Abundant Peace

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced on 10/01/2026 to conduct a case management visit. LPA Lee met with Administrator Filipe Waqa Naikaso and explained the purpose of the visit. The facility census was 5 residents. The purpose of today’s visit was to follow up on a LIC 624 Incident Report received by the Department on 09/28/2026. According to the incident report, on 09/28/2026, at 12:00 PM, Administrator Naikaso became aware that resident 1 (R1) was not present at the facility after conducting a search of the facility and the surrounding areas. Administrator Naikaso contacted law enforcement and filed a missing person report with local law enforcement. A review of R1's LIC 602, Physician's Report, dated 07/14/2026, documented that R1 is unable to leave the facility unsupervised and has wandering behavior. As of today 10/01/2026, R1 has not been located. Based on interview and information obtained during today's case management visit, the facility did not provide adequate care and supervision to ensure R1’s safety, resulting in R1 leaving the facility unsupervised and being reported as a missing person. This posed an immediate risk to the resident's health and safety. Therefore, a deficiency is being cited under California Code of Regulations, Title 22, Division 6, for lack of care and supervision. An immediate civil penalty of $500 was assessed on 10/01/2026. An exit interview was conducted with Administrator Naikaso. A copy of this LIC 809, LIC 809-D, LIC 421IM, and the Appeal Rights was provided to the Administrator Naikaso at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 1, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Oct 8, 2026

87464(f)(1) Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in This requirement is not met as evidenced by: Based on records review and interviews with Administrator Naikaso the facility did not provide care and supervision to residents in care resulting in residents leaving the facility unassisted and a missing person was filed with law enforcement. This poses an immediate health and safety and/or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 1, 2026

Plan of correction: The Licensee/Administrator will provide LPA Lee with the facility’s policies and procedures regarding resident elopement and conduct in-service training for facility staff on basic services, care and supervision, and elopement prevention and response. The Licensee/Administrator will submit the training sign-in sheet, resident elopement policies and procedures, and a statement of acknowledgment to LPA Lee by the Plan of Correction (POC) due date of 10/08/2026. Administrator stated that he will put an alarm on the courtyard side gate to alert if residents leave.

Allegation investigated: The facility allowed excluded individuals to work in the facility.

On 07/30/2026, Licensing Program Analyst (LPA) Pang Lee conducted an unannounced visit to the facility. LPA Lee met with Filipe Waqanaikaso and explained the purpose of the visit. The purpose of the visit was to deliver the findings related to the allegations above. At the time of the visit, the facility census was 6. It was alleged that the facility allowed excluded individuals to work at the facility. The investigation consisted of interviews with the Administrator Filipe Waqanaikaso and facility residents. During an interview, Administrator Waqanaikaso acknowledged that Excluded Individual 1 (E1) had been present at the facility approximately December and or January of 2025. The Administrator stated that E1 comes into the facility with another individual who Administrator was not familiar with and that E1 and the individuals would go through the resident’s file. Administrator Waqanaikaso also acknowledged that E2 comes to the facility to talk to E1 and then would leave the facility. CONTINUED LIC 9099-C Substantiated Administrator stated they were unaware that E1 and E2 were excluded from being in the facility. Moreover, three out of six residents interviewed reported seeing both E1 and E2 at the facility. Based on interviews conducted during the investigation, sufficient evidence was obtained to support the allegation that excluded individuals were permitted to be present in the facility. This was observed not in compliance with Title 22 regulation 87777(a) Exclusions as the facility did not ensure an excluded individual was not permitted to be present in the facility. As a result, this allegation is SUBSTANTIATED. The finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted, and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility. An immediate civil penalty of $500 was assessed during today's visit. In interviews with six out of six residents in care, all who stated that either the facility, family members or themselves take them to the clinic for their appointments and that the facility calls EMS if needed. On 02/17/2026, LPA Lee conducted a visit to the facility and collected LIC 602 Physician’s Reports for six residents. Based on the records reviewed, all Physician’s Reports contained physician signatures and were filled out and complete. On 03/18/2026, LPA Lee contacted the Licensed Medical Professionals who had completed the residents’ LIC 602 Physician’s Reports; however, they were unable to provide information or verify whether the records were forged or falsified. Based on the information obtained, there is insufficient evidence to substantiate the allegation that the facility is forging resident documents. It was alleged that the Administrator is not present at the facility for a sufficient amount of time. This investigation consisted of interviews with facility staff, residents, a review of facility records, and observations. Based on interview the Administrator denied the allegation and stated that their work schedule is consistent with the facility's LIC 500, Personnel Report. Additionally, interviews with six of six residents identified Administrator Filipe as the person in charge of the facility and stated that they’re at the facility “everyday” and “all week.” A review of the facility’s LIC 500 Personnel Report states that the Administrator is scheduled to work Saturday, Sunday and Monday from 9:00 a.m. to 5:00 p.m. The Department has conducted two facility visits since the change in Administrator on 10/29/2025 and during those two facility visit the Administrator was present. Based on interviews, records reviewed, and the Department's observations, there is insufficient evidence to support the allegation that the Facility Administrator is not present at the facility for a sufficient amount of time. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Jul 30, 2026 · control 27-AS-20260211151258

