A Ohana Home for Seniors

Type of visit: Required - 1 Year

On 09/17/2026 at 11:15AM, Licensing Program Analyst (LPA) Andrew Christy arrived unannounced to conduct the 1-Year Annual Required inspection. LPA met with Administrator, Amelia Talau, and explained the purpose of the visit. The facility is currently at max capacity with six (6) residents. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area, and backyard. All outdoor and indoor passageways are kept free of obstruction. No bodies of water were observed. A comfortable indoor temperature is maintained at 69.0 degrees Fahrenheit. The hot water temperature in the residents’ shared bathroom was measured at 117.9 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 09/22/2025. At 12:30PM, LPA reviewed five (5) resident files and four (4) staff files. The emergency disaster plan was last reviewed 09/11/2026. Quarterly emergency drills were last conducted 09/29/2025. A review of resident medications and the Medication Administration Record (MAR) found no outstanding errors. Continued on LIC809C..... Continued from LIC809..... The following deficiencies were cited during inspection: At 11:30AM, there was unlocked medication found in the fridge. At 12:15PM, during file review, it was found that resident files were incomplete. At 12:45PM, during file review, it was found that staff files were incomplete. At 1:15PM, during file review, it was found quarterly emergency drills were not being completed. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report, along with Appeal Rights, was provided to the administrator.the state’s words, verbatim · CDSS document, Sep 17, 2026

Type of visit: Case Management - Other

On 02/27/2026 at 8:15AM, Licensing Program Analyst (LPA) Andrew Christy arrived unannounced to conduct a Case Management visit. LPA met with Mary Mataele, administrator, and explained the purpose of the visit. During the course of the visit, LPA interviewed R1. No deficiencies cited during visit. Exit interview conducted and a copy of this form was provided to the administrator.the state’s words, verbatim · CDSS document, Feb 27, 2026

Allegation investigated: Licensee not providing prompt access to or copies of resident records.

On 02/17/2026 at 9:30AM, Licensing Program Analysts (LPAs) Andrew Christy and Ardalan Gharachorloo arrived unannounced to deliver findings for the above allegation. LPAs met with Administrator Mary Mataele and explained the purpose of the visit. Allegation: Licensee not providing prompt access to or copies of resident records - Substantiated LPA Andrew Christy received the email correspondence from RP, which lays out the time frame that documents were requested. RP is the legal representitive of W1 and has authority to request documents in regards to W1 and the resident that was staying (R1). Email correspondence showed that S1 did not provide the documents over a two month period despite constant communication. The preponderance of the evidence standard has been met, and the allegation is SUBSTANTIATED. Continued on LIC9099C..... Substantiated Continued from LIC9099..... Deficiency is cited under the California Code of Regulations listed on LIC 9099-D. Failure to submit proof of correction (POC) by plan of correction and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted appeal rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Feb 17, 2026 · control 15-AS-20260120143023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Feb 24, 2026

To have prompt access to review all of their records and to purchase photocopies of their records. Photocopied records shall be provided within two (2) business days... - This requirement is not met as evidenced by: Based on interviews and record review, the authorized representative has not received records in two months since the initial request.the state’s words, verbatim · CDSS document, Feb 17, 2026

Plan of correction: On or before plan of correction due date, Licensee will send an email of the requested documents to the RP and will include CCL in the email as proof

Allegation investigated: Staff did not ensure the facility maintained liability insurance Staff did not safeguard resident personal belongings

On 02/17/2026 at 11:00 AM, Licensing Program Analysts (LPAs) Andrew Christy and Ardalan Gharachorloo arrived unannounced to conduct 10-day initial complaint and deliver findings for the above allegations.LPA met with administrator Mary Mataele and explained the purpose of the visit. During the course of the investigation, LPAs collected the following documents, including but not limited to: R1's inventory list (LIC 621), and expired copy of Liability Insurance.In addition, LPAs interviewed staff (S1) and reviewed 3 residents files (R1-R3). Continued on LIC9099C..... Substantiated Continued from LIC9099..... Allegation: Staff did not ensure the facility maintained liability insurance The expired form of Liability Insurance shows that the policy lapsed on 08/04/2025 due to Non-payment. The preponderance of the evidence standard has been met, and therefore the allegation is SUBSTANTIATED. Allegation: Staff did not safeguard resident personal belongings LPAs interviewed S1 regarding the above allegation and about training in regards to belongings of residents no longer in the facility. S1 states that R1 passed away on 12/22/2025, and that W1 stated they would arrive later that week on 12/26/2025 to pick up the belongings. S1 stated that a caregiver (S2) was cleaning the room and threw away the belongings that were listed on LIC621. S1 stated that she understands that belongings need to be kept until picked up but S2 did not. LPAs also requested to view training logs for staff in regards to personal belongings of residents and did not see any training for that area. The preponderance of the evidence standard has been met, and therefore the allegation is SUBSTANTIATED. Deficiencies are cited under the California Code of Regulations listed on LIC 9099-D. Failure to submit proof of correction (POC) by plan of correction and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report, along with Appeal Rights, was provided to the administrator.the state’s words, verbatim · CDSS document, Feb 17, 2026 · control 15-AS-20260211103109

