducted, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation “resident missed medication due to staff not ordering medication” is deemed Substantiated at this time. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. There is a $250 civil penalty due to repeat violation of Section 87465(a)(4) as it has been cited previously within the last 12 months. Failure to correct the deficiencies may result in additional civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 20, 2025 · control 29-AS-20250613134719

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a) · Plan of correction due date: Jun 23, 2025

The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing… or has it administered by an appropriately skilled professional. Based on interviews, the Licensee did not comply with the section cited above as facility staff are performing the glucose testing for R1, which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 20, 2025

Plan of correction: The Licensee will review Regulation 87628 and submit a statement of understanding to CCL no later than POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a) · Plan of correction due date: Jun 23, 2025

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review and interviews, the Licensee did not comply with the section cited above as facility staff are not ensuring residents receive the refills on time resulting in missed dosages, which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 20, 2025

Plan of correction: The Licensee will review Regulation 87465 and submit a statement of understanding to CCL no later than POC due date. Civil Penalty assesed due to repeat violation.

Allegation investigated: Staff do not ensure residents incontinence needs are met

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to the above facility. The purpose of today’s visit is to deliver findings for the above allegation. The initial visit was conducted on 04/14/2025 by LPA M. Arroyo. On today’s visit, the LPA met Administrator, Susan Vincecruz and Licensee Representative, Roberto Ramirez.. On 04/14/2025, the LPA conducted a plant tour at 9:15am, conducted interviews with four staff and four residents between 10:35am and 12:40pm, conducted a medication review at 9:30am, and conducted a file review and obtained copies of pertinent documents. Report Continued on LIC 9099C... Unsubstantiated Report Continued from LIC 9099... It was alleged that staff do not ensure residents incontinence needs are met. It was reported that a resident may have been wearing the same diaper since discharge from the hospital. Interviews conducted with staff revealed that incontinent residents are changed at least three times per day, and all other residents are checked and changed as needed. Staff also stated that residents are alert and able to notify staff when they require assistance with changing. Furthermore, staff reported that no residents have complained about being left wet for extended periods of time. Additionally, 4 out of 4 residents interviewed expressed no concerns regarding the frequency of diaper changes or the assistance provided for their incontinence needs. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff do not ensure residents incontinence needs are met”. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Report was reviewed and copy provided. Report Continued from LIC 9099... It was alleged that staff did not ensure resident had a physician’s order for bed rails. It was reported that Resident #1’s (R1’s) bed is equipped with bed rails; however, the care plan has not yet been approved by a physician. Records reviewed and interviews conducted revealed that R1 does not have a physician’s order authorizing the use of bed rails. Staff stated that the bed had been placed in the room prior to R1’s admission to the facility. Additional staff interviews further revealed that they had not reviewed R1’s file to verify if a physician’s order for bed rails was present. Furthermore, staff indicated they were currently waiting for home health to send a copy of the care plan confirming that R1 is approved to use a bed with rails. Based on record review and interviews conducted, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation “staff did not ensure resident had a physician’s order for bed rails” is deemed Substantiated at this time. It was also alleged that staff are not adequately trained. It was reported that facility staff is inadequate in providing care to the residents. Records reviewed revealed that facility staff have not yet completed the required 20 hours of annual training as specified by regulations. The Administrator stated that staff have completed the 20 hours and also participate in monthly refresher trainings. However, during staff interviews, employees reported having completed some training but were unsure of the total number of hours or whether it met the 20-hour requirement. Furthermore, although the facility maintained a designated training binder, the LPA was unable to verify compliance with the required training hours for the past 12 months. Based on record review and interviews conducted, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation “staff are not adequately trained” is deemed Substantiated at this time. It was also alleged that resident has missed medications and staff do not ensure residents medication needs are being met. It was reported that the resident is not receiving all prescribed medications, and some medications are missing and not being administered at all. Records reviewed revealed that R1 had twelve new prescriptions added to their medication list. According to inpatient discharge instructions dated 03/24/2025, R1 was prescribed several new medications, including acetaminophen–oxycodone, miconazole topical cream 2%, pantoprazole 40 mg, polyethylene glycol 3350, and selenium sulfide topical 1%. Report Continued on LIC 9099C... Report Continued from LIC 9099C... However, these medications are not listed on R1’s Centrally Stored Medication and Destruction Record (CSMDR). Staff interviews indicated that R1 was being administered gabapentin, and staff believed that additional pain medications were unnecessary, as they considered gabapentin sufficient for pain management. However, R1 has physician orders for PRN (as-needed) medications for pain, which include acetaminophen–oxycodone (1 tablet every 4 hours as needed) and acetaminophen 650 mg (2 tablets every 8 hours as needed), both specifically prescribed for pain management. Furthermore, during the medication review on 04/14/2025, the LPA did not observe any missing medications stored centrally, as the facility did not have medications available on-site. Based on record review and interviews conducted, the Department has sufficient evidence to say the alleged violations occurred. Therefore, allegations “resident has missed medications” and “staff do not ensure residents medication needs are being met” are deemed Substantiated at this time. It was further alleged that staff are not meeting resident's needs. It was reported that resident was recently discharged from the hospital, and facility staff had not checked R1’s blood sugar levels. A review of R1’s inpatient discharge instructions, dated 03/24/2025, revealed that R1 was to have their glucose checked twice daily for 30 days. Records reviewed and interviews conducted indicated that R1’s glucose levels had been monitored; however, when inspecting the documentation, it was found that the glucose readings were recorded from 12/14/2024 to 02/03/2025. Staff confirmed that all readings had been documented but indicated that they were unaware that R1's glucose levels needed to be checked twice daily for 30 days after being discharged from the hospital. Furthermore, although staff had been checking R1’s glucose levels daily prior to the hospitalization, they failed to continue monitoring R1’s glucose levels after discharge, as per the doctor's orders. Based on the information obtained and reviewed, the Department has sufficient evidence to say the alleged violation occurred. Therefore, allegation “staff are not meeting resident’s needs” is deemed Substantiated at this time. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 22, 2025 · control 29-AS-20250408080938

