A Caring Home

Type of visit: Required - 1 Year

On September 16, 2026, Licensing Program Analysts Arvin Villanueva (LPA), arrived unannounced at this facility to conduct the annual inspection visit. LPA initially met with staff on duty, S1 and S2, and stated the purpose of the visit. The Licensee/Administrator, Elaine Tolentino (AD), was notified and arrived shortly after, along with co-Licensee, Marivic Daduya. Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 elderly residents; up to 6 may be non-ambulatory. Facility has a clearance for one bedridden. Bedroom #2 on the facility sketch was approved for one bedridden use. Facility does not have clearance for delayed egress, and secured/locked perimeter. Facility has a hospice waiver for 6 residents. Upon arrival: LPA observed the room temperature to be at 70 degrees Fahrenheit. All 6 residents were present with 2 staff on duty. The fire door was observed to be propped open with a door stopper. This was a deficiency last year. Per Fire Inspection (STD850), it specify that the fire door needs to be closed. Physical Inspection: Areas that were inspected include, but not limited to, the resident bedrooms, bathrooms, kitchen area, dining room, other common areas and outdoor areas. LPA and staff inspected 5 of 5 resident bedrooms, one staff room and 2 resident bathrooms. Hot water temperature was measured in one of the bathrooms, and it was at 1119.3 degrees Fahrenheit. Advisory provided to lower the hot water temperature just a little. {1} In the kitchen area, LPA observed at least 7-day nonperishable and 2-day perishable food supplies. Knives/sharps and cleaning solutions were locked. Fire extinguishers observed and last serviced on February 4, 2026. Smoke and carbon monoxide detectors were observed throughout. Medication cabinet was observed to be locked and not accessible. The outdoor area was inspected, and the fences and gate were observed to be in good repair. No bodies of water were observed. The LPA noted a shaded area with appropriate outdoor furniture available for client use. An advisory was provided, reminding the facility to ensure all staff are familiar with the location and operation of utility shut-off valves in case of emergency. Record Reviews: Documents that were reviewed include, but not limited to, resident files, staff files, and other pertinent facility records. Review of 4 of 6 resident file(s) was conducted, including but not limited to, review of Admission Agreement, Physician Reports, and Ambulatory Status. Advisory was provided to ensure the facility update Restricted Health Condition Care Plan for those residents with restricted health conditions. Advisory was provided for facility to obtain home health care plan and training records from the home health agency. Review of 3 staff files included but not limited to background clearance, first aid/CPR certification, and training. Advisory provided for facility to update their training on Hoyer lift operation. Facility conducts monthly Fire Drills. Advisory was provided to conduct other types of disaster drills as required, such as earthquake and flood. Advisory was provided to administrator to ensure they review their infection control plan and emergency disaster procedure plan at least annually and document each review. Interviews: 1 staff member was interviewed and 1 resident was interviewed. Documents Requested: LPA obtained a copy of updated Liability Insurance, Personnel Records (LIC500), and Designation of Facility Responsibility LIC308. Per the California Code of Regulations, Title 22, Division 6, Chapter 6 and Health and Safety Code, deficiencies were cited. Civil penalties are being assessed in the amount of $500 for the fire door. Advisories were provided. Exit interview was conducted with AD. A copy of the report and appeal rights was provided. {2}the state’s words, verbatim · CDSS document, Sep 16, 2026

The state marks this report as 14 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