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(j) · Plan of correction due date: Feb 27, 2026

Upon the death of a resident, all cash resources, personal property, and valuables of that resident shall immediately be safeguarded. -This requirement is not met as evidenced by: Based on record review and staff interviews, the resident's belongings were thrown away two days after the resident's passing.the state’s words, verbatim · CDSS document, Feb 17, 2026

Plan of correction: On or before plan of correction due date, Licensee will submit proof to CCL that all caregivers have participated in an inservice/training on the handling of a resident's belongings.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.605 · Plan of correction due date: Feb 27, 2026

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000)...or neglect by, the licensee or its employees. -This requirement is not met as evidenced by: Based on records review, the liability insurance was outdated.the state’s words, verbatim · CDSS document, Feb 17, 2026

Plan of correction: Licensee shall submit the proof of renewed liability insurance to CCL by the POC date.

Type of visit: Case Management - Other

On 02/04/2026 at 12:05 PM, Licensing Program Analyst (LPA) P.Manalo arrived unannounced to conduct a Case Management inspection of O Ohana Home for Seniors, LLC. LPA met with Administrator, Mary Mataele, to ensure the facility is in compliance with applicable statues and regulations. During the visit, LPA conducted interviews with residents, ADM, and staff. Based on interviews with the residents, 3 of 5 residents stated that they are happy and like the food at the facility. Based on observations, LPA did not observe the Industrial Welfare Commission and California Minimum Wage Poster. LPA toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 108.7 degrees F in the hallway bathroom. Fire extinguisher was last serviced on 09/22/2025. During the visit, LPA obtained a copy of the LIC500 and resident roster. LPA conducted a tour of the physical plant and observed the following deficiencies: At 12:05 PM, when LPA first arrived to the facility, LPA and S1 had difficulty communicating with each other due to language barrier. At 12:50 PM, LPA observed Bedroom #1 unlocked with paint, ladder, drill, and screwdriver. At 12:52 PM, LPA observed unlocked Laxaclear, Disinfectant Deodorizer, and Dayquill in the kitchen pantry. Continue to LIC809-C... Continued from LIC809... At 12:53 PM, LPA observed multiple bugs such as spiders in the kitchen pantry. At 12:54 PM, LPA observed two kitchen drawers in disrepair. At 12:55 PM, LPA observed multiple knives unlocked in the kitchen drawer and in the kitchen dish rack. At 1:05 PM, LPA observed items such as mattress, furniture, carpet, boxes, window panel, and other debris in the backyard. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Therefore, the facility appears to be not in compliance. An exit interview was conducted. A copy of the report, Appeal Rights, and LIC421FC were provided.the state’s words, verbatim · CDSS document, Feb 4, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Feb 5, 2026

87309(a) Storage Space and Access(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects... locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: The licensee did not comply with the section cited above by having unlocked items such as paint, ladder, drill, screwdriver, disinfectant deodrozier, dayquill, laxaclear, and knives all around the kitchen which poses an immediate health and safety risk to person in care.the state’s words, verbatim · CDSS document, Feb 4, 2026

Plan of correction: The Administrator agrees to self-certify the regulation, lock the items, and send proof to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(d)(3) · Plan of correction due date: Feb 13, 2026

87411(d)(3)Personnel Requirements - General (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above when S1 was left alone in the facility with a language barrier which posed a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 4, 2026

Plan of correction: By POC date, the Administrator agrees to self-certify the regulation and ensures that a staff member is always present that can communicate with the residents. Proof of correction will be sent to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Feb 13, 2026

87303(a) Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times... This requirement is not met as evidenced by: The licensee did not comply with the section cited above by having items such as mattress, furniture, carpet, boxes, window panel, and other items in the backyard, the kitchen drawer in disrepair, and multiple bugs such as spiders found in the kitchen pantry, which poses a potential safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 4, 2026

Plan of correction: The Administrator agrees to schedule a bulk pick up to remove the items, fix the kitchen drawers, and clean the kitchen pantry. Proof of correction will be sent to CCLD by POC date.