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87777(a) · Plan of correction due date: Aug 7, 2026

87777(a) Exclusions The Department may prohibit an individual from serving as a board of directors, executive director, or officer; being employed or allowed in a licensed facility as specified in Health and Safety Code Sections 1569.58 and 1569.59. This requirement was not met as evidenced by: The facility did not ensure excluded individuals (E1) and (E2) were prohibited from being at a licensed facility. (E1) and (E2) were observed at the facility on multiple occasions.the state’s words, verbatim · CDSS document, Jul 30, 2026

Plan of correction: Effective immediately, all excluded individuals are prohibited from entering or being present at the licensed facility. The Administrator stated that they will ensure no excluded individual is permitted to work, provide services, visit, or otherwise be present at the facility or have any contact with residents or staff. The Administrator will submit a written plan to CCLD outlining the procedures that will be implemented to ensure excluded individuals are not allowed to work, provide services, interact with residents or staff, or enter the facility in the future. An immediate civil penalty in the amount of $500 was assessed during today's visit

Allegation investigated: Staff do not provide care and supervision to resident resulting in resident being left on floor for extended periods of time. Staff do not seek medical attention to resident in a timely manner. Staff is mismanaging resident's medications.

On 10/23/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with care staff Atelaite Peti and explained the purpose of the visit. LPA Lee was later met by Assistant Administrator Vereas Taqasi. The purpose of this visit is to deliver complaint finding for the allegation above. A brief interview conducted with care staff Peti. and Assistant Administrator Taqasi. The current census is six residents with one staff. It was alleged that staff do not provide care and supervision to residents, resulting in residents being left on the floor for extended periods of time. The investigation included a review of records and interviews with staff, and residents in care. It was learned that Resident 1 (R1) had multiple incidents that led to hospital visits on 08/08/2025, 08/14/2025, 08/19/2025, 09/04/2025, and 09/11/2025. During interviews, three out of three staff members denied not providing care and supervision to residents that leaves residents on the floor for extended periods. CONTINUED LIC 9099-C Unsubstantiated Additionally, all six out of six residents interviewed reported that when R1 experiences a fall, facility staff does assist in helping R1 up. None of the residents expressed concerns regarding staff not providing care and supervision to residents. Furthermore, R1 denied the allegation, stating that when falls occur, staff respond and provide assistance, and R1 is not left on the floor for an extended period of time. Based on records review and interviews statement conducted during the investigation process LPA Lee was unable to corroborate the allegation. It was alleged that Staff do not seek medical attention to resident in a timely manner. The investigation included a review of records and interviews with staff and residents in care. The investigation revealed that on 09/15/2025, Resident 1 (R1) fell in the bathroom and hit their head on the toilet. During an interview, Staff 1 (S1) stated that they heard a noise, checked on R1, found R1 on the floor, and assisted R1 in getting up. In a separate interview, R1 confirmed that S1 assisted them after the fall and stated that they did not believe the incident was serious, therefore refusing medical treatment. Additionally, six out of six residents interviewed reported having no concerns regarding staff not seeking medical attention for residents in care in a timely manner. Based on records review and interviews statement conducted during the investigation process LPA Lee was unable to corroborate the allegation. It was alleged that staff is mismanaging residents’ medications. The investigation included a review of records, as well as interviews with staff, residents in care, and the resident’s responsible party. During facility visits conducted on 09/22/2025 and 10/21/2025, LPA Lee reviewed the medications on hand for Residents 1 through 3 (R1–R3), along with their Medication Administration Records (MARs). The review found that all medications were complete and accurate, with no discrepancies observed. Interviews were conducted with three staff members, all of whom denied the allegation of medication mismanagement. Additionally, all six out of six residents interviewed stated that staff are administering medications and that they have no concerns regarding medication management. An interview was also conducted with R1’s responsible party (RP), who confirmed they had no concerns regarding R1’s medications at the facility. RP clarified that their concerns were related to the hospital from which R1 was discharged. It was learned that following R1’s hospital visits on 09/04/2025, R1 was discharged with additional medications and those medications was not present at the facility; therefore Assistant Administrator Taquasi called R1's RP to question the 11 medications. CONTINUED LIC 9099-C Based on RP’s discussion with R1’s primary care physician (PCP), RP followed R1’s PCP order of not refilling R1’s medications until R1 and RP meet with R1’s PCP to go over R1’s medications. RP reiterated that they had no concerns regarding the facility’s medication management or pharmacy services and confirmed that the issue originated with the hospital discharge process. Based on records review and interviews statement conducted during the investigation process LPA Lee was unable to corroborate the allegation. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. An exit interview was conducted with care staff Peti, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 27-AS-20250918210117

