A Heavenly Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced annual required inspection and met with designated administrator Cleof e Lucas and stated the purpose of the visit. Administrator Diana Fontanilla was not available at the time of the visit due to prior commitment. The facility is licensed for 6 adults 60 and over. All may be non-ambulatory. One maybe bedridden, and hospice waiver for 3. LPA observed 5 residents and 2 staff present,5 residents were in their respective rooms and were asleep. LPA toured the facility, including common areas, resident rooms, kitchen, bathrooms, driveway, and outdoor spaces and storage areas. Indoor temperature was within acceptable range of 70°F to 84.7°F. The kitchen was sanitary and organized; knives and chemicals were locked. Food supply met requirements (2 days perishable, 7 days non-perishable). Kitchen water temperature measured at 110.8°F. Bathroom water temperature measured at 114.6°F. Bathrooms had grab bars and non-skid mats; resident rooms had adequate storage. Medications were locked and inaccessible to residents; first aid kit was complete. Outdoor areas were free of hazards; laundry appliances were functional, and cleaning supplies were secured. Fire, smoke, and carbon monoxide systems were operational; hallways were clear and well-lit. page 1 of 2 LPA reviewed resident and staff records, including medication logs, admission agreements, care plans, personal and incidentals, health screenings, and training. All staff have required clearances, training and certification were up to date. Technical Assistance was provided to administrator and designated administrator for the following; for record maintenance and upkeep, request copies of doctor's visit from the case managers when residents are taken to the doctor. Retain and request copies of prescription note for over the counter medications called in by the care provider to the pharmacy. The facility conducts fire and earthquake drill quarterly for each shift. Last drill practice training was on 02/28/2026. The facility is equipped with carbon monoxide, fire and smoke alarm system. The fire extinguisher was inspected and on 01/24/2026 and staff monitors the fire extinguisher every month there after. No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with DADM Cleofe Lucas and a copy of the report was provided. end of report page 2 of 2the state’s words, verbatim · CDSS document, Jun 11, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management visit and met with Cleofe Lucas. During visit, LPA reviewed the resident records of staff S1-S3. S1 had a Health Screening form that indicated S1 had been cleared of TB on 01/17/2025. S2 had a tuberculosis exam dated 05/23/2025. S3 stated to have started started working at the facility on 06/12/2025 and took a tuberculosis test on 06/12/2025. During visit, S3 received a telephone call from S3's doctor saying S3's tuberculosis test was complete and S3 needed to arrive at the clinic to pick it up. During visit, LPA Marrufo received a copy of Administrator Diana Fontanilla's tuberculosis test via email. LPA Marrufo requests that a copy of S3's tuberculosis exam be sent to CCL by 06/17/2025. No deficiencies were cited at this time as per California Code of Regulations Title 22.the state’s words, verbatim · CDSS document, Jun 13, 2025

Type of visit: Required - 1 Year

On 5/21/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Mario Caliboso, Caregiver and Cleofe Lucas, Caregiver and explained the purpose of the visit. Diana Fontanilla, Administrator/Licensee arrived later during the visit. LPA Calandra toured the physical plant. This is a 1-story building with 4 bedrooms(3 for residents and 1 for staff), 2 bathrooms, a living room, dining room, kitchen, garage, and front and back yards. All bedrooms had the required furniture and sufficient lighting. No accessible bodies of water or hazards were observed in hallways or the backyard. The facility's fire alarms and Carbon Monoxide detector were observed to be in working order. The facility's first aid kit was observed to have all required items. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired. The facility was maintained at a comfortable temperature of 70 degrees Fahrenheit. The facility's fire extinguishers were observed to be fully charged. All sharp objects, medications, soap, detergents, and poisons were observed to be locked and in-accessible to persons in care. LPA reviewed 3 resident files and 3 staff files. All were observed to be complete except S1's file was missing Tuberculosis(TB) results. A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records kept at the facility. Deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties. An exit interview was conducted. This report was reviewed with Diana Fontanilla, Administrator/Licensee and a copy of the report along with Appeal Rights was left at the facility.the state’s words, verbatim · CDSS document, May 21, 2025

