A Peaceful Home of Covina

Allegation investigated: Staff is not meeting residents’ diabetic needs. Staff is not meeting residents’ hygiene needs.

Licensing Program Analyst (LPA) Tao conducted unannounced complaint investigation for the allegations listed above today. During today’s visit, LPA met with Licensee, Thang Duong. LPA explained the purpose of today's visit regarding the above-mentioned allegations. Investigation consisted of the following: interviews of staff from staff #1 (S1) through staff #4 (S4); interviews of residents of resident#3 (R3), resident#4 (R4) and resident#6 (R6) and attempted to interview resident #1 (R1), resident #2 (R2) and resident #5 (R5), interviewed visitor#1 (V1); reviewed resident#1’s record reviews, and facility tour was conducted. LPA obtained copies of staff/resident rosters; and resident files for resident #1 (R1) with relevant information. (-continued in LIC 9099 C-) Unsubstantiated The investigation revealed that: In regard of the allegation, “staff is not meeting residents’ diabetic needs,” it was alleged that facility did not provide residents with proper dietary to meet their special dietary needs. The investigation revealed the following: interviewed with residents of R3, R4 and R6, residents interviews revealed that staff provided adequate diet for their dietary needs. LPA attempted to interview R1, R2 and R5, all attempts failed. Per staff interviews, all four (4) staff denied the allegation. LPA interviewed visitor #1 (V1), who was resident#1 (R1)’s family member and could not corroborate with the allegation. File review revealed residents’ special dietary needs was written on a sheet and posted on the refrigerator in the kitchen. Staff would follow instructions on that sheet when preparing residents’ meals. Thus, staff meets residents’ diabetic needs. In regard of the allegation, “staff is not meeting residents’ hygiene needs,” it was alleged that staff did not bath residents to meet their hygiene needs. The investigation revealed the following: interviewed with residents of R3, R4 and R6, residents interviews revealed that staff bathe residents at least twice a week. LPA attempted to interview R1, R2 and R5, all attempts failed. Per staff interviews, all four (4) staff denied the allegation. LPA interviewed visitor #1 (V1), who was resident#1 (R1)’s family member, and could not corroborate with the allegation. LPA toured the facility and observed residents looked clean. LPA was not aware of foul smell at the facility. Thus, staff meets residents’ hygiene needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore, the allegation is UNSUBSTANTIATED. No deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted with Licensee/ Administrator, Steven. A hard copy of this report was providedthe state’s words, verbatim · CDSS document, Aug 29, 2023 · control 28-AS-20230822154400