Allegation investigated: Staff left resident in soiled clothing for an extended period of time

On 10/23/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with care staff Atelaite Peti and explained the purpose of the visit. LPA Lee was later met by Assistant Administrator Vereas Taqasi. The purpose of this visit is to deliver complaint finding for the allegation above. A brief interview conducted with care staff Peti. and Assistant Administrator Taqasi. The current census is six residents with one staff. It was alleged that facility staff left resident in soiled clothing for an extended period of time. The investigation included observations and interviews with staff, residents, the resident’s responsible party, and four outside agencies. Based on LPA Lee’s observations during facility visits on 08/05/2025, 09/22/2025, 10/14/2025, 10/21/2025, and during today’s visit no malodorous or incontinent odors were observed in the facility. LPA Lee interviewed three facility staff members who denied the allegation and stated that only resident 1 uses incontinence briefs and the rest of the resident doesn't wear incontience briefts. Interviews were also conducted with two family members of a resident, who confirmed the allegations. CONTINUED LIC 9099-C Unsubstantiated However, interviews with six out of six residents stated that staff are assisting residents with incontinence care and that they have no concerns regarding residents being left in soiled clothing. Additionally, three out of four outside agency representatives interviewed reported that they have not observed or detected any incontinence related odors during their visits to the facility. Based on observations and interviews statement conducted during the investigation process LPA Lee was unable to corroborate the allegation. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred. An exit interview was conducted with care staff Peti, and a copy of this report was provided to the facility. On 10/21/2025, LPA Lee met with an individual who identified himself as the Assistant Administrator, Veresa Taqaso which LPA Lee was not made aware that the facility had an Assistant Administrator nor have LPA Lee met the individual. Assistant Administrator Taqaso stated that he believed staff #1 (S1) was the facility’s Administrator; however, LPA Lee confirmed that S1 is not associated with the facility as the designated Administrator. Former Administrator Barbara Williams reported that she has not been to the facility since late July and was informed by the Licensee Murphy Grant that he would handle the responsibility for administrative duties. She also confirmed that she resigned as Administrator as of 10/16/2025. Moreover, LPA Lee was not aware that Former Administrator Williams had stopped performing administrator duties and responsibilities. Interviews with two family members of residents corroborated that, following LPA Lee’s visit on 08/05/2025, Administrator Williams has not been present at the facility. They noted that various staff have been coming to the facility since that time and are not sure who are the main caregivers to the facility. Six out of six residents interviewed stated that Administrator Williams has not been seen at the facility since late July and that different staff have been appearing on-site. Residents and family members expressed confusion and concerns about who the caregivers and management staff. Two outside agencies also confirmed that they have not met or communicated with an Administrator at the facility and have only interacted with care giving staff. During a telephone call with Licensee Grant on 09/22/2025, he stated that Administrator Barbara Williams would continue to serve as the facility’s administrator until a new administrator was hired. However, it was learned that Administrator Williams had not been present at the facility since LPA Lee’s visit on 08/05/2025. According to the facility’s LIC 500 Personnel Report dated 08/27/2025, Barbara Williams was listed as the designated administrator. The LIC 500 however, did not specify the days and hours that administrator Williams would be present at the facility. During LPA Lee’s visit on 10/21/2025, a newly posted LIC 500 dated 10/20/2025, was observed at the facility. This updated report listed Filipe Naikaso as the designated administrator, with the following schedule: Saturday from 9:00 a.m. to 5:00 p.m., Sunday from 9:00 a.m. to 5:00 p.m., and Monday from 5:00 p.m. to 9:00 p.m. On 10/02/2025, Licensee Grant emailed LPA Lee requesting to change the designated administrator and associate Naikaso in the role as the new administrator to the facility. However, on October 13, 2025, LPA Lee sent a follow-up email to Licensee Grant indicating that Filipe could not be associated as the new administrator until documentation of Filipe’s education or equivalent qualifications was received. CONTINUED LIC 9099-C As of today, LPA Lee has not received the required documentation verifying Filipe’s education or equivalent qualifications. Based on observation, records review and interviews statement conducted during the investigation process LPA Lee was able to corroborate the allegation. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with care staff Peti and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 27-AS-20251015132407