Allegation investigated: Staff pushed a resident in care Staff are not providing adequate amounts of food to meet the nutrition needs of residents in care Staff entered residents bedroom without knocking

Licensing Program Analyst (LPA) Monter and Marcella Tarin conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Administrator Diana Fontanilla On January 28, 2025, the Department received a complaint alleging Staff pushed a resident in care. It has been alleged that staff S1 pushed resident R2. On January 30 & 31, 2025, LPA Monter interviewed residents R1-R5. Resident R1 stated staff S1 pushes R1 onto his/her bed. R1 stated this has happened multiple times, in the mornings, but doesn’t have the actual dates when this occurred. 3 Out of 5 residents (R3-R5) stated they have never seen or heard about staff pushing residents. Resident R2 did not respond to LPA’s questions, grunted towards and ignored LPA’s questions. Page 1 Out of 4. Unsubstantiated On January 31, 2025, LPA Monter interviewed staff S1-S3. 3 Out of 3 staff (S1-S3) stated they have not seen staff push residents. Staff S1 stated he/she has never pushed residents. On February 26, 2025, LPA Monter interviewed ADM Fontanilla. ADM stated, she has never seen any staff pushing residents. ADM stated she has not heard anyone mention this allegation. On March 6 & 11, 2025, LPA Monter interviewed Witness W1-W3. 3 Out of 3 Witness interviewed stated they have not seen staff pushing residents in care. Based on a facility record review, there are no incident reports regarding the alleged push. There are also no incident reports noting any hospitalization's for R2 in late 2025 or 2024. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Staff are not providing adequate amounts of food to meet the nutrition needs of residents in care On January 28, 2025, the Department received a complaint alleging Staff are not providing adequate amounts of food to meet the nutrition needs of residents in care. It has been alleged that facility staff are serving small portions during meals which do not meet the nutrition needs of residents in care. Page 2 Out of 4. On January 30 & 31, 2025, LPA Monter interviewed residents R1-R5. R1 stated the facility only provides steamed vegetables. R1 stated the facility only gives small portions with no rice/meat or seconds for residents. R3 stated the facility does not give small portions and provide seconds if requested. R3 stated the facility makes chicken, beef, vegetables, fruits, rice, bread, soup and pasta. R3 stated the facility will make the food they request if they ask. R4 stated the facility gives big portions and provides seconds if he/she asks. R4 stated the facility makes food such as burritos, pancakes, sandwiches, pasta, eggs, salads, chicken and soup. R4 stated the facility will also make the food they request as well. Resident R5 stated he/she is provided enough food to keep him satisfied. Resident R2 did not respond to LPA’s questions, grunted towards and ignored LPA and ignored LPA’s questions. On January 31, 2025, LPA Monter interviewed staff S1-S3. Staff S1 and S3 stated they follow the facility menu. S1, S2 and S3 stated the facility is providing proteins, vegetables, fruits, vegetables, and other food to meet residents’ nutrition needs. S1, S2 and S3 stated when he/she fills out a plate for a resident, they fill the plate with food to meet the nutrition needs of the resident. S1, S2 and S3 stated if a resident requests for seconds, the staff will provide seconds. On February 26, 2025, LPA Monter interviewed ADM Fontanilla. ADM stated, the facility provides plenty of food. ADM stated the facility provides fruit, vegetables, carbohydrates, and proteins. ADM stated the facility will also make food sure the food has all the nutrients that residents need. ADM stated the staff will provide residents seconds if they request. On March 6 & 11, 2025, LPA Monter interviewed Witness W1-W3. 3 Out of 3 Witness interviewed stated they have never observed the facility staff serving small portions for residents meals. On March 14, 2025, LPA observed residents eating dinner, which included a full plate of the following: fries, chicken, coleslaw, fruits, juice / tea, and yogurt. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 3 Out of 4. Staff entered residents bedroom without knocking On January 28, 2025, the Department received a complaint alleging Staff entered resident’s bedroom without knocking. On January 30 & 31, 2025, LPA Manuel Monter interviewed resident R1-R5. R1 stated the staff enter his/her bedroom and don’t knock. R1 stated staff doesn’t tell him/her when they go in. R1 stated he/she hasn’t discussed this issue with the facility ADM. Resident R2 did not respond to LPA’s questions, grunted towards and ignored LPA and ignored LPA’s questions.. Residents R3-R5 stated staff always knock before entering their bedroom. On January 31, 2025, LPA Manuel Monter interviewed staff S1-S3. 3 Out of 3 staff interviewed stated they knock before entering a resident’s bedroom. On February 26, 2025, LPA Monter interviewed ADM Fontanilla. ADM stated, staff knock before entering a residents bedroom. ADM stated the staff even knocks before entering a residents bedroom that has the door open. On March 6 & 11, 2025, LPA Monter interviewed Witness W1-W3. 3 Out of 3 Witness interviewed stated they have observed staff knock on the residents door before entering. Based on investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. Page 4 Out of 4. END OF REPORT.the state’s words, verbatim · CDSS document, Mar 14, 2025 · control 26-AS-20250128124742