Allegation investigated: Residents in care have access to centrally store medications. Staff are unable to communicate with residents in care.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced complaint visit at the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Administrator Elizah Arganosa and explained the purpose for the visit. During today's visit, LPA Maldonado obtained a copy of the resident and staff roster, conducted a tour of the physical plant with Staff# 2 (S2) and obtained the following documents for Residents# 1-6 (R1-R6): Facesheet, Physcian's Report, Needs and Services Plan, and Special Incident Reports (SIRs) for July-August 2023. LPA also reviewed staff files for proof of completed training regarding Resident Personal Rights, Medication Administration, Centrally Stored Medications, and Continence Training. Interviews were conducted with S1-S3, attempted interviews with R1-R5. A telephonic interview with R6 was attempted due to resident being out of the facility, however LPA was unsuccessful.. The investigation revealed the following: (Report Continued on LIC9099-C...) Substantiated Regarding allegation: Residents in care have access to centrally store medications. It is alleged that resident's creams and ointments are being left in resident rooms, accessible to them. At 8:30AM, during the tour of the physical plant, LPA observed resident medication baskets filled with medications, left on top of the kitchen counter, along with other food items, while R3 was walking around the facility. LPA asked S2 why the medication was left out. S2 responded that due to deep cleaning of the kitchen cabinets, the medication was taken out and would be put back once completed. Staff continued to leave the medication out and unattended while S3 passed by several times sweeping and mopping the home. Shortly after, S1 arrived at the facility and sat at the kitchen counter in front of medication while speaking with S2, and the medication was still not put back. During the tour of resident bedrooms, LPA did not observe any medications, special creams, and/or ointments left accessible in their rooms. Per staff training records, training on Centrally Stored Medications was successfully completed on January, February March and August of 2023. Per interviews conducted with staff, (2) of (3) staff state that deep cleaning of the cabinets happens every other day and medications are usually left out that way. This allegation is Substantiated. Regarding allegation: Staff are unable to communicate with residents in care. It is alleged that residents are having trouble with speaking to care staff due to a language barrier and not understanding English well, causing issues to arise. During the interview conducted with S3, LPA Maldonado had to rephrase the questions being asked several times due to S2 speaking little English and not fully understanding the questions. During interviews conducted with staff, (3) of (3) denied the allegation and stated they had no issues communicating with residents due to language barriers. Per interviews conducted with residents, R2 corroborated the allegation, stating that it is hard to communicate with S2 because S2 does not understand much English. R2 stated that many times, R2 has to ask the same questions for S2 to understand what R2 is asking- however R2's needs are still being met. This allegation is Substantiated. Based on LPA's observations and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED. Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on the LIC9099-D. An exit interview was conducted with Administrator Elizah Arganosa and a copy of the report and appeal rights were provided. The investigation revealed the following: Regarding allegation: Resident sustained pressure injuries while in care due to lack of care and supervision. It is alleged that R3 was taken to the hospital due to bed sores. Per review of incident report dated 7/25/23, 911 was called on 7/20/23 due to R3 passing out, as R3 was eating less and drinking less fluids. At the time of the incident, R3 was being provided physical therapy and regular nurse checks by Home Health. Per interview with R1, R3 returned back to the facility on Hospice due to R3's declining health, with admission date of 8/03/23 and hospice care plan requires R3 to be repositioned every two hours. Per interviews conducted with staff, (3) of (3) staff stated that all bedridden residents are repositioned every (2) hours. Per hospice notes, on 8/11/23, 8/15/23 and 8/21/23, R3 did not receive any wound care. On 8/25/23, R3 was treated for four (4) stage 2 ulcers on the sacral/buttocks area. LPA attempted to interview R3, but was unable to due to R3's cognitive impairment. This allegation is Unsubstantiated. Regarding allegation: Staff do not ensure facility is kept clean. It is alleged that the facility is unclean and staff do not clean resident rooms regularly. Per interviews conducted with R1-R5, (3) of (5) residents denied the allegation and stated that staff clean daily by sweeping, moping, dusting, and washing resident personal items. Upon arrival, LPA observed S2 sweeping and moping the common areas and resident rooms, and S3 was cleaning the kitchen cabinets and dining room area. LPA inspected resident rooms and resident bathroom. They appeared to be clean, sanitary, organized, and free of hazards. (3) of (3) staff stated the facility is cleaned regularly on a daily basis and deep cleaning of the kitchen is done every other day. This allegation is unsubstantiated. Regarding allegation: Staff do not provide proper incontinence care to residents in care. It is alleged that R1 was neglected by staff and acquired a diaper rash while in care. Per staff interviews, (3) of (3) staff stated that residents who require incontinence care are checked on and changed every 2 hours or more frequently, if needed. LPA was unable to interview R1 due to R1 being in the hospital. LPA attempted to interview R1 telephonically at the hospital, however, LPA was informed by hospital staff that R1 is no longer there. (3) of (5) resident's interviewed denied the allegation and stated that staff assist them with changing and frequently check them for changing needs. This allegation is unsubstantiated. Regarding allegation: Residents are not provided proper food service. It is alleged that the facility is not serving residents healthy meals. During today's visit, LPA observed the facility food supplies and obtained a copy of the facility menu and resident's dietary restrictions. LPA observed a sufficient amount of food that meets Title 22 Regulation requirements of 2-day perishables and 7-day non-perishables for the amount of residents in care. (Report Continued on LIC9099-C...) There was a variety of nutritious foods available such as fresh fruits, vegetables, proteins, milk, and juices. The menu posted on the refrigerator reflected a variety of nutritious meals to be served and the resident's dietary restrictions was posted next to it to remind staff of resident's requirements/needs during meals. (3) of (5) residents interviewed denied the allegation and stated that they have no complaints about the food service. They are provided options when they ask and are given 3 meals a day with snacks in between. (3) of (3) staff interviewed stated they follow resident's special diets, provide them with 3 meals per day, give them options if they desire something different, and provide snacks between meals. This allegation is unsubstantiated. Regarding allegation: Residents are not provided proper medication assistance. It is alleged that staff are making medication errors. LPA reviewed resident medications and the MARs. It was determined that (6) of (6) residents medications are being administered as described and documented properly. (3) of (5) residents interviewed stated that staff assist them with administering their medications. (3) of (3) staff interviewed stated medications are given to residents daily as prescribed and denied any medication errors occurring. Per staff training certification, it was discovered that all staff have received proper medication administration training and resident's personal rights on medication refusal/acceptance. This allegation is Unsubstantiated. Regarding allegation: Objects that pose a risk to residents are accessible to residents in care. It is alleged that residents that there are harmful objects in residents rooms with dementia and psychosis. LPA Maldonado inspected resident rooms and did not observe any hazardous items accessible to residents in care. (3) of (5) residents denied the allegation and stated that all hazardous objects/materials are locked in different cabinets in the facility. (3) of (3) staff stated that all hazardous/toxic items including medications and ointments are kept locked and inaccessible to residents in care. LPA observed all sharps, medications, special ointments, and cleaning supplies/toxins to be stored in a locked drawer in the kitchen, in the garage which remains locked, and in a locked cabinet in the hallway- all inaccessible to residents in care. This allegation is unsubstantiated. Regarding allegation: Staff do not ensure resident's personal items are safeguarded. It is alleged that care staff are asking for things/money from residents. (3) of (5) residents denied the allegation and stated that staff are very professional and caring. R3 stated to have offered S2 a bracelet one time as a thank-you, however S2 did not accept it. (3) of (3) staff denied the allegation and stated staff are trained to not accept anything from residents for the care being provided. This allegation is Unsubstantiated. (Report continued on LIC9099-C...) Regarding allegation: Staff are not meeting residents need by abandoning their shift. It is alleged that care staff are abandoning their posts. Per interviews conducted (3) of (3) staff denied the allegation and stated that residents are never left unsupervised and their care needs are being met. Per S1, there are no issues with staffing, nor have there been at any time. Per the staff roster, there are currently (7) staff working at the facility, some on-call. Per S1, if any staff call off, they can call their on-call staff to cover shifts if needed. (3) of (5) residents interviewed, the allegation was denied and staff are always present at the facility to provided assistance and supervision. This allegation is Unsubstantiated. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. Per California Code of Regulations, Title 22, no deficiencies were observed or cited. An exit interview was conducted with Assistant Administrator Elizah Arganosa, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 25, 2023 · control 28-AS-20230821113631