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Oct 24, 2025

87405(a) Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility… This was not met as evidence by: Based on interviews, observation and visits to the facility, the Administrator has not at facility. It was learned that administrator Barbara Williams has not been present at the facility since LPA Lee’s visit on 08/05/2025 and is not carrying out administrator duties. This posed a potential health and safety risk to residents.the state’s words, verbatim · CDSS document, Oct 23, 2025

Plan of correction: Licensee/facility agrees to appoint/assign an Administrator by 10/27/2025. Implement a temporary point of contact/Admin by10/24/2025. Admin documents and Temporary admin information should be emailed to LPA Lee by 10/24/2025 by 5:00 PM. A statement of reviewing and understanding the regulation cited will also be provided to LPA Lee by POC due date 10/27/2025 end of day.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced on 10/23/2025 to conduct a case management visit. LPA Lee met with care staff Atelaite Peti and explained the purpose of the visit. The census is six with one facility staff. LPA Lee was later met with Assistant Administrator Veresa Taqasi. The purpose of this visit is to follow up on deficiencies learned during complaint investigation control number 27-AS-20250918210117. The investigation revealed that Resident 1 (R1) experienced multiple incidents resulting in hospital visits on the following dates: 08/08/2025 (fall), 08/14/2025 (seizure disorder), 08/19/2025 (rib pain), 09/04/2025 (pericarditis), and 09/11/2025 (mood problems). A review of facility records and Community Care Licensing Division (CCLD) electronic facility files indicated that the facility did not report these incident to CCLD and R1's responsible party. LPA Lee also observed that the facility has an incident report binder. Based on a review of these incident records there were one incident report for the month of June, six for July, twelve for August, two for September, and five for October. Moreover, the LIC 624 incident reports did not indicate which agencies or individuals who was notified of the incidents. The facility was also unable to provide LPA Lee with documentation showing that some of these incidents had been reported to CCLD and residents’ responsible party. Furthermore, during interviews with two facility staff members, it was learned that they were unaware that, according to R1’s LIC 602 Physician’s Report, R1 requires supervision for safety during repositioning, transferring, and toileting as well as having a poor safety awareness such as unsafe wandering. In a separate interview, Staff 1 (S1) confirmed that during R1’s incident on 09/15/2025, in which R1 fell in the bathroom and hit their head on the toilet, S1 was not providing supervision at the time of the incident due to not being aware of R1’s needs per R1’s physician’s report. CONTINUED LIC 809-C During today’s visit, LPA Lee also observed that the broken tiles in the kitchen were repaired. Once LPA Lee received the rest of the POC cited on 10/21/2025 LPA Lee will clear the citations. The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the 809-D page. An exit interview was conducted with care staff Peti and a copy of the 809 report, 809-D page, and appeal rights were given to the facility.the state’s words, verbatim · CDSS document, Oct 23, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Oct 30, 2025

87464(d) Basic Services (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources. This was not met as evidence by: Based on interviews with two facility staff who both stated that they were not aware of R1 who need supervision for safety in regard to repositing, transferring and toileting needs as well as wondering behavior. This posed a potential health and safety risk to residents.the state’s words, verbatim · CDSS document, Oct 23, 2025

Plan of correction: Licensee/facility staff will review all residents in care LIC 602 Physician’s report to ensure understanding of all resident’s needs. An in-service training course for all staff in regard to basic services will be conducted. Documents used for training and staff sign-in sheets along with statement of reviewing and understanding the regulation cited will also be provided to LPA Lee by POC due date 10/30/2025 end of day.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(D) · Plan of correction due date: Oct 30, 2025

7211(a)(1)(D) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below… (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidence: Based on file reviewed, CCLD electronic facility files and interviews, the Licensee did not ensure to submit R1’s incident reports to CCLD. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Oct 23, 2025

Plan of correction: The licensee/staff agrees to conduct an in-service training course for all staff in regard to reporting requirements that will be conducted. Documents used for training and staff sign-in sheets along with statement of reviewing and understanding the regulation cited will also be provided to LPA Lee by POC due date 10/30/2025 end of day.

