Sally Residential Care Home 3

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 facility staff, who then contacted the Facility Designee (FD) via telephone and informed them of the visit. The FD, Sara Jackson arrived during the inspection and the reason for the visit was explained. Entrance interview conducted. Beginning at 09:50 a.m., the LPA along with staff 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 09:50 a.m. Knives and sharps were observed in a locked drawer at the time of the visit. 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. Common Areas: This includes the living room and dining room area. Furniture in the common areas was observed to be in good condition at the time of the visit. The facility maintained a comfortable temperature. The LPA observed activity supplies in the living room accessible to residents in care. The LPA observed a new fire extinguisher with a purchase date of 05/28/2026. Required postings were observed throughout the common space. There is a working telephone on premises. Cameras were observed in the common areas. No hazards/obstructions 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 fixtures were in operating condition. Showers had non-skid surfaces and grab bars. The bathrooms were sufficiently stocked with all necessary supplies. Starting at 10:01 a.m., the hot water temperature was measured in resident bathrooms, and they measured between 110.1 – 113.4 degrees Fahrenheit which is within the required range of 105 – 120 degrees Fahrenheit. Bedrooms: There are five (5) bedrooms for resident use. Resident bedrooms are both designated as shared / double occupancy and single / private occupancy. Bedrooms were observed to be furnished appropriately and had sufficient lighting. Additional clean linens and towels were observed in a closet. LPA observed personal hygiene items in a locked closet at the time of the visit. Garage: The garage does not have direct access to the house. The washer and dryer were observed inside the garage. Cleaning supplies, toxins, and detergents were observed in a locked cabinet at the time of the visit. A sufficient supply of emergency food and water was observed. Backyard: The backyard has a shaded area with adequate furniture for resident use. Emergency passageway was observed to be clear of any obstructions. There are two (2) side gates with latching mechanisms for emergency purposes. No bodies of water noted at the time of the visit. Records: Record review began at approximately 10:20 a.m. Six (6) 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. Two (2) personnel files were reviewed for, but not limited to: personnel record, health assessment with negative TB test results, criminal record clearance, first aid/CPR training, and the appropriate yearly training. All personnel files were complete. Report Continued on LIC 809C... Report Continued from LIC 809C... Medications: The LPA conducted a medication review at approximately 12:50 p.m. Medications are centrally stored and kept in a locked file 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 Plan: During today’s visit, the LPA reviewed the facility's infection control plan and emergency disaster plan, which were observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; last disaster drill conducted on 09/04/2026. No citations issued at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Sep 9, 2026

Allegation investigated: Due to neglect/lack of care: Staff did not seek timely medical care for resident leading to hospitalization for dehydration, sepsis, and urinary tract infection Staff did not notice resident's change in condition Staff did not provide authorized representative a copy of resident's file”