Type of visit: Case Management - Deficiencies

On 01/21/2026 at 2:45PM, Licensing Program Analysts (LPAs) Andrew Christy and Tonica Syess-Gibson conducted a Case Management for deficiencies as a result of observations made during complaint investigation 15-AS-20260120143023. LPAs met with Mary Mataele, House Manager, and explained the purpose of the Case Management. During the course of an investigation, it was found that the facility still has not found a full time certified Administrator during the the last month. This is considered a repeat violation and a Civil Penalty of $250.00 will be assessed as of 01/21/2026. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report, along with Appeal Rights, was made available to the House Manager.the state’s words, verbatim · CDSS document, Jan 21, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87505(a) · Plan of correction due date: Jan 30, 2026

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as the facility does not have a certified administrator, which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 21, 2026

Plan of correction: A civil penalty of $250.00 is assessed for a repeat violation. On or before plan of correction due date, licensee will find a certified administrator to be associated with the facility and ensure they are on site a sufficient amount of hours. Licensee will send LPA the up to date administrator certificate, updated LIC308, updated LIC500, LIC501, and fingerprint clearance information.

Allegation investigated: Staff left residents unattended

On 12/15/2025 at 9:00AM, Licensing Program Analysts (LPAs) Kelly Nguyen and Andrew Christy arrived unannounced to conduct 10-day initial complaint and deliver for the above allegation and met with house manager, Rose Malekamu, and explain the purpose of the visit. During the investigation house manager had to leave and gave verbal permission to the care staff, Teresa Caal, to sign the report. During the course of the investigation, LPAs conducted file review, including but not limited to, resident roster, staff schedule, staff shift record log, staff communication via text, and residents’ records. LPAs also conducted interviews with residents and staff. Report Continued on LIC 9099c... Substantiated Allegation: Staff left residents unattended - Substantiated Based on record reviews and interviews Staff 1(S1) was on duty during 12/3/25 from 5pm to 10pm. However, at around 9:30pm S1 left the facility and confirmed by Staff 2 (S2) S1 was outside the facility. Staff 3 (S3) confirmed S3 arrived at the facility either at 10pm or around 10pm. LPAs interviewed Resident 1 (R1), Resident 2 (R2), Resident 3 (R3), Resident 4 (R4), and attempted to interview Resident 5 (R5) at the facility. R1, R2, R3, and R4 stated there are times that the facility has no staff available. Therefore, the above allegation is substantiated due to staff left residents unattended. The preponderance of the evidence standard has been met, and the allegation is SUBSTANTIATED. Deficiency is cited under the California Code of Regulations listed on LIC 9099-D. Failure to submit proof of correction (POC) by plan of correction and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted appeal rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 15, 2025 · control 15-AS-20251205101323

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 22, 2025

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). -This requirement is not met as evidenced by: -Based on record review and interviews, the licensee did not comply with the section cited above by leaving the residents unattended.the state’s words, verbatim · CDSS document, Dec 15, 2025

Plan of correction: On or before plan of correction due date, licensee will submit an updated LIC500 and staff schedule that will mitigate gaps of coverage in case of staff running behind.

Type of visit: Case Management - Other

On 11/17/2025 at 2:30PM, Licensing Program Analysts (LPAs) Andrew Christy and Grace Luk arrived unannounced to conducted a Case Management visit. LPAs met with staff member Amelia Talau and explained the nature of the visit. Acting administrator Rose Malekamu was not available until 6:00PM, and stated caregiver Teresa Caal is authorized to sign the forms on her behalf. The facility is currently at max capacity with 6 residents. The purpose of the visit is to confirm payment of the accrued annual and late fees, as well as confirm there is a new certified administrator associated to the facility. Per the CDSS website, the annual fees along with late fees were paid on 11/14/2025. The facility currently does not have a certified administrator, as Amelia and Rose are still getting the administrator courses scheduled. In addition, the background check for Amelia is listed as still in process, even though she is associated to the facility. Rose ensured LPAs that the staff member will not be allowed back to the facility until the background check is complete. The following deficiencies were cited during the visit: The facility is still lacking a certified administrator. This is considered a repeat violation. There is a staff member that has a background check listed as still in process and has been working for four days so far. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report, along with appeal rights, was provided to the caregiver.the state’s words, verbatim · CDSS document, Nov 17, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Nov 18, 2025

87355 Criminal Record Clearance (e) All individuals...shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as there is a staff member working while the background check is still in process, which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 17, 2025

Plan of correction: Before LPAs left the facility, the staff member in question left the facility. In addition, licensee will contact Guardian to see why there is a delay, and will provide LPA an update via email for proof of this occurance. A civil penalty of $400.00 is assessed for the failure to complete the caregiver background check.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Dec 1, 2025

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as the facility does not have a certified administrator, which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 17, 2025

Plan of correction: On or before plan of correction due date, licensee will find a certified administrator to be associated with the facility and ensure they are on site a sufficient amount of hours. Licensee will send LPA the up to date administrator certificate, updated LIC308, updated LIC500, LIC501, and fingerprint clearance information. A civil penalty of $250.00 is assessed for a repeat violation.