Type of visit: Required - 1 Year

On 10/21/2025, Licensing Program Analyst (LPA) Pang Lee conducted an unannounced annual inspection at the above-referenced facility to evaluate compliance with California Code of Regulations, Title 22. Upon arrival, LPA met with care staff Mereisi Naisausau and explained the purpose of the visit. LPA requested that the facility designated administrator (FDA) be contacted to notify the Community Care Licensing Division (CCLD) presence. Care staff stated she did not know who the current administrator was and reported that she had been scheduled to work at the facility by an individual named Charles (last name unknown). Approximately two hours later, Veresa Taqasi arrived and identified himself as the Assistant Administrator. He provided the staff files for Mereisi Naisausau and Luisa Biu. The census is 6 with 1 staff. The facility is a single-story building licensed to serve six non-ambulatory residents, with hospice waiver approval for two residents. LPA conducted an inspection of the physical plant, including the common areas, kitchen, dining area, resident bedrooms and bathrooms, laundry room, garage, and outdoor courtyards. The facility was observed to be clean and free of odor but was observed not in good repair due to broken tiles in the kitchen that posed a tripping hazard. There was no incontinence odors observed during the inspection. Resident bedrooms were properly furnished with appropriate bedding and adequate lighting. No bodies of water were present on the premises. The kitchen contained a sufficient supply of food, including a seven-day supply of non-perishable items and a two-day supply of perishable items. The hot water temperature measured in a resident bathroom sink was 113.4 degrees Fahrenheit, which is within the regulatory range of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mats in the bathrooms were stable and in good condition. CONTINUED LIC 809-C Smoke and carbon monoxide detectors were operational and compliant with fire safety regulations. A fire extinguisher located in the common area was last serviced on 05/12/2025. The facility thermostat was observed to be set at 72 degrees Fahrenheit. A public telephone was located in the kitchen. During the garage inspection, the door was found to be unlocked, and multiple toxic substances were accessible to residents. These included multipurpose cleaner, tire shine spray, five paint cans, two toilet bowl cleaners, a Comet deodorizing cleanser, and a super oxygen bathroom cleaner. Sharp knives were properly stored and locked away, making them inaccessible to residents. Medication storage was found to be unlocked and accessible to residents, which is not in compliance with regulations. LPA reviewed medication for 3 of the 6 residents along with their Medication Administration Records (MAR), and the documentation was completed. The first aid kit was checked and found to contain the required components. LPA reviewed all 6 resident files, which were complete and up to date. 3 staff files were reviewed and found to be complete. A review of criminal record clearances indicated that all facility staff and individuals requiring caregiver background checks were fingerprint cleared and associated with the facility. During the visit, LPA addressed concerns regarding the facility’s administrator. Assistant Administrator Taqasi stated that Filipe Naikas is the new administrator; however, LPA was unable to verify Filipe Naikas as an administrator associated with the facility in CCLD records. It was learned that Administrator Barbara Williams had not been present at the facility following an incident related to complaint control number 27-AS-20250731120824 and a case management visit dated 08/ 05/ 2025. This matter is currently under follow-up as part of complaint control number 27-AS-20251015132407. LPA also informed Assistant Administrator Taqasi that the facility’s annual fees were due and provided the PIN number for payment. The following documents will be emailed to LPA by 10/31/2025 at the end of day 5:00 PM: (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (4) LIC 610 Current Emergency Disaster Plan (5) Proof of Current Liability Insurance (6) LIC 500 Current Personnel Report CONTINUED LIC 809-C During today’s visit it was brought to LPA Lee’s attention that there were no staff on site on 10/20/2025 at approximately 5:00 PM. Based on interviews with residents in care, facility staff and residents family it is unclear whether staff were in the facility or not. Statements from residents, staff and residents’ families are contradictory. As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with Assistant Administrator Veresa Taqasi, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Oct 21, 2025

Allegation investigated: Staff did not assist resident in a timely manner.

On August 05, 2025, Licensing Program Analyst (LPA) Pang Lee and Ombudsman Byron Toliver conducted an unannounced visit to initiate and conclude the investigation into the complaint allegation noted above. Upon arrival, LPA Lee and Ombudsman Toliver met with direct care staff Emi Kanaimuri and explained the purpose of the visit. LPA Lee requested that care staff Kanaimuri contact the Facility's Designated Administrator (FDA), Barbara Hall Williams. A brief phone interview was conducted with FDA Williams, who arrived at the facility approximately an hour later to participate in the visit. The facility census was six residents with 1 staff member present. It was alleged that staff did not assist a resident in a timely manner. The investigation included interviews with FDA Williams and multiple residents. During an interview, FDA Williams admitted she did not provide timely assistance to Resident 1 (R1). CONTINUED LIC 9099-C Substantiated She stated that on July 10, 2025, at approximately 10:46 PM, she left the facility and returned around 11:56 PM. Upon her return, R1 and other residents informed her that R1 had fallen and was unable to get up. Further investigation revealed that no other care staff were present during this time, leaving the residents unsupervised. As a result, no staff were available to call emergency services. Resident 2 (R2) called EMT, who arrived (exact time unknown) and assisted R1 back into bed. Interviews with six out of six residents confirmed that staff were not present during the incident and that R2 had to call EMT for assistance. Based on observations and statements gathered during the investigation, the LPA was able to corroborate the allegation. Due to this investigation, the Department finds the allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with FDA Williams and a copy of the LIC 9099 report, LIC 9099-D, and appeal rights were given to the facility.the state’s words, verbatim · CDSS document, Aug 5, 2025 · control 27-AS-20250731120824