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(2) · Plan of correction due date: Aug 26, 2023

87465 Incidental Medical and Dental Care (2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the...medication. This requirement was not met as evidenced by: Based on observations and interviews, the licensee failed to maintain centrally stored medication inaccessible to residents in care, as LPA observed the medications on top of the kitchen counter, which poses a immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 25, 2023

Plan of correction: Staff put medications away in their centrally stored cabinet under lock and key during the visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2 · Plan of correction due date: Sep 1, 2023

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (14)To reasonable accommodation of their individual... preferences in all aspects of life in the facility... This requirement was not met as evidenced by: Based on obsevation and interview, the licensee failed to have direct care staff who can speak and understand the same language as other residents who reside in the facility, which can pose a potential Health, Saftey, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 25, 2023

Plan of correction: Licensee will submit a written plan on how staff will continue to provide services and meet resident needs despite language barriers, to LPA via email by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cynthia Chan conducted the required annual inspection. LPA arrived unannounced and met with Staff, Kamaria Noor, who allowed entry. The purpose for the visit was explained. The facility is licensed for residents ages 60 and over. The fire clearance is approved for (5) non-ambulatory residents in rooms #1, 2, 4, and 5. Bedroom #3 is approved for (1) bedridden. There is a hospice waiver approved for 6 residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents and medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan posted by the entrance. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. There are currently 5 non-ambulatory residents residing at the facility. Bedroom #3 is the designated room for (1) bedridden resident only. The facility has the sufficient amount for liability insurance covering injury to residents and guest. Physical Plant & Environment Safety: There are no pool or bodies of water at the premises. There are 5 bedrooms, 2 bathrooms, living room, dining room, kitchen, and an attached garage. The garage has an additional room allotted for a live-in staff room. Facility has operable smoke and carbon monoxide combo detectors located in each room and hallway. Knives, cleaning solutions, and disinfectants are locked in the cabinets. No firearms or weapons are stored at the facility. LPA measured the hot water temperature in the bathrooms and kitchen sink. The hot water temperature in the bathrooms were measured between 126 -129 degrees F which are above the required range of 105-120 degrees. Staffing: There appears to be sufficient staffing at the facility. The administrator's (Thang Duong) certificate expires on 06/02/23. Staff employed are all over the age of 18. Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training and sufficient on-going training. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. Resident Rights-Information: The Complaint poster and Residents personal rights are posted by the main entry. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. Food Service: There are sufficient food supplies of 2-day perishable and a week of non-perishable items. The food are properly stored in the refrigerator to avoid cross contamination. Incidental Medical & Dental: The medications are centrally stored and in their original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. During the visit today, LPA reviewed all 5 residents' medication and did not observe the MAR to be completely filled out according to the date administered. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Residents with Special Health Needs: The facility accepts and retains residents with dementia and/or hospice. The staff received training on appropriately caring for residents with dementia, those on hospice, and receiving oxygen. No Smoking - Oxygen in use signs are posted on the doors of residents using oxygen. During the visit today, LPA observed some deficiencies and are indicated on the LIC809D. Technical advisories were also provided. An exit interview was held. A copy of this report, LIC809D, technical advisory notes, and appeal rights were given to Co-Administrator Elizah Arganosa.the state’s words, verbatim · CDSS document, Mar 6, 2023

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Staff mismanaged resident's medication.

Licensing Program Analyst (LPA) Cynthia Chan conducted an unannounced complaint investigation regarding the above allegation. LPA met with Administrator, Thang Duong, and explained the reason for the visit. The investigation consisted of the following: LPA obtained copies of the Staff & Resident rosters. LPA reviewed files and medications for 4residents. Interviews were conducted with the Administrator, 3 Staff, and 3 Residents. The investigation revealed the following: Regarding allegation, Staff mismanaged resident’s medication. It is alleged that the labels on the medications did not match the written instructions on the Medication Administration Record (MAR) log or had been altered, extra medication are given to the residents, and/or a resident is storing medication in the room. Substantiated During the visit today, LPA reviewed medication for 4 residents. There were discrepancies found on all 4 residents’ medications. LPA observed that 3 of the medications listed on Resident #1’s MAR log were missing. Residents #2, #3, and #4 all had an extra bottle of medication that was not listed on the MAR log. Staff could not provide the physician’s order for the extra medications found. Staff stated that residents are medication compliant. LPA interviewed 3 residents and all 3 stated they take their medications daily. In addition, LPA observed a clear container with 3-4 pills on a chair inside Resident #1's room at approximately 11am. When LPA inquired about the container of pills, staff replied the resident wanted to take the morning pills later. Resident #1's physician's report indicated that resident is not able to store own medication. Based on LPA observation, interviews conducted, and record review, 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 and Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted. The Plan of Corrections were reviewed and developed with Staff Elizah Arganosa. A copy of this report and appeal rights were provided. The residents interviewed stated they get 3 meals a day and snacks. Some stated they offer snacks but sometimes decline it. They have no concerns in regard to not getting fed enough. LPA observed sufficient amount of food for 4 residents. Regarding allegation, Staff failed to treat resident with dignity and respect. Administrator and staff stated they treat all residents with dignity and respect. The Administrator stated if he observes or hears a staff member mistreating a resident, he will terminate the staff immediately. Staff denied making inappropriate comments toward a resident or disrespecting them. They stated they receive training on personal rights and are aware of how they interact with residents. 2 out of the 3 residents interviewed feel that the staff are always helpful and respectful. 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. An exit interview was conducted with Staff Elizah Arganosa and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 12, 2023 · control 28-AS-20230103145542

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(4) · Plan of correction due date: Jan 13, 2023

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws.... This requirement is not met as evidenced by: Based on record review, all 4 residents' medication either had medications not written on the MAR log or the medication was not found which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: The licensee shall review medications for all residents and ensure that all medications ordered by the physician are maintained at the facility and written on the MAR log. The POC is due by 1/13/23.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jan 13, 2023

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision... This requirement is not met as evidenced by: Based on observation, Resident #1 had a clear container with 3-4 pills in the room which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jan 12, 2023

Plan of correction: The licensee shall ensure that no medications are kept in the residents' rooms and have an in-service training with staff to go over this subject matter. This POC is due by 1/13/23.