Type of visit: POC

On January 16, 2025, LPA Monter conducted a case management POC visit. LPAs met with Administrator, Administrator Diana Fontanilla On January 31, 2025, the facility was issued the following citations during a case management - deficiencies. The deficiencies cited had a POC due date of February 1, 2025 for the Type A deficiency and February 7, 2025 for the Type B deficiency. The following deficiencies were cleared during visit: Type A - 87468.1 Personal Rights of Residents in All Facilities (a)(1) Type B - 87303 Maintenance and Operation (a) No deficiencies cited during todays visit. This report was reviewed with A copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 26, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced visit to open a complaint investigation. During the complaint investigation, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Staff (S1) Cleofe Lucas. Staff S1 informed LPA that the Administrator was on vacation. LPA contacted the facility's designee (FD) (based on a review of the facility's LIC309). FD stated he/she was preoccupied due to an emergency. FD stated staff S1 could sign on his/her behalf. While investigating the complaint 26-AS-20250128124742, LPA toured the facility. While touring the backyard, LPA observed 12 pieces of bread, with mold in the backyard, directly across from exit #2, in the dinning room. (Photographs were taken.) LPA spoke with FD via phone call, who stated, the staff put the bread there to feed the birds. Staff S1 disposed of the molded bread during visit. While touring resident bedroom #3, LPA observed the doorway to the private bath did not have a door. LPA observed it only contained a brown curtain. LPA took photographs of the bathroom, from the inside of bedroom #3. (Photos with light on and off.) Based on observation, the curtains do not obscure the inside of the bathroom, resulting in a violation of a residents personal rights to privacy and dignity when using the restroom. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Staff S1 Cleofe Lucas and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 31, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Feb 1, 2025

87468.1 Personal Rights of Residents in All Facilities (a)(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by; Based on observation, resident bedroom #3 private bath does not have a door. Based on observation, the curtains do not obscure the inside of the bathroom when in use. This poses an immideate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 31, 2025

Plan of correction: ADM stated she will send a written plan of action on how she will ensure residents who use the private bathroom, in bedroom #3 are accorded privacy and dignity. ADM stated she will send this written plan of action to LPA by POC date February 1, 2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Feb 7, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by; Based on observation and interview, LPA observed 12 pieces of bread, with mold in the backyard, directly across from exit #2. FD stated the staff put the bread there to feed the birds. This poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 31, 2025

Plan of correction: Staff S1 disposed of the molded bread during visit. ADM stated she will send a letter of understanding regarding the regulation, and the importance of ensuring the facility remains clean, safe, sanitary and in good repair at all times. ADM stated she will send this written plan of action to LPA by POC date February 7, 2025.