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Aug 12, 2025

87465(a)(1) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility... (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on interviews conducted, Administrator Williams did not assist Resident 1 (R1) in a timely manner after R1 experienced a fall and was unable to get up.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: The Administrator has agreed to conduct an in-service training on Incidental Medical and Dental Care. As part of the Plan of Correction (POC), the Administrator will provide LPA Lee with the following documentation: Training materials used during the session, a sign-in sheet listing all staff members who attended the training and a written statement of acknowledgment confirming administrator have read and understood the cited regulation. The completed POC is due to LPA Lee by August 12, 2025, no later than 5:00 PM.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced on 08/05/2025, to conduct a case management visit. LPA Lee met with Facility’s Designated Administrator (FDA) Barbara Hall Williams and explained the purpose of the visit. The purpose of this visit was to follow up on deficiencies identified during complaint investigation control # 27-AS-20250731120824. During the investigation, it was discovered through an interview with FDA Williams that she had provided false or misleading information regarding an incident on July 10, 2025, involving Resident 1 (R1), who had experienced a fall. Initially, FDA Williams stated she had gone for a walk lasting approximately five minutes and returned to the facility upon seeing EMTs on-site, with whom she stated that she had spoken to. However, when LPA Lee and Ombudsman Byron Toliver questioned the timeline of the incident, FDA Williams admitted to providing a false statement. She then corrected her account, stating that she had left the facility at approximately 10:46 PM and returned around 11:56 PM, resulting in a period of approximately 1 hour and 10 minutes during which no care staff were present. Upon her return, FDA Williams was informed by R1 and other residents that R1 had fallen and had been unable to get up. Further investigation revealed that no staff were available to provide assistance or contact emergency services during this time. Resident 2 (R2) then called EMT, who responded (exact arrival time unknown) and assisted R1 back into bed. Additionally, it was determined through interviews and a review of records that this incident was not reported to the Community Care Licensing Division or to R1’s responsible party (RP), as required. Upon request to review R1’s file, FDA Williams was unable to produce any documentation for R1. CONTINUED LIC 809-C During the visit, R1’s responsible party (RP) arrived at the facility, and FDA Williams attempted to work with RP to complete the necessary facility documents for R1. Per R1’s Responsible Party (RP), the RP will take the licensing documents to complete the paperwork. The RP also stated that they will request assistance from R1’s social workers in completing the documents and will return a copy to the facility once completed. Moreover, FDA Williams acknowledged that her husband (DW) regularly visits the facility about six time and they will sit outside to eat despite knowing that DW is not being associated with the facility. An immediate $500.00 civil penalty was assessed on August 05, 2025; based on interview, the administrator did not provide care and supervision in violation of California Code of Regulations Section 87464(f)(1). A $600.00 civil penalty was assessed on August 05, 2025, based on interview, the administrator did not adhere to personnel requirements/background association of DM who comes to the facility six times in violation of California Code of Regulations Section 87355(e). The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the LIC 809- D page. An exit interview was conducted with FDA Williams and a copy of the LIC 809 report, LIC 809-D page, and appeal rights were given to FDA Williams.the state’s words, verbatim · CDSS document, Aug 5, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Aug 12, 2025

87464(f)(1) 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 interviews, the licensee did not ensure care and supervision needs were provided on July 10, 2025, when the administrator left the facility resulted in absence of care and supervision for longer than 1 hour 10 minutes. This poses/posed an immediate health and safety risks to residents in carethe state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: License/Administrator to submit a written care plan on how the facility will provide adequate care and supervision for residents in care. Licensee/Administrator will also conduct in-service training on basic services and provide training documents used, and staff sign in sheet. A statement of acknowledgement of reading and understanding the regulation cited will also be provided to LPA Lee. The facility shall submit the care plan and statement to Licensing by POC due date of 08/12/2025 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e) · Plan of correction due date: Aug 12, 2025

87355(e) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to the Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by: Based on interviews and records reviews, the licensee/administrator did not ensure that the administrator’s husband (DW) is associated with the facility prior to visiting the facility on multiple occasions.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: The License/Administrator will conduct in-service training on criminal record clearance and association and provide training documents used, and staff sign in sheet. Administrator/Licensee will also provide a statement of acknowledgement of reading and understanding the regulation cited will also be provided to LPA Lee. The facility shall submit R1’s complete file for LPA Lee to review once completed and a statement to Licensing by POC due date of 08/12/2025 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87207 · Plan of correction due date: Aug 19, 2025