Type of visit: POC

On 10/08/2025 at 12:00PM, Licensing Program Analyst (LPAs) Andrew Christy arrived unannounced to conduct a Proof Of Correction (POC) visit. LPA met with administrator Mary Malekamu and explained the purpose of the visit. The facility currently houses four (4) residents. The following deficiencies cited during the annual visit on 09/22/2025 were cleared during this visit: 87307(d)(6) - The fire exit through the backyard was cleared on the original POC date with photo proof sent to LPA. During today's visit, the pathway was still clear. 87303(a) - The fridge's busted freezer drawer now opens properly. Administrator has a contractor coming out to fix the windows and screens with a date of 6-8 weeks. Administrator will send a picture of contractor doing work within a week of that date. 87411(a) - There was additional staff during POC visit that were able to effectively communicate with residents and LPA. 1569.618(c)(3) - All staff have gotten their CPR cards and administrator sent email proof. 1569.695(b) - The emergency drill was ran during the last week of September with all employees having signed the form. Administrator verbalized understanding that this needs to be done every three months. 87412(a) - Staff have the necessary forms that were discussed during the initial Annual Visit besides the LIC503. Staff have their health screenings scheduled and administrator will submit the forms after each one is done. 87506(b) - Residents have the necessary forms that were discussed during the initial Annual Visit. Continued on LIC809C..... Continued from LIC809..... The following deficiency cited during that same annual visit has a new POC due date: 87405(a) - Administrator and the TSP are currently working on getting all the proper documents submitted. While the initial POC date is 10/20/2025, an extension will be granted once contact with Cynthia is made to get additional info on how much progress was made. No deficiencies cited during visit. Exit interview conducted and a copy of this report was provided to the administrator. POC Letters were also generated and given to administrator.the state’s words, verbatim · CDSS document, Oct 8, 2025

Type of visit: Required - 1 Year

On 09/24/25 at 08:30AM, Licensing Program Analyst (LPA) Andrew Christy and Licensing Program Manager (LPM) Harpreet Humpal arrived unannounced to do an annual inspection. LPA and LPM meet with caregiver Gualip Hermenelinda and explained the purpose of the visit. Administrator Mary Malekamu arrived at 9:15AM. Facility currently houses four (4) residents. LPA inspected the facility inside out. Facility is kept at a comfortable temperature at 73.0 degrees Fahrenheit. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Hot water measured to 119.6 degrees Fahrenheit. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Outdoor activity space was observed furnished with tables, chairs and shade. Fire extinguishers were observed fully charge and tags showed serviced 09/22/2025. At 10:30AM, LPA reviewed four (4) residents records and five (5) staff records. Emergency Disaster Plan was last updated 09/22/2025. Continued on LIC809C..... Continued from LIC809..... The following deficiencies were found during the inspection: At 8:30AM, LPA and LPM experienced difficulty in communication with staff members due to a language barrier. Interviews with all four residents confirmed they face similar issues when communicating needs. During inspection, most resident rooms were found to not have screens on the windows, with one resident's window being broken itself found at 10:25AM. At 8:45AM, the first room inspected was found to have a damaged electrical outlet and a window that will not shut. The kitchen was found to have a broken cabinet and the freezer door on the fridge was completely stuck and unable to move without two people attempting. As well, all resident doors shut by themselves in a quick and forceful manner. At 8:55AM, one storage closet, which is unlocked, had a can of paint primer easily accessible. At 9:30AM, the first bathroom inspected had a bottle of Pepto Bismal in an unlocked cabinet. At 10:25AM, one of the pathways in the backyard was found to be blocked with various pieces of furniture and debris/junk. At 10:30AM, during overview of resident files, all files were found to be missing forms, including the Consent To Treat form (LIC627C), Appraisal Needs and Services form, and the Personal Rights form (LIC613) At 11:15AM, during overview of staff files, all were found to be missing multiple forms. This includes the Personnel Record (LIC501) and the Health Screening Report (LIC503). This also includes none of the staff having updated CPR/First Aid training. 11:50AM, administrator revealed that their certificate has not been renewed. At 12:00PM, it was discovered that emergency drills were not being conducted quarterly. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Administrator expressed interest in the Technical Support Program (TSP). LPA will create referral. Exit interview conducted, and a copy of this form, along with a copy of appeal rights, was provided to the administrator.the state’s words, verbatim · CDSS document, Sep 22, 2025