Licensing Program Analyst (LPA) Martha Arroyo conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Facility Designee, Sara Jackson and explained the reason for the visit. Entrance interview. On 09/11/2025, the Department received a complaint alleging neglect/lack of care and supervision. The complaint alleges that staff did not seek timely medical care for Resident #1 (R1), leading to hospitalization for dehydration, sepsis, and Urinary Tract Infection (UTI) and staff did not notice resident’s change in condition. The complaint was referred to the Community Care Licensing Investigations Branch (IB). The case was also reviewed by the Departments Program Clinical Consultant (PCC). Report Continued on LIC 9099 Unsubstantiated Report Continued from LIC 9099... On 09/12/2025, LPA Arroyo conducted the initial complaint visit. During the initial visit, between 01:55 p.m. and 02:45 p.m., the LPA conducted a physical plant tour with staff, interviewed one staff member, conducted a resident file review, and obtained copies of pertinent documents relevant to the investigation. On 09/24/2025, at approximately 10:24 a.m., IB Investigator conducted an interview with R1. Additional interviews were conducted on 10/28/2025 at approximately 10:49 a.m. and 11:06 a.m. with two staff members, and at approximately 11:19 a.m. with the Administrator. On 01/14/2026, at approximately 9:05 a.m., IB Investigator interviewed R1’s family member. Further interviews were conducted on 01/16/2026 at approximately 9:15 a.m. and 10:07 a.m. with representatives from Foundation Aiding the Elder (FATE), and at approximately 10:59 a.m. with R1’s family member. On 02/12/2026, at approximately 5:25 p.m., IB Investigator interviewed the former facility Administrator. On 03/13/2026, interviews were conducted at approximately 10:30 a.m. and 11:11 a.m. with former facility administrators, and at approximately 11:27 a.m. with a Highland Hospice nurse. Attempted interviews were also made on 02/27/2026, at approximately 10:13 a.m., and on 03/13/2026, at approximately 10:10 a.m., with R1’s Primary Care Physician (PCP). Additional attempted interviews were conducted on 03/03/2026, at approximately 8:07 a.m., and on 03/13/2026, at approximately 10:06 a.m., with the hospital’s Licensed Clinical Social Worker (LCSW). On 03/13/2026, attempted interviews were also conducted at approximately 10:14 a.m. with an APS nurse; at approximately 10:17 a.m. with an APS Social Worker; at approximately 10:52 a.m. with a representative from Integrity Care Management; and at approximately 10:55 a.m. and 11:36 a.m. with a representative from Los Robles Home Health. IB Investigator also requested and reviewed copies of St. John’s Hospital medical records, Kaiser Medical Center medical records, and facility file documents related to the investigation. Record review and interviews conducted revealed that R1 was admitted to the facility on 06/12/2021. A review of R1’s Physician’s Report, dated 07/30/2025, listed R1’s primary diagnoses as major neurocognitive disorder due to an unspecified disease, mild, without behavioral disturbance; atherosclerosis of the aorta; hyperthyroidism; inflammatory polyarthritis; migraine; osteoporosis; and dermatitis. The report indicated that R1 was able to communicate and follow directions/instructions and did not exhibit behavioral expressions such as disorientation, lack of hazard awareness, lack of impulse control, unsafe wandering, elopement, expressions of frustration, or hallucinations. Report Continued on LIC 9099C... Report Continued from LIC 9099C... The report also described R1 as non-ambulatory. R1 required assistance with activities of daily living (ADLs), including bathing, dressing/grooming, toileting, and managing personal cash resources. The investigation revealed that on 08/17/2025, R1 complained of left-sided abdominal pain and nausea and was administered PRN Zofran. R1 was asked whether they wanted to go to the emergency room (ER) for evaluation; however, R1 initially declined. Approximately one (1) hour later, although the pain had decreased, it was still present. R1 was again advised to go to the ER in case the condition was more serious and required medical attention, to which R1 agreed. R1 was subsequently transported by ambulance to the hospital. While at the hospital, R1 underwent testing and was kept overnight for observation. Record review of hospital records revealed that R1 was admitted to the hospital on 08/17/2025 and discharged on 08/21/2025. Per report, R1 was admitted with left side plank pain which was described as aching and cramping and only on the left side. R1 was noted to be nauseous but no vomiting with one (1) episode of diarrhea in the morning. R1 denied any other symptoms while at the hospital and noted that pain was rather abrupt and consistent since it had started earlier that same day. Upon admission, it was noted that R1 did not meet the criteria for sepsis; however, R1 later developed a fever and became significantly hypotensive, while still not meeting sepsis criteria at that time. By 08/19/2025, while hospitalized, the physician’s assessment indicated that R1 was septic and severely dehydrated. R1 was treated with intravenous (IV) fluids, pain medication, and antiemetic medication. R1 was subsequently discharged on 08/21/2025 to a board and care facility while under hospice care. Staff interviews revealed that R1 was transported to the hospital after stating they did not feel well and complained of “cramping.” Staff stated that whenever R1 complained of pain, the information was reported to R1’s family, and R1 was subsequently sent to the hospital for evaluation. Staff added that this procedure was followed whenever R1 became ill or complained of pain. Staff further stated that R1 had eaten all meals during the days preceding the hospitalization and had not complained of any pain or discomfort prior to the day of hospitalization. Report Continued on LIC 9099C... Report Continued from LIC 9099... A review of resident notes dated 01/22/2025 through 08/17/2025 revealed that facility staff documented physician appointments, resident complaints of pain, emergency room visits, visits from friends and family members, and notifications made to residents’ family members, when necessary. Additionally, R1’s appraisal/needs and services plan had been updated on 04/15/2025 to reflect R1’s current health needs based on the most recent health updates. During an interview with R1, R1 stated that facility staff prepared their favorite meals and provided high-quality food and care while R1 resided at the facility and expressed no concerns with the care provided by facility staff. Furthermore, PCC’s review of the information and documents obtained during the investigation reflected that although it took a couple of hours for R1 to be transported to the hospital following the initial complaint of pain, R1 had the right to accept or refuse medical care and services. Additionally, R1 did not have a fever or exhibit changes in vital signs prior to hospital admission; therefore, staff would not have recognized a change in R1’s condition. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. 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, therefore allegations “Due to neglect/lack of care: Staff did not seek timely medical care for resident leading to hospitalization for dehydration, sepsis, and urinary tract infection” and “Staff did not notice resident's change in condition” are deemed Unsubstantiated at this time. It was also alleged that staff did not provide authorized representative a copy of resident's file. It was reported that R1’s family member requested copies of R1’s complete file on 08/22/2025 and had not yet received the requested documents. Record review and interviews conducted revealed that R1’s family member had been appointed as the successor trustee for R1’s trust, but not as Power of Attorney (POA). Furthermore, the LPA was not provided with any legally binding documentation designating R1’s family member as conservator or POA. Based on the information obtained during the investigation, the Department does not have sufficient evidence to corroborate the allegation. 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, therefore allegation “staff did not provide authorized representative a copy of resident's file” is deemed Unsubstantiated at this time. No citations issued at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 9, 2026 · control 29-AS-20250911125121