On 8/7/2025, Licensing Program Analyst, Arvin Villanueva (LPA) arrived unannounced at this facility to conduct their annual inspection visit. LPA met with one of the staff on duty and stated the purpose of the visit. The Administrator, Elaine Tolentino, was notified and arrived shortly after. Overview: Facility is a one-story home located in a residential neighborhood. Facility is licensed to serve up to 6 residents, ages 60 and above, all may be non-ambulatory. Bedroom #2 was approved for bedridden use. Facility has 5 resident bedrooms and 3 resident bathrooms, and one staff room. Initial Observation: Upon arrival LPA observed 2 staff on duty. Two residents were in the living room. The other residents were in their bedrooms. LPA observed required posters and facility license at the entrance. Room temperature was at 72 degrees Fahrenheit upon arrival. Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas. LPA observed the inside of the facility to be clean and in good repair at this time. LPA inspected 5 resident bedrooms and were observed to be equipped with the required furniture and sufficient lighting throughout. Bedroom #2 is currently vacant. Bedroom #4 is a shared bedroom with their own bathroom. LPA measured the hot water temperature in the 1 of 3 bathrooms to be at 112 degrees Fahrenheit. Grab bars and non-skid flooring were observed. Resident bathrooms were observed to be in clean and good repair at this time. {Con't from 809} Fire extinguisher was observed at the foyer area and was last inspected on 1/27/2025. Smoke and carbon monoxide detectors were observed throughout, tested and found operable at this time. LPA observed centrally stored medications, toxins, and sharp objects were kept locked and inaccessible to residents in care. In the kitchen area, LPA observed sufficient seven day non-perishable and two day perishable food supplies. Pantry was observed to be fully stocked with non-perishable food items. Proper storage of food items were observed. Kitchen refrigerator and freezer were maintained at regulatory temperature. Outdoor area was inspected. LPA observed outdoor furniture for resident use. Ramps were observed to be in good repair at this time. Emergency walkways were observed to be unobstructed. The following advisories were provided to Administrator: Necessary repair is needed for the fence on the garage side of the facility The latch of the exit gate do not automatically lock Per staff, exit door for room #6 was broken earlier today by the ambulance personnel and Administrator has arranged for it to be repaired by 8/9/25. Based on today's visit, this annual will need continuation. The Department will return at a later date to continue the inspection. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 7, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual continuation visit. LPA Valerio met with facility staff, and explained the purpose of the visit. LPA Valerio conducted the initial annual inspection on 08/12/2024. No deficiencies were cited during the visit. LPA Valerio toured the facility to ensure compliance with Title 22 regulations. No health, safety, or personal rights risk were observed. LPA Valerio reviewed six (6) resident files and three (3) staff files. Resident files were observed to be complete with required annual documentation and assessments. Staff files were observed to have required dementia, first aid, and annual training. During file review, LPA observed medication documentation showing that Resident 1 (R1) sustained a fall on 09/01/2024. The facility reported the fall to CCL on 09/04/2024 at 6:04 AM via fax. LPA obtained a copy of the fax transmission receipt. R1 fell at the dinning room after moving the wheelchair and leaning forward. R1 fell on face, resulting in a laceration, which required stitches. According to an interview with Administrator Elaine, Administrator and Facility Staff were on shift. Two residents were eating dinner at the dinning table. Administrator was walking back from getting a plate from Room 1 and facility staff was feeding resident in their room. Administrator was walking back and observed that resident moved the wheelchair and R1 was falling forward to the floor. Administrator tried to catch R1 but it was too late. Staff immediately contacted 911 and responsible party while Administrator assessed R1. Resident was transferred to the emergency department and returned the same evening. Technical Assistance was provided to Administrator Elaine. Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited. An exit interview was held, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 4, 2024

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct a case management visit - health and safety check. LPA Valerio met with facility staff, and explained the purpose of the visit. LPA was later met by Administrator Elaine Tolentino. LPA Valerio received notification from an outside agency regarding COVID positive residents and staff inside the facility. LPA Valerio reviewed the Regional Office (RO) electronic facility files and did not observe any submitted incident reports. LPA attempted to contact the facility on 08/06/24, but did not receive a response. On 08/07/24, LPA Valerio was able to reach Administrator Elaine via cellphone. Initially, Administrator Elaine stated she only had one resident that was COVID positive. After further discussion, it was learned that two residents were COVID positive. Both residents were in a shared room. According to Administrator Elaine, no staff tested positive. LPA inquired about the facility's Infection Control Procedures. Due to the facility's full capacity, Administrator Elaine stated there was no available room to be utilized as an isolation room. Administrator Elaine admitted that an incident report was not sent for the COVID cases. LPA requested they be sent to the RO. The RO received two incident reports on 08/08/2024. According to the Unusual Incident Reports (UIR) received, Resident 1 (R1) returned from the hospital on 07/21/24. Staff observed R1 displayed cough symptoms. R1 tested positive for COVID on 07/25/2024. R1 was in a shared bedroom with Resident 2 (R2). R2 was not removed from the room, and R1 was not isolated per the facility's infection control procedures. On 07/28/2024, R2 was observed to have symptoms of a cough and tested positive for COVID. Per California Code of Regulations (CCR) - Title 22, deficiencies are being cited on the attached LIC 809 - D. Appeal rights provided. Failure to correct deficiencies may result in the issuance of civil penalties. An exit interview held, and a copy of the report was provided to Administrator Elaine.the state’s words, verbatim · CDSS document, Aug 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(a) · Plan of correction due date: Aug 13, 2024

87470 Infection Control Requirements (a) A licensee shall ensure that infection control practices are maintained as follows... This requirement was not met as evidenced by: Based on records review and interviews, The licensee did not ensure infection control practices were followed by staff to minimize the spread of COVID, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 12, 2024

Plan of correction: Licensee will submit an in-service training for Administrator and all staff regarding current CCLD and LPH guidelines for COVID positive cases. Licensee to submit proof of training along with a detailed plan of how the facility will address COVID cases in the future. Licensee to send by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1(a)(2) · Plan of correction due date: Aug 13, 2024

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable... This requirement was not met as evidenced by: Based on records review and interviews, the licensee did not ensure to remove R2 from the shared bedroom once R1 was learned to be positive for COVID, which poses an immediate health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 12, 2024