87207 False Claims No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by: Based on interviews, the administrator provided false statements to LPA Lee and Ombudsman Toliver. This poses/posed a potential health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: License/Administrator will provide a statement of acknowledgement of reading and understanding the regulation cited by POC due date of 08/19/2025 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(d)(2) · Plan of correction due date: Aug 19, 2025

87405(d)(2) Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by: Based on interviews and records reviews the administrator did not conform to title 22 regulations when administrator left residents in care unsupervised, incidents reports are not reported to CCLD and responsible party, providing false statement and allowing an individual at the facility without being associated to the facility. This poses/posed a potential health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: License/Administrator will provide a statement of acknowledgement of reading and understanding the regulation cited by POC due date of 08/19/2025 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 19, 2025

87211(a) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified… (D) Any incident which threatens the welfare, safety or health of any resident… This requirement is not met as evidenced by: Based on interviews and records reviews, the licensee/administrator is not reporting incident reports to CCLD. This poses/posed a potential health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: The License/Administrator will conduct in-service training on reporting requirements and provide training documents used, and staff sign in sheet. Administrator/Licensee will also provide a statement of acknowledgement of reading and understanding the regulation cited will also be provided to LPA Lee. The facility shall submit statement to Licensing by POC due date of 08/19/2025 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(d) · Plan of correction due date: Aug 19, 2025

87506(d) Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by: Based on interviews and records reviews, the licensee/administrator did not ensure that R1 has a complete file on site for LPA Lee and Ombudsman Toliver to review. This poses/posed a potential health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: The License/Administrator will conduct in-service training on resident records and provide training documents used, and staff sign in sheet. Administrator/Licensee will also provide a statement of acknowledgement of reading and understanding the regulation cited will also be provided to LPA Lee. The facility shall submit R1’s complete file for LPA Lee to review once completed and a statement to Licensing by POC due date of 08/19/2025 end of day 5:00 PM.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Michael Hood arrived at the facility and met with Administrator, Barbara Hall Williams, to conduct a case management following the relocation of residents from another care home to Abundant Peace. LPA met with residents R1, R2, R3, and R4 to observe the well-being of the residents. Interviews with R1, R2, R3, and R4 indicated that they feel comfortable at the care home and are treated well by facility staff. Resident (R5) could not be interviewed as they were at the hospital during visit. LPA observed the care home to be clean and in good repair. LPA checked the kitchen area for the ability to prepare and store food. Care home has required two (2) day perishable and seven (7) day non-perishable food supply on cite. LPA reviewed resident records for R1, R2, R3, R4, and R5 and observed updated assessments on file. LPA observed that resident (R3) had assessment completed after admission. Sacramento North Regional Office gave permission to facility to admit residents prior to obtaining medical assessment due to need for relocation. As a result of today's inspection, no deficiencies are being cited. Exit interview was conducted and a copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Jul 17, 2025

Type of visit: Case Management - Health Checks

On 06/13/25, Licensing Program Analysts (LPAs) Pang Lee and Shakaricka Hughes arrived at Abundant Peace for the purpose of conducting a case management inspection to address deficiencies observed on 11/26/24 and on 05/16/25 during a health and safety visit to ensure compliance prior to accepting any residents in care. LPAs met with administrator Barbara Williams who assisted with today’s visit. LPAs conducted a case management inspection to ensure there are no health and safety concerns. The facility is a single-story building licensed to serve six (6) non-ambulatory residents and approved for 2 hospices wavier. LPAs conducted an inspection of the physical plant, including but not limited to the common areas, kitchen, dining area, resident bedrooms and bathrooms, laundry room, garage and outdoor courtyards, to ensure compliance with Title 22 regulations. The facility was observed to be clean and odor-free. The facility was in good repair. Resident bedrooms were properly furnished with appropriate bedding and adequate lighting. The facility has sufficient supply of food, including a seven-day supply of non-perishable and a two-day supply of perishable items. Grab bars and non-slip mats in the bathrooms were secure and in good condition. Smoke and carbon monoxide detectors were found to be operational and in compliance with fire safety requirements. The following deficiencies that were observed on 11/26/24 and 05/16/25 has been corrected: • The facility shall be in good repair. Exposed wires made inaccessible to residents. • The Licensee removed the dried vegetation, branches and weeds. Continued LIC 809-C • The required documents were posted: Administrator's Certificate, facility sketch, the Local Ombudsman poster, CCLD complaint poster. • Ramps in patio deck was extended to prevent tripping hazards. Side rails was sturdy. • Facility now has telephone services for residents in care. • Various activities were observed made accessible to residents in care. • All sheds are locked at this time. • Garage was de-cluttered; however, the facility still has miscellaneous items garage. Per administrator Barbara residents will not have access to the garage and that the garage will be locked at all times. As a result of this case management, the facility is in compliance with Title 22 Regulation and may now accept residents for care. An exit interview was conducted with administrator Barbara and a copy of the LIC 809 report were provided to the facility.the state’s words, verbatim · CDSS document, Jun 13, 2025