Type of visit: POC

While at the facility for other reason, Licensing Program Analyst (LPA) Delmundo conducted proof of correction (POC) visit. LPA met with Mary 'Rose' Malekamu Mataele, administrator (ADM), and informed the purpose of visit. On 8/27/25, LPA issued a citation, deficiency section # 87355(e)(2), under case management visit with due date to submit POC by 8/28/25. On 9/02/25, LPA reminded ADM that the POC was overdue. Again, on 9/08/25, LPA reminded ADM that the POC is long overdue. A civil penalty is assessed on this day for failure to submit the POC. Civil penalty = $100.00/day x 13 days (8/29/25 to 9/10/25) = $1,300.00 The civil penalty was discussed with the ADM. Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, and copy of this report provided.the state’s words, verbatim · CDSS document, Sep 10, 2025

Type of visit: Case Management - Deficiencies

While at the facility conducting investigation of a complaint (Control # 15-AS-20250711090435) and upon meeting staff (S1) and review of names of employees fingerprinted and associated to the facility and conducting interviews, Licensing Program Analyst (LPA) Delmundo learned that a staff (S1) who has been working at the facility is not cleared and associated. This was discussed with Mary 'Rose' Malekamu Mataele, administrator (ADM). LPA asked for S1's file, and ADM stated S1 has no file. ADM only has a copy of correspondence from the Department's Care Provider Management Bureau dated March 7, 2025 indicating S1's case closure which is stored in ADM's cell phone. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $3,000.00 civil penalty is assessed for section 87355(e)(2) and $250.00 for section 87412(a) for repeat violations within 12 month period. Deficiencies, plan and proof of corrections and civil penalties were discussed with ADM. Exit interview conducted. Appeal Rights, LIC421FC and LIC421BG Civil Penalty Assessments, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Aug 27, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Aug 28, 2025

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required..... -This requirement is not met as evidenced by: -Based on record review and interviews, the licensee did not comply with section above in allowing S1 worked without exemption which posed an immediate risk to persons in care. This is a repeat violation. A citation was issued onthe state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Staff left while LPA was at the facility. Administrator stated she'll have the staff re-frigerprinted and request for exemption. Administrator not to allow the staff worked until exemption is approved. A $3,000.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: Sep 10, 2025

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: -This requirement is not met as evidenced by; -Based on interview, the licensee did not comply with the section in not having file/record for staff, S1, which poses a potential health, safety and/or personal rights risks to persons in care. This is a repeat violation. A citation was issued on 9/23/24.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Administrator to complete record and submit self-certification by 9/10/25. A $250.00 civil penalty is assessed.

Type of visit: POC

While at the facility for other reason, Licensing Program Analyst (LPA) Delmundo conducted proof of correction (POC) visit. LPA met with Mary 'Rose' Malekamu Mataele, administrator (ADM), and informed the purpose of visit. On 7/15/25, LPA issued a citation, deficiency section # 87309(a), under case management visit with due date to submit the POCs by 7/16/25. ADM submitted incomplete POCs. On this day, 7/24/25, LPA conducted inspection and observed the shovel still in the yard. A civil penalty is assessed on this day. On this same day, the shovel was locked. Civil penalty = $100.00/day x 8 days (7/17/25 to 7/24/25) = $800.00 The civil penalty were discussed with the ADM. Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, and copy of this report provided.the state’s words, verbatim · CDSS document, Jul 24, 2025

Type of visit: Case Management - Deficiencies

While at the facility conducting investigation of a complaint (Control # 15-AS-20250711090435) and upon review of names of employees fingerprinted and associated to the facility and conducting interviews, Licensing Program Analyst (LPA) Delmundo learned that a staff (S1) who has been working at the facility is not fingerprinted. This was discussed with Mary 'Rose' Malekamu Mataele, administrator (ADM). LPA also observed no Pre-placement Appraisal and LIC621 Client/Resident Personal Property And Valuables for residents. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $500.00 civil penalty is assessed and will continue for $100.00/day until corrected. Deficiencies and plan and proof of corrections were discussed with ADM. Exit interview conducted. Appeal Rights, LIC421BG Civil Penalty Assessment, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Jul 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Jul 25, 2025

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required.. .....by the Department... -This requirement is not met as evidenced by: -Based on record review and interviews, the licensee did not comply with section above in allowing S1 worked without fingerprint clearance which posed an immediate risk to persons in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: Administrator stated she'll have S1 fingerprinted. Proof to be submitted by 7/25/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Aug 7, 2025

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff....... -This requirement is not met as evidenced by: -Based on records review and interview, the licensee did not comply with the section for not having Pre-placement Appraisals and LIC621 for residents which pose a potential personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Jul 24, 2025

Plan of correction: Administrator stated she'll complete the documents. Copies to be submitted by 8/07/25.