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. Upon arrival, there were two (2) staff and four (4) residents present. The LPA was greeted by staff and at this time the reason for the visit was explained. The facility designee, Sara Jackson arrived during the inspection. Entrance interview conducted. At approximately 9:55 a.m., the LPA along with staff 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 09:55 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. At 10:00 a.m., the hot water temperature in the kitchen faucet was measured at 116.7 degrees Fahrenheit. 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 recently purchased with a date of 07/07/2025. Required postings were observed throughout the common space. There is a working telephone on premises. Activities were observed in the living room. Auditory alarms were observed functioning during the inspection. Cameras were observed in the common areas. No hazards/obstructions observed inside or out. Report Continued on LIC 809C... Report Continued from LIC 809... Restrooms: There are two (2) restrooms for resident use. The first bathroom is located by the main hallway and the second bathroom is located in bedroom #4. 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 10:09 a.m., the hot water temperature was measured in both bathrooms, and they measured between 113.7 and 117.5 degrees Fahrenheit. Personal hygiene items were observed locked and inaccessible to residents at the time of the inspection. Bedrooms: There are five (5) bedrooms for resident use. Four (4) bedrooms are designated as private / single occupancy, and one (1) bedroom is designated as a double / shared occupancy. Resident rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. There is a closet with additional clean linens and towels for resident use. The LPA observed a staff bedroom on premises. Garage: The washer and dryer were observed inside the garage. Detergents and cleaning supplies were observed locked and inaccessible during the inspection. The LPA observed an adequate amount of emergency food and water; properly stored. Outdoors: The backyard has a covered patio area with patio furniture adequate for resident use. There is (1) side gate with latching mechanisms. All passageways were observed to be clear of any obstructions. Records: The LPA began record review at approximately 10:25 a.m. Four (4) 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. Report Continued on LIC 809C... Report Continued from LIC 809C... Two (2) personnel files 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 complete. Emergency Disaster Planing: 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; the last one was conducted on 07/07/2025. Medications: Medications review began at approximately 12:00 p.m. Medications are centrally stored and kept in a locked file cabinet adjacent to the dining room. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Four out of four resident’s medications were observed and reviewed. Medications are properly documented on the Centrally Stored Medications and Destruction Record (CSMDR) and medications appear to be given as prescribed at the time of the inspection. Exit interview conducted. A copy of report was provided.the state’s words, verbatim · CDSS document, Sep 25, 2025