Type of visit: Case Management - Health Checks

On 05/16/25, Licensing Program Analyst (LPA) Pang Lee arrived at Abundant Peace for the purpose of conducting a Case Management Inspection to address deficiencies observed on 11/26/24 during an annual inspection to ensure compliance prior to accepting any residents in care. LPA Lee met with care staff Barbara Williams who assisted with today’s visit. LPA conducted a case management inspection to ensure there are no health and safety concerns. The facility is a single-story building licensed to serve six (6) non-ambulatory residents and approved for 2 hospices wavier. LPA Lee conducted an inspection of the physical plant, including but not limited to the common areas, kitchen, dining area, resident bedrooms and bathrooms, laundry room, garage and outdoor courtyards, to ensure compliance with Title 22 regulations. The facility was observed to be clean and odor-free. The facility was not in good repair. LPA Lee observed exposure wires in the common area on both side of the television. Resident bedrooms were properly furnished with appropriate bedding and adequate lighting. No bodies of water were observed on the premises. During the kitchen tour, LPA Lee observed a sufficient supply of food, including a seven-day supply of non-perishable and a two-day supply of perishable items. The hot water temperature in the resident bathroom sink measured 111.2°F, which falls within the regulatory range of 105°F to 120°F. Grab bars and non-slip mats in the bathrooms were secure and in good condition. Smoke and carbon monoxide detectors were found to be operational and in compliance with fire safety requirements. The facility's fire extinguisher, located in the common area and was last serviced on 05/02/25. Two public telephone was observed in the common area and in the kitchen; however, there are no services. Required documents and posting were visibly displayed; however, PUB 475 needs to be in the size of 20” x 26". Continued LIC 809-C The facility thermostat was set to 69°F at the time of the inspection. Toxic cleaning agents were stored underneath the kitchen cabinet inaccessible to residents. Sharp knives were observed secured in a locked kitchen cabinet. The first aid kit was inspected and contained all required supplies. The facility has a designated lock area for residents Medications, residents and facility staff files. One staff file was reviewed and complete. Based on LPA’s walk through of the facility it was observed that one of the resident’s bedroom was switched with the staff room and did not aligned with the submitted facility sketch to the department. A review of staff records confirmed that all individuals requiring background checks were fingerprint cleared and associated with the facility. LPA Lee inspected the courtyard and observed the health and safety concerns. Ramps that were put in placed in the patio were observed not sturdy and a tripping hazard. The following dependencies that were observed on 11/26/24 has not been corrected: • The facility shall be in good repair. Exposed wires made accessible to residents. • The Licensee shall remove the dried vegetation, branches and weeds. • The following shall be posted and visible to residents in care: The Administrator's Certificate, facility sketch, the Local Ombudsman poster, CCLD complaint poster. • Ramps in patio deck needs to be extended to prevent tripping hazards. Side rails need to be sturdy. • Residents needs to have access to telephone • The licenses will ensure that there are various activities made accessible to residents in care. • Ensure all sheds are locked at all times. • Garage will be de-cluttered and ensure all potential hazard are locked. As a result of this case management, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with caregiver Barbara and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, May 16, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(d)(4) · Plan of correction due date: May 23, 2025

87307(d)(4) Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. This requirement is not met as evidenced by: PA Lee observed ramps that were put in place in the patio were not sturdy and a tripping hazards. This posed an immediate risk to residents in care.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: Licensee will ensure that the there are no tripping hazards, side rails will be added to the patio for safety of the residents and fence are to be sturdy. POC will be clear by visit. POC due by 05/23/25 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87311 · Plan of correction due date: May 23, 2025

87311 Telephones All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility. This requirement is not met as evidenced by: LPA Lee observe telephone on the premises does not have services. This posed an immediate risk to residents in care.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: Licensee will ensure to have telephone services on the premises. POC will be cleared by visit. POC due by 05/23/25 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87212(c) · Plan of correction due date: May 23, 2025

87212(c) Emergency Disaster Plan (c) Emergency exiting plans and telephone numbers shall be posted. This requirement is not met as evidenced by: LPA Lee did not observe an emergency telephone number posted in the facility. This posed a potential risk to residents in care.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: Licensee will post emergency telephone numbers in the facility and made visible. Licensee will send LPA Lee pictures of the emergency telephone numbers being posted by 05/23/25 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: May 23, 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: LPA Lee observed exposed wires in the common area by the television. This posed a potential risk to residents in care.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: Licensee will remove the exposed wires for the safety of the residents in care. POC will be cleared by visit. POC due by 05/23/25 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87208(a)(7)(A) · Plan of correction due date: May 