Plan of correction: Licensee will submit an updated Infection Control Plan that addresses individuals in a shared room and the facility's plan to ensure all residents safety in the future. Licensee to send by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(2) · Plan of correction due date: Aug 13, 2024

87211 Reporting Requirements (a)Each licensee shall furnish to the licensing agency...: (2)Occurrences, such as epidemic outbreaks....which threaten the welfare, safety or health of residents,, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer... This requirement was not met as evidenced by: Based on records review and interviews, the licensee did not ensure COVID cases were reported via phone or via a written report, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 12, 2024

Plan of correction: Licensee to send an acknowledgement of understanding letter regarding 87211 by POC due date of 08/13/2024. Licensee to conduct in-service training on Reporting Requirements and send proof of training by 08/26/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(d) · Plan of correction due date: Sep 12, 2024

87405 Administrator - Qualifications and Duties(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.... This requirement was not met as evidenced by: Based on records review and interviews, the licensee did not ensure Administrator Elaine provide care and supervision appropriate to the residents and did not show ability to conform to the applicable laws, rules and regulations when two residents tested positive for COVID, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 12, 2024

Plan of correction: Licensee will have administrator submit an acknowledgement of understanding of Infection Control Requirements, Personal Rights of Residents in All Facilities, and Reporting Requirements.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA Valerio was met by facility staff and later met by Administrator Elaine. LPA Valerio and facility staff toured the facility to ensure compliance of Title 22 regulations. LPA Valerio inspected residents bedrooms, which were observed to be free from odors, clean, and fully furnished. Resident bathrooms were observed to be clean and free from debris. The kitchen was observed to have medications, sharps, and cleaning supplies locked and inaccessible to residents. The facility was observed to have an adequate food supply and an emergency supply of food. Staff were observed sitting outside with residents, assisting residents with craft activities, assisting residents with ADLs, cleaning, and preparing meals. The backyard was observed to have a shed utilized for storage. There is no live in care staff; however, there is a staff designated room for staff breaks. LPA Valerio requested the following annual documentation be sent to LPA: LIC 500, LIC 308, LIC 610, and copy of Liability insurance Per California Code of Regulations (CCR) - Title 22, no deficiencies are being cited. An exit interview was held, and a copy of the report was provided,the state’s words, verbatim · CDSS document, Aug 12, 2024

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a Post-Licensing Inspection. LPA Valerio was met by Administrator Elaine Tolentino, and explained the purpose of the visit. LPA observed 6 residents and 2 staff present in the facility. LPA Valerio and Administrator toured the facility to ensure compliance with Title 22 regulations. LPA observed the common room area, kitchen, residents bedrooms, resident bathroom, staff bedroom, garage area, and exterior area. Common room area was observed to be fully furnished and equipped with areas to conduct indoor activities. Residents were observed living to music while watching live motion pictures, enjoying a snack, taking a nap, completing ADLs, or visiting with family. Resident bedrooms were observed to be clean, free from odors, and no emergency exits being obstructed or blocked. Resident bathrooms were observed to be stocked with paper towels, toilet paper, hand soap, skid mats, hand rails, and a trash can. The facility was observed to have an extra supply of linen bed sheets, bed comforters, and hygiene supplies. The staff bedroom was observed to be only used for staff and free from resident belongings. The kitchen area was observed to be clean. The facility was observed to have an adequate food supply in addition to an emergency supply of food for staff and residents. The exterior shed was observed to be utilized for storage. Exit walkways were not obstructed. LPA reviewed 2 resident and 2 staff files. Files were observed to be completed with required documents. Resident files were observed to have necessary documents. Staff files were observed to have fingerprint clearances and yearly training. LPA Valerio and Administrator Elaine discussed Title 22 regulations, recommendations for resident documentation, exceptions and waivers, and reviewed Medication Administration Records. Per California Code of Regulations (CCR) - Title 22, Division 6, no deficiencies were observed. An exit interview was held, and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 16, 2024

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Christina Valerio and LPA Arvin Villanueva arrived unannounced to conduct a case management visit. LPAs met with designated staff Marivic Daduya, and explained the purpose of the visit. Licensee informed LPA that a resident's family member wanted to install a camera inside the bedroom for observation purposes due to falls. Licensee sent the request to LPA, which included information regarding the resident having a full bed rail. LPA requested a copy of the doctors orders. LPAs observed the order in the file. LPA Valerio contacted responsible party for Resident 1 and observed the placement of the webcam video. LPA confirmed that the video respects the privacy of the roommate. LPA observed the camera in person and observed the camera to be facing towards R1's side of the room. R1's side of the room is separated by a wall. No health, safety, or personal right concerns observed. Based on observations, records review, and interviews, no deficiencies were observed during today's visit. An exit interview was held with designated staff, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 31, 2023