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a post-licensing visit today. Upon arrival, the LPA met with facility staff who contacted Administrator, Sara Jackson and at this time the reason for the visit was explained. The Administrator arrived at the facility at approximately 09:50 AM. Beginning at 09:55 AM, the LPA along with Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. The LPA observed knives and sharps in a locked drawer at the time of the visit. Refrigerator and pantry were checked for expirations dates; dates were clearly marked. COMMON AREAS: This includes the living room, hallway, and dining area. The LPA observed the living room to be clean and properly furnished at the time of the visit. The dining area was observed to be equipped with adequate seating for resident use. All furniture throughout the facility was observed to be clean and in good repair. The LPA observed a new fire extinguisher with a purchase date of 08/04/2024. All exits in the facility were observed to contain functioning auditory alarms. The LPA observed a working telephone on premises. No tripping hazards were observed inside or out. Report Continued on LIC 809C... Report Continued from LIC 809... BEDROOMS: There are five (5) bedrooms in the facility for resident use; four (4) are designated for single occupancy, and one (1) is designated for shared / double occupancy. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Additional clean linens and towel were observed in a storage closet by the hallway. The LPA observed personal hygiene items locked and inaccessible to residents in care at the time of the visit. Staff room observed on premises. BATHROOMS: There are two (2) bathrooms at the facility. One (1) is designated as a private resident bathroom, and one (1) is designated as a shared/common resident bathroom. All resident bathrooms were observed to be clean and were equipped with nonskid surfaces. Grab bars were observed near resident toilets and were properly secured. Beginning at 10:00 AM, the water temperature was measured in resident bathrooms, and they measured within the required range of 105 and 120 degrees Fahrenheit. OUTDOOR SPACE: The LPA observed an adequate shaded seating area with appropriate outdoor furniture for resident use. The facility has one (1) self-latching gate for emergency use. All passageways were observed to be clear of any obstructions. No bodies of water noted at the time of the visit. GARAGE: The garage is attached to the house. Washer and dryer were observed inside. Laundry detergents and cleaning supplies were observed inaccessible to residents at the time of the visit. The LPA observed an adequate amount of emergency food and water at the time of the visit. RECORD REVIEW: Record review began at 10:20 AM. Five (5) resident files were reviewed for but not limited to; signed admissions agreement, medical assessment, negative tb test results, consent for treatment form, pre-appraisal, appraisal, needs & service plan, and personal rights. All records were complete. Three (3) staff files were reviewed for but not limited to; personnel record, health screening with negative tb test result, fingerprint clearance, first aid / cpr certification, and annual staff training. All files were in order. Administrator Certificate valid until 07/26/2025. Renewal has been started and training is in progress. The LPA conducted interviews with one (1) staff and one (1) resident during today's visit and no concerns were noted. Report Continued on LIC 809C... Report Continued from LIC 809C... MEDICATION REVIEW: Medication review began at approximately 12:00 PM. Medications are centrally stored and kept locked in a file cabinet adjacent to the kitchen. Medications for two (2) residents were observed. Medications appear to be given as prescribed at the time of the visit. EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed facility's emergency disaster plan. The facility’s emergency disaster plan is up to date and is adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 04/14/2025. Next emergency disaster drill is scheduled for mid July. Exit interview conducted. Report was reviewed and copy provided.the state’s words, verbatim · CDSS document, Jul 1, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management - Deficiencies visit to the above facility. The purpose of the visit is to issue citations for deficiencies observed during a complaint visit (CC # 29-AS-20240917164844) under the closed facility Sally’s Residential Care Home, Inc (# 565800706). Upon arrival LPA met with staff, Flordeliza Paltep and explained the reason for the visit. The Administrator stated they were unable to come to the facility but gave permission for staff to sign the report. Entrance interview conducted. During the course of the investigation, it was revealed that Staff #1 (S1), who is employed by Sunshine Residential Home, LLC, collected all checks for the facility including R1’s August 2024 check (Check # 875, dated 08/01/2024). However, prior to depositing the checks, S1 noticed the check reflected “Sally’s” versus “Sunshine” and assumed it was done in error and corrected the check to reflect “Sunshine” prior to depositing it on 08/13/2024. S1 further stated that S1 was aware that the check belonged to R1 for the services provided to R1 and there was no malicious intent in adjusting the name on the check. Additionally, interviews reflected that the bank reversed the check on 09/13/2024 after the POA contacted the bank regarding the payment however, the facility had not received a replacement check for the services provided. S1 stated that he was interviewed by the detectives regarding the altering of the checks and was cleared of any wrongdoing due to it having no malicious/financial abuse intent. S1 and the licensee was advised that in the future to ensure the check issuer is contacted and a replacement check be requested rather than changing information that is already written. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC809-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Dec 17, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Dec 27, 2024

87411(a) Personnel Requirements – General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…This requirement is not met as evidenced by: Based on record review and interviews, Staff #1 (S1) altered the check issued for R1’s monthly services from “Sally’s” to “Sunshine”, which is potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 17, 2024