Type of visit: Case Management - Health Checks

On this day, 7/15/25, at 11:4 Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management health and safety check as a result of a complaint (15-AS-20250711090435 ) received by the Department. LPA was granted entry by Teresa Casl, staff. LPA spoke over the phone with Mary 'Rose' Malekamu Mataele, administrator (ADM) and informed the reason for visit. ADM stated she can not come to the facility to meet with LPA and gave permission to Teresa Taal to be with LPA during inspection and to sign and receive this report. LPA toured the facility inside out with staff. LPA observed the following: -at 12:10 pm, hole in the kitchen door. -at 12:22 pm, shovels and hospital bed in the backyard and soiled mattress and foam in the side yard. -at 12:23 pm, the following in the side yard: pails of paints; unlocked storage with tools and cleaning agents (409; broken door; hospital beds headboards Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099Ds. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty, LPA called and left message on ADM's voicemail and informed of the deficiencies observed and plan of corrections. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to Teresa Caal.the state’s words, verbatim · CDSS document, Jul 15, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jul 16, 2025

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger residents.... -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above which posed an immediate health, safety and/or personal rights risks to persons in care: shovels; unlocked storage; pails of paintthe state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: Administrator to do the following and submit proof by 7/16/25: 1. Lock the items and submit pictures. 2. In-service the staff.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Jul 29, 2025

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. -This requirement is not met as evidenced by: -Based on observation, the licensee did not comply with the section above for the following in the yard: soiled mattress; foam; hospital bed and board; hole in the kitchen doorthe state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: Administrator to have the yard cleaned and repair the kitchen door. Pictures to be submitted by 729/25.

Type of visit: Case Management - Health Checks

On 05/15/25 at 1:15PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced Health and Safety check due to the department receiving a priority 2 complaint. During the health and safety check, LPA observed a total of 2 staff members and 4 residents at the facility. LPA toured facility with staff, including but not limited to bedrooms, kitchen, bathroom, and common areas. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date. No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 16, 2025

Allegation investigated: Personal rights x 1

On 06/05/25 at 5PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to amend the complaint delivered on 05/15/25. LPA explained the purpose of the visit with ADM. During investigation, LPA obtained the following documents from ADM: Resident roster, Staff roster (LIC 500), R1's admission agreement, Needs & Services Plan, Physician's report, centrally stored medication logs, incident reports. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Resident subjected to physical abuse while in care Investigation Finding: Unsubstantiated During investigation, LPA interviewed resident’s responsible party (POA), resident (R2), staff (ADM, S1) and reviewed resident’s (R1) documents. Review of R1’s admission agreement showed R1 was first admitted at the facility on 02/25/25. R1’s physician’s report dated 02/23/25 showed his primary diagnosis as acute exacerbation of COPD community acquired pneumonia with a secondary diagnosis of severe alcohol use disorder with alcohol intoxication. LPA interviewed S1 who stated that on 04/25/25 at around 7PM, he witnessed R1 drunk and was being verbally and physically aggressive towards another resident who is the grandmother of the licensee. S1 stated R1 moved his wheelchair aggressively towards R2, side swiping and breaking a bunch of side table decorations which caused bruising on his upper left arm. S1 stated R2 then kicked the kitchen half door with his leg punching a large hole in the middle. LPA interviewed R2 who stated she defended herself by striking him with a thin bamboo back scratcher on his shoulder. ADM stated staff called the police who arrived around 7:30PM, conducted a health check, interviewed residents (R1, R2) and did not file a report when they found out that R1 was drunk and was verbally and physically abusive towards another elderly resident who is the grandmother of the licensee. On 05/30/25 at 9:30AM, LPA interviewed R1’s responsible party (POA) who stated that on 05/14/25, R1 called 911 and was taken by ambulance to the hospital. He claimed physical abuse while in care and refused to go back to the facility. POA stated R1 was safely relocated to another elderly facility in Livermore on 05/19/25. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that resident was subjected to physical abuse while in care is unsubstantiated. No deficiencies cited. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, May 15, 2025 · control 15-AS-20250514133236

Type of visit: Required - 1 Year

On 09/23/24 at 11:00 am Licensing Program Analysts (LPA) J. Clancy-Czuleger arrived unannounced to do an annual inspection. LPA meet with Mary 'Rose' Malekamu/Administrator and explained the purpose of the visit. LPA inspected the facility inside out. There is no body of water. Physical plant is consistent with the facility sketch received by Central Application Bureau (CAB) and approved by the fire department. LPA inspected the living room, dining area, kitchen, bedrooms, hallways, bathrooms, side and backyards. Bedrooms were observed appropriately furnished with adequate lighting and drawers. Facility has sufficient towels, extra bed sheets and comforters. Equipment and supplies for residents' personal hygiene are available and on site. Dinner and silver wares were observed sufficient for residents' use. Food supplies checked and observed good for seven days of non-perishables. Facility was observed equipped with refrigerator, microwave, dishwasher, washer and dryer. Cabinet for knives, cleaning supplies, and central storage for medications were observed with locks. Activity supplies were available. Outdoor activity space was observed furnished with tables, chairs and shade. The facility has a mitigation plan. Fire extinguishers were observed fully charge and tags showed serviced 04/16/2024. At 12:02 pm LPA reviewed 4 residents records. At 12:45 pm, LPA reviewed 2 staff records and 2 of 2 were fingerprint cleared and associated to the facility. Continued on LIC809C... ...Continued from LIC 809 The following deficiency was observed during the visit: Chemicals in Laundry room and bathroom left unlocked Staff records are not complete R4 does not have admissions agreement in file Residents do not have Safeguard Property and Valuables form in files R1 and R2 need updated medical assessments No sign for oxygen tank The Facility was cited, and citations can be found on the LIC 809-D. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 23, 2024

Allegation investigated: -Staff do not provide meals to residents in a timely manner.

At 11:30 a.m. on this day, 5/09/24, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation and met with staff, Rey Usaraga. Mary 'Rose' Malekamu, admnistrator, arrived after several minutes. LPA informed the reason for visit. During the course of investigation, LPA reviewed resident records, and interviewed staff, residents and reporting party (RP). LPA also interviewed witness (W1) who is not related to any residents and staff and has visited the facility. It was alleged that the facility staff has guests regularly and residents wait until guests finish eating lunch before the resident are given meals. ..............continued next page (page 2) Substantiated RP stated that RP went to the facility in April 2024 and observed the residents were still in the middle at 1:30 pm. RP stated that one of the residents was upset because they are given lunch late, W1 stated that W1 was at the facility in April 2024, day other than the day RP was at the facility. W1 stated she was at the facility at 11:00 am and residents were not served lunch until the time she left at 2:00 pm. Based on information gathered. the preponderance of evidence has been met, therefore, the allegation is substantiated. Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. Failure to submit proof of correction by plan of correction due date and any repeat violation within 12 month period may result in civil penalty, Deficiency and plan and proof of correction were discussed with the administrator, Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided. LPA tried to reach FR several times but unsuccessful. LPA interviewed 3 residents and one of the 3 residents stated there's no issue on the restrooms. LPA was not able get information from the other 2 residents due to their medical condition/diagnosis. LPA also interviewed FM who stated the resident never brought to her attention any issue about the restroom. FM further stated that when she comes and visit, she's able to use the restroom. Allegation: Individuals in the home pose a risk to residents in care RP stated that resident (FR) brought to RP's attention that facility staff has guest regularly especially on weekends, and hang out on the lower level of the home until the late hours of the night socializing, and watching television loudly. Furthermore, the guests are staying overnight causing a disturbance to residents' sleep. One night, the resident was awoken by one of the guests entering the resident's room unannounced in the middle of the night. LPA tried to reach FR several times but unsuccessful. LPA interviewed 3 residents and one of the 3 residents stated not being bothered by the presence of the guests and no incident of staff's guest entering the resident's room. LPA was not able get information from the other 2 residents due to their medical condition/diagnosis. LPA also interviewed FM who stated the resident never brought to her attention any issue staff's guest entering the resident's room nor have observed staff's guests hanging out late at night. Based on information obtained, the allegations are closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, May 9, 2024 · control 15-AS-20240503132850

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: May 23, 2024

§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency ...... ........to meet their needs. -This requirement is not met as evidenced by: -Based on interviews, the licensee did not comply with the section above in not providing meals to residents in timely manner which poses a potential health and/or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: Administrator to in-service the staff and submit copy of training topic with attendees signatures by 5/23/24.

Type of visit: Case Management - Deficiencies

While at the facility investigating a complaint (Complaint Control # 15-AS-20240503132850) and upon observation and interview of staff and administrator's family member, Licensing Program Analyst (LPA) Delmundo learned the following: 1. Staff (S1 and S2) who works as reliever are fingerprint cleared but not associated to this facility. LPA interviewed administrator who stated she has not yet worked on the association of these 2 staff. 2. Administrator's family members (FM1 and FM2) who been staying in the facility are not fingerprinted. FM1 stated she comes and stay at the facility regularly. FM2 stated she's been staying here for about 2 months now. 3. FM1 stated she use the common area to sleep. LPA interviewed administrator who confirmed FM1 sleeps in the common area. Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. A $500 civil penalty for each, FM1 and FM2, is assessed and will continue for $100.00/day until corrected. Failure to submit proof of corrections by plan of correction due dates for the other 2 citations and any repeat violation within 12 month period may also result in civil penalties. Deficiencies and plan and proof of corrections were discussed with the administrator. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form, LIC421BC, and copy of this report provided.the state’s words, verbatim · CDSS document, May 9, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: May 10, 2024

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record ....exemption as required by the Department. -This requirement is not met as evidenced by: -Based on review of roster, checking of Guardian Portal and interviews, the licensee did not comply with the section in FM1 and FM2 not fingerprinted and cleared which pose an immediate safety risks to persons in care.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: Administrator to have FM1 and FM2 fingerprinted and submit proof by 5/10/24. A total of $1,000.00 civil penalty ($500 for each) is assessed on this day.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87355(e)(2) · Plan of correction due date: May 23, 2024

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance... -This requirement is not met as evidenced by: -Based on review of staff roster, checking of Guardian Portal and interviews, the licensee did not comply with the section above for not having S1 and S2 associated to this faciltiy which poses a potential safety and/or personal right risks to persons in care.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: Admiinistrator to have the staff assiociated and submit proof by 5./23/24.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(a) · Plan of correction due date: May 23, 2024

87307 Personal Accommodations and Services: (a) Living accommodations and grounds shall be related to the facility's function. 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 interviews, the licensee did not comply with the section above in FM1 sleeping in the common area of the facilty which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: Administrator to have the family member stop sleeping in the common area.

Type of visit: Case Management - Other

On 12/27/2023 at 3:20 PM, Licensing Program Analysts (LPA) P. Watson arrived unannounced to deliver amended report for visit conducted on 10/06/2023. LPA met with Caregiver, Rose Kioa and explained the purpose of the visit. Administrator is out of town and unable to sign report. Amended report was delivered to caregiver. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Dec 27, 2023

Allegation investigated: Staff did not ensure that resident’s bedrails were in place, resulting in resident sustaining a fall Staff dispensed incorrect medication to resident Staff did not ensure that resident took the medication that was dispensed to them

On 10/06/2023 at 12:10 PM, Licensing Program Analyst P Watson arrived unannounced deliver findings for the above allegations. Administrator arrived at1:00 PM. LPA met with Administrator, Mary Malekamu and explain the purpose of the visit During the course of the investigation the Department interviewed residents and staff and obtained documents. Documents including but not limited to: Staff roster with contact information, staff schedule for June and July, resident roster, resident care plans, resident progress notes, MARS and LIC 622 for June and July, and recent Physicians report. Report continues on 9099 C Unsubstantiated It was alleged that Staff did not ensure that resident’s bedrails were in place, resulting in resident sustaining a fall. Based on interview with resident (R1), he kept his bedrails up most of the time. Based on interview with home health nurse, when they would visit the resident, they observed R1 bedrails to be up. It was alleged that Staff dispensed incorrect medication to resident. Based on interviews with residents (R2, R3, R4 and R5), residents stated that they have had no issues with staff dispensing their medication incorrectly and/or not receiving their medication. R4 stated that facility staff knows what she needs and regulates her. Based on interview with R1, there was one incident where staff offered R1 the wrong medication, once R1 brought it to staff attention, they dispensed the correct medication to him. R1 stated that other than this one incident, all other medication has been dispensed with no issues. It was alleged that Staff did not ensure that resident took the medication that was dispensed to them. Based on interview with R1 home health nurse, they once observed medication on the floor in the resident’s room. Home health nurse asked resident about it and was informed that the medication was dropped by accident and staff gave them another pill to take. Based on interview with R1, there has been no issues with them not talking their medications. Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided. This is an amended report from 10/06/2023. It was alleged that Staff did not respond to resident’s calls for help after resident sustained a fall Based on interview with (R1), R1 went about 6-8 hours before they were helped back into bed. R1 was unable to reach their call button but verbally called out for help. Live-in Staff were unable to hear R1's verbal call. Once R1 was assisted back to bed he was okay. R1 stated they did not sustain any injuries. Based on LPA interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) is being cited on the attached LIC 9099D. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 6, 2023 · control 15-AS-20230808160115

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 7, 2023

87468.2(a)(4) (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall..(4)To care, supervision, and services that meet their individual needs ... Based on interview, the licensee did respond to R1's verbal call for help after they sustained a fall which poses/posed an immediate Health, Safety or Personal Rights risk to persons in carethe state’s words, verbatim · CDSS document, Oct 6, 2023

Plan of correction: Adminstrator will review regulation with staff and think of alternative methods that can be used for fall risk residents. Administrator will submit a self certification and list of alternatives to CCL by POC date