Type of visit: Required - 1 Year

On 6/21/2024 at 8:30 a.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza arrived and conducted an unannounced required 1 year inspection visit. LPA was greeted by 1 staff and Administrator (ADM) Diana Fontanilla. LPA stated the purpose of the visit with ADM. The facility is a Residential Care Facility for the Elderly (RCFE) licensed to serve ages 60 and over 6 non-ambulatory, 1 may be bedridden and a waiver for 3 hospice care. The facility has 3 residents (R1 to R3) that have neurocognitive impairment and are non-ambulatory. 2 staff were present at the time of the visit. 3 residents were present at the facility and 2 out of 3 were in their bedroom resting and watching TV. 1 out of 3 was asleep. LPA was able to interview 2 out of 3 residents. At 8:55 a.m. LPA toured the facility inside and outside with ADM, including but not limited to the kitchen, bathroom, dining room, living room, residents rooms, staff room, backyard and walkways. LPA observed the Personal Rights disclosure, Long Term Care Ombudsman (LTCO) and Centralized Complaint and Information Bureau (CCIB) of the CA Department of Social Services (CDSS) prominently posted on the wall, visible to visitors, resident and staff. The temperature inside the home was at 68 to 69.8 degrees F. LPA and ADM toured the 3 resident bedroom and 1 staff room. LPA observed the rooms to be organized and free from debris and has sufficient storage for resident's personal belongings. Resident's bedroom has a bell call system to alert staff if assistance is needed. Bedroom #3 have an exit door and are free from obstruction. 1 of 3 bedroom is shared by 2 residents. 2 out 3 bedroom are private rooms. LPA observed 3 out of 3 residents' bed linens was recently changed and organized and sanitary. page 1 of 2 (see LIC809C). LPA observed that the facility has a wall pull fire alarm system connected to the fire department emergency line and a carbon monoxide alert system that is in good working condition. LPA observed night lights on the hallway. Hallways are free from obstruction. The sliding door going out to the backyard slides easily and free from obstruction. LPA observed ramps and walkways are free from obstruction. LPA observed the backyard area to be free from debris and is maintained. LPA observed the backyard fence is currently being repaired. LPA with ADM toured 2 full bathrooms (B1, B2). LPA observed B1 and B2 have non-skid mats and grab bars and a raised toilet seat . The facility stores incontinent supplies, cleaning and laundry detergents in a locked cabinet not easily accessible to residents in care. LPA with ADM inspected the staff room and found the room to be organized and sanitary. LPA was not able to measure the water temperature at the time of the visit due to scheduled maintenance. Dining and kitchen area and living room area were observed to be sanitary and organized. The facility has sufficient supply of perishable food for 2 days and non-perishable food for 7 days. The fire extinguisher located in the kitchen was bought on 1/1/2024. LPA and ADM inspected the laundry area located in the garage and door is kept locked with alarm for resident's safety. The washer and dryer are in good working condition LPA with ADM inspected the medication cabinet. LPA observed the medication cabinet is locked and is not easily accessible. LPA observed first aid kit was complete and stored with the PPEs. LPA observed a staff in the kitchen during the time of visit and staff showed LPA that knives are locked after use. LPA reviewed facility record, 2 out of 2 staff record and 3 out of 3 resident record. Facility's fire drill training conducted on 6/8/2024, facility records are up to date. Staff training records were up to date. Staff records were reviewed with current first aid certifications, clearance and training. Residents files were reviewed to be complete. Residents' medications are labeled and current. No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with administrator Diana Fontanilla. A copy of the report were provided.the state’s words, verbatim · CDSS document, Jun 21, 2024