Plan of correction: Licensee will review regulation 87411 and submit a statement of understanding to CCL no later than POC due date.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Martha Arroyo conducted a Subsequent Pre-Licensing Visit to the facility today. The reason for this visit is to update the fire clearance approved after the pre-licensing visit initiated on 08/06/2024. LPA met with Applicant Representative, Sara Jackson as this is a change of ownership application from Sally’s Residential Care Home, Inc. #565800706 to Sally Residential Care Home 3 #565850406. The applicant has obtained fire clearance for a total capacity of six (6) residents, all of which may be bedridden in bedrooms #1 - #4 and bedroom #5 approved for ambulatory only. The facility has a dementia program in place. During today’s visit, the LPA toured the physical plant areas to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations and conducted a medication review. The following was observed: The LPA observed two (2) resident restrooms, which were clean and sanitary and in operating condition with non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The LPA observed five (5) resident bedrooms; four (4) bedrooms are designated as single occupancy; and one (1) bedroom is designated as double occupancy. All resident bedrooms were observed to be furnished appropriately and had sufficient lighting. Fire clearance also approved for staff bedroom on premises. The LPA inspected the kitchen/food service area. The facility has a sufficient supply of perishable and non-perishable food. All indoor and outdoor passageways were free from obstructions in case of an emergency. No bodies of water noted at the time of the visit. Report Continued on LIC 809C... Report Continued from LIC 809... Physical plant is consistent with the updated facility sketch/floor plan and fire clearance approved from 08/14/2024. The physical plant of this facility location is in compliance with Title 22 regulations at this time. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted. The report was reviewed, and a copy was provided.the state’s words, verbatim · CDSS document, Aug 29, 2024

Type of visit: Prelicensing

Licensing Program Analysts (LPAs), Martha Arroyo and Erica Mosley conducted a pre-licensing visit to this property at 9:30 a.m. LPAs met with Applicant Representative Sara Jackson as this is a change of ownership application from Sally’s Residential Care Home, Inc. #565800706 to Sally Residential Care Home 3 #565850406. The applicant has obtained fire clearance for a total capacity of six (6) residents, all of which may be bedridden in bedrooms #1 - #4. The facility has a dementia program in place. LPAs inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The hard-wired smoke alarms and carbon monoxide detectors were tested and function properly. LPAs observed one (1) fire extinguisher to be new and fully charged on 08/04/2024. There is one (1) double occupancy bedroom and four (4) single occupancy bedrooms for resident use and one (1) staff room. Each bedroom is equipped with clean mattresses, pillows, and bedding. Bedrooms have sufficient lighting. There is a cabinet in the hallway with a sufficient supply of linens, including blankets, bath towels and wash cloths. There is a locked closet with the resident’s personal hygiene items. The facility has two (2) bathrooms for resident use. Resident bathrooms contained appropriate non-skid mats and grab bars. Bathrooms have sufficient paper products. Hot water temperature was measured in both bathrooms, and they measured between 105- and 120-degrees Fahrenheit. LPAs observed trash cans with tight fitting lids at the time of the visit. LPAs toured the kitchen area at 9:40 a.m. The facility has at least seven (7) day supply of non-perishable food and two (2) days perishable food. Report Continued on LIC 809C... Report Continued from LIC 809... Appliances and all equipment appear to be clean and in good repair. Kitchen knives and sharps were observed in a locked drawer next to the gas range. The kitchen has a sufficient supply of plates, cups, cookware, and utensils. The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. Enough seating for six (6) residents at the same time in the dining room table. A working telephone is present. There are activity supplies in the living room. Night-lights were present in the common areas. All doors have functioning auditory alarms when opened. Medications are stored and locked in a file cabinet adjacent to the dining room. Facility records and First aid kit was by the medications. First aid kit was observed to have bandages, thermometer, scissors, tweezers and a current first aid manual. Facility has an adequate 30-day supply of Personal Protection Equipment (PPE). The garage is attached to the house and inaccessible to residents in care. The washer and dryer was observed inside the garage. Detergents, disinfectants, and cleaning supplies are stored locked and inaccessible. There will be no firearms/ammunition stored on the property. There is a sufficient supply of emergency food and water. The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights. The exterior passageways were clean and clear of any obstructions. There is one (1) self-latching gate for emergency use. There are no bodies of water on the premises at the time of the visit. LPAs observed the backyard, which has a covered outdoor area with a table and chairs for resident use. Comp III conducted with Applicant Representative. Report Continued on LIC 809C... Report Continued from LIC 809C... Physical plant is NOT accurate with the submitted facility sketch / floor plan. The following needs to be completed prior to licensure: · Submit a new facility sketch / floor plan and obtain fire clearance for additional rooms. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted. The report was reviewed, and a copy was provided.the state’s words, verbatim · CDSS document, Aug 6, 2024

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 6 COMP II Participants: Joseph Jose (Corporate Board Member) & Oluwatosin Akinmade (Administrator) Interview Method: Virtual interview via Microsoft Teams On June 07, 2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jun 7, 2024