Allegation investigated: Facility did not follow resident's care plan. Resident developed gangrene while in care. Resident did not receive medication as prescribed by a physician.

***This report serves as an amendment and supersedes the original complaint investigation report created on 05/24/2022. The purpose of this amended Licensing report is to clarify findings. The findings remain unsubstantiated. *** Licensing Program Analyst (LPA) Tao, conducted an initial unannounced complaint investigation for the allegations listed above on 05/24/22. LPA was allowed entry by Donisio Cueto, staff, then, met with staff, Elizah Arganosa. Licensee, Steven Dong, joined the visit via phone call. LPA explained the purpose of the visit to staff and Licensee. Investigation consisted of the following: interviews of staff from Staff #1 (S1) through Staff #3 (S3); interviews of residents from Resident #1 (R1) through Resident#2 (R2); interview of resident#3's family member; and reviews of Resident#3’s record. LPA obtained copies of the staff and resident rosters; and resident#3 files with relevant information. The investigation revealed the following: (-Continued in LIC9099 C-) Unsubstantiated ***This report serves as an amendment and supersedes the original complaint investigation report created on 05/24/2022. *** In regard to allegation: “Facility did not follow resident's care plan," it was alleged that staff did not follow resident's care plan to take care of resident#3. Two (2) residents were interviewed. Two (2) out of two (2) residents could not corroborate the allegation which revealed that staff followed their care plan to provide care. LPA interviewed with staff from Staff#1 to Staff #3. They denied the allegation. Interviews revealed that staff followed residents' care plan. Review of residents' records revealed staff followed residents care plan to provide care. In regard to allegation: "Resident developed gangrene while in care," it was alleged that resident#3 developed gangrene while residing at the facility. Two (2) out of two (2) residents could not corroborate the allegation. Interview with resident#3 family member stated there was a wound on resident's right toe and no medical document to confirm the wound was a gangrene. Interviews staff from Staff#1 to Staff #3, staff denied the allegation. Review of residents' records revealed no medical record stated resident#3 developed gangrene when residing at the facility. Interviews and record reviews did not reveal resident#3 developed gangrene while in care. In regard to allegation: "Resident did not receive medication as prescribed by a physician," it is alleged that staff did not administer medication to resident#3 as physician prescribed. Two (2) out of two (2) residents could not corroborate the allegation. Interviews staff from Staff#1 to Staff #3, staff denied the allegation. Review of residents' records revealed staff administered medication as prescribed. Staff interview revealed that residents have right to accept or reject medication. Interviews and record reviews did not reveal staff failed to administer medication as physician prescribed to residents. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED. No deficiencies are being cited according to California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted with staff, Elizah; a hard copy of the report was provided on 5/24/22. This amended Licensing report is emailed to Licensee / Administrator, Steven Dong for signature on 6/15/22.the state’s words, verbatim · CDSS document, May 24, 2022 · control 28-AS-20220519103342

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Tao conducted an announced visit for pre-licensing follow up inspection. The applicant notified the department for visit since corrections were made. The initial pre-licensing visit was conducted on 01/22/2022. LPA met with applicant, Thang Duong, to discuss the purpose of today's visit and the inspection. During this visit, LPA observed the following corrections: - Medication cabinet is installed with a key lock. - Kitchen drawer containing sharp objects (knives, scissors and etc) is installed with a key lock. - Water heater closet is secured with a key lock - Cleaning supply, linen, and toxin closet on far end of hall is secured with a key lock. - Five bedrooms have a keyless lock doorknobs. - The dead-bolt on fire door leading to four resident bedrooms/bathroom has been removed. - Toxins and gardening tools in backyard are stored in garages and inaccessible to residents. - Sliding screen leaning on wall in the backyard is removed. - Auditory alarm device on sliding glass door leading to backyard is operable. - Sufficient supply of linen, bed sheets, blankets, pillows, and towels are observed. - Hot water temperature is measured at 110.1 degrees Fahrenheit. Component III was conducted with applicant during the initial visit on 1/22/22. No further corrections are needed. Exit interview held and copy of the report was provided.the state’s words, verbatim · CDSS document, Jan 18, 2022