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(3) · Plan of correction due date: May 26, 2025

Postural supports may be used under the following conditions. A written order from a physician... shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Based on record review, the Licensee did not comply with the section cited above as R1 has bed rails and an approved physician’s order is not on file, which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: The Licensee will remove bed rails from resident's bed or obtain a physician’s order for bed rails and submit proof to CCL no later than POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: May 26, 2025

Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on record review and interviews, the Licensee did not comply with the section cited above as facility staff are not ensuring resident is given medications as prescribed by their doctor resulting in missed dosages, which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: The Licensee will review all residents’ medications and CSMDR to ensure all prescribed medications are available and submit proof to CCL no later than POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: ILS 87465(a)(2) · Plan of correction due date: May 26, 2025

A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical care and provide for assistance in obtaining such care... the licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met as evidenced by: Based on record review and interviews, the Licensee did not comply with the section cited above as staff are not checking resident’s blood sugar levels and documenting twice a day as stated per doctor’s orders, which poses an immediate health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: The Licensee will submit a plan on how the facility will ensure all doctor’s orders are followed and submit proof to CCL no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: May 26, 2025

Training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626 and subdivision (a) of Section 1569.696. This requirement is not met as evidenced by: Based on record review, the Licensee did not comply with the section cited above as staff has not completed the required 20 hours annual training or recorded accordingly, which poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: The Licensee has submitted proof that staff has completed the 20 hours training since the last visit. POC has been met.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Martha Arroyo conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20250408080938). The purpose of the visit is to issue a citation for deficiencies observed during the initial complaint investigation. During the visit on April 14, 2025, the LPA observed deficiencies unrelated to the complaint allegations. During the plant tour, which began at 9:15 a.m., the LPA observed five (5) beds total in Bedroom #2. Resident #1 (R1) and Resident #2 (R2) currently share Bedroom #2; however, there were three (3) additional beds. Staff interviews revealed that the extra beds are being temporarily stored in the room and will be moved to storage shortly. Additionally, although the facility has a designated staff room on the premises, interviews indicated that a staff member occasionally sleeps in Bedroom #2 next to R2 due to R2’s tendency to wander at night and their increased risk of falling. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview was conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, May 22, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a) · Plan of correction due date: May 23, 2025

Personal Accommodations and Services (a) ...The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility...This requirement is not met as evidenced by: Based on LPA observation and interviews, the Licensee did not comply with the section cited above as staff occasionally sleeps in bedroom #2 with R1 and R2, which poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: The Licensee will remove staff used bed in bedroom #2 and submit proof to CCL no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87308(c) · Plan of correction due date: May 23, 2025

General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage. This requirement is not met as evidenced by: Based on LPA observation, the Licensee did not comply with the section cited above as bedroom #2 was observed with a total of five (5) bed which exceeds the limit of two (2) bed, as staff stated beds are temporarily being stored there, which poses a potential health, safety, or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 22, 2025

Plan of correction: The Licensee will remove stored beds and place in storage area and submit proof to CCL no later than POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today. Upon arrival, there was (1) staff and two (2) residents present. LPA met with staff and the reason for the visit was explained. The Licensee Representative, Roberto Ramirez arrived at 11:00 a.m. Entrance interview conducted. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: The LPA inspected the kitchen/food service area at 11:30 a.m. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. Cleaning supplies were observed locked and inaccessible under the kitchen sink. The kitchen faucet was measured for hot water temperature, and it measured 119.3 degrees Fahrenheit at 11:35 a.m. COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were observed newly purchased on 04/14/2024. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 08/02/2024. Activities were observed in the common areas. LPA observed working telephone on premises. Report Continued on LIC 809C... Report Continued from LIC 809... RESTROOMS: The two (2) resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured; the first bathroom measured at 115.5 degrees Fahrenheit at 11:21 a.m.; and the second bathroom measured at 116.7 degrees Fahrenheit at 11:25 a.m. BEDROOMS: There are three (3) total bedrooms in the facility; all bedrooms are approved for double occupancy. Resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. GARAGE/BACKYARD: The garage was observed and locked at the time of the visit. There is a washer and dryer on premises. Laundry detergent was observed locked and inaccessible. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed one (1) self-latching gate. There is a pool on premises which was locked and inaccessible at the time of the visit. RECORDS: LPA reviewed Resident Records at 11:55 a.m. and Personnel Records at 12:22 p.m. Two (2) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. One (1) out of two (2) residents did not have a completed preplacement appraisal on file. Licensee Representative completed at the time of the visit. Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Although the facility had a designate training binder, LPA was unable to determine the number of hours completed per regulation for the past 12 months. During today’s visit, the LPA conducted interviews with one (1) staff and two (2) residents. Report Continued on LIC 809C... Report Continued from LIC 809C... MEDICATIONS: Medications review began at approximately 1:10 p.m. The medications are locked in a cabinet adjacent to the kitchen. Medications are labeled and checked for expiration dates. At 1:25 p.m., medication review revealed that two (2) out of two (2) residents have an over-the-counter medicine that is being administered; senna-s 50mg, and complete multivitamin for seniors 50+. however, the facility does not have the doctor’s order on file. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 12, 2024