Type of visit: Prelicensing

Licensing Program Analysts (LPAs) Hanna and Tao conducted an initial Pre-licensing visit and met with Applicant Thang Duong, Applicant secretary Janice Jabonero and House Manager Jeremias Jabonero who assisted with the walk-through. Per Thang, he will be the primary Administrator at the facility. This is an initial application applying for dementia program. A component III was conducted during the visit. There are currently 0 residents living in the facility. The fire clearance has been approved for 5 non ambulatory and 1 bedridden. All (5) bedrooms have been cleared for non-ambulatory clients and bedroom # 3 is cleared for bedridden. The physical plant was toured and the following was observed. This facility is located in a residential neighborhood, single story house, with (5) bedrooms, (1) bathrooms, living room, dining area, kitchen, and a car garage. The facility has (4) single rooms and (1) shared room for clients. There will be no live-in staff at the facility. Appliances in the kitchen such as dishwasher, microwave, stove and oven were observed to be clean and operational. The washer and dryer are located inside the garage. Living room has required furniture. Dining room has a table and (4) chairs and a bench for a total seating of (6). There is a fireplace located in the shared bedroom (#1) and observed to have gas disconnect with gas control removed. Resident rooms were observed to have the required furniture such as bed frames, dressers, chairs and sufficient closet space. Bedrooms also have the required bedding sheets. The bathrooms have operational showers, hand washing sinks and toilets. (Continued on a LIC 809-C) The smoke alarms and carbon monoxide detectors were tested and observed to operating properly. The facility has (2) fire extinguishers located in the kitchen/dining room. The facility has central air conditioning at a set temperature of 76 degrees. There is sufficient lighting throughout the home. There are no security bars on the windows. There were no obstructions observed on the premises. The home has all the required posters posted. Resident and staff files were not reviewed since there are no residents living in the facility. First aid is complete with manual. The backyard has a shaded patio area with patio furniture. LPAs observed corrections required: Interior: -Medication cabinet with no key lock. - Kitchen drawer containing sharp objects (knives, scissors and etc) with no key lock. - Water heater closet unsecured - Cleaning supply, linen, and toxin closet on far end of hall is unsecured. --> All areas listed above will need to be secured with a key lock. - 5 bedrooms have key lock doorknobs (Applicant will need to switch to keyless doorknobs) - Fire door leading to 4 resident bedrooms/bathroom has dead-bolt (applicant to remove dead-bolt) - Unsecured toxins and gardening tools found in backyard (Applicant to secure all items) - Sliding screen leaning on wall (install or replace) - No auditory alarm on sliding glass door leading to backyard - Insufficient supply of linen, bed sheets, blankets, pillows, and towels - Hot water temperature at 122 degrees Fahrenheit. Applicant shall submit pictures to LPA as proof of correction via email/fax by 01/05/2022. An exit interview was conducted with Applicant and copy was provided.the state’s words, verbatim · CDSS document, Dec 22, 2021

Type of visit: Office

COMP II by CAB successfully completed. Facility Type: RCFE Application Type: Initial Capacity: 6 (5 non-ambulatory and 1 bedridden) Census (if any clients in care): 0 COMP II Participants: Thang Duong, Licensee and Myrna Bugasto, Administrator Interview Method: Telephone interview On December 2, 2021 at 9:00 AM, Licensee and Administrator participated in COMP II via telephone with Analyst, Celia Phomphachanh from CAB. Identification of the Licensee and Administrator was verified by providing California Driver License number verbally. During COMP II, Licensee and Administrator confirmed the understanding of Title 22 and Health and Safety Codes. Component II was successfully completed. Licensee and Administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB Analyst confirmed Licensee and Administrator’s understanding of following areas: 1. Facility Operation: License type, client/resident populations, and program 2. Staff Qualifications and responsibilities 3. Applicant and Administrator Qualifications 4. Program Policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical Plant and Food Service 7. Application Document Review and Technical Assistance: Criminal Record Clearance, Health Screening, Fire Clearance, First Aid/CPR Certificate, Administrator Certificate, Financial Verification, Pre-licensing Inspection, Compliance History and Control of property. Interviewed concluded with Licensee and Administrator. LIC 809 will be sent via email PDF to Administrator.the state’s words, verbatim · CDSS document, Dec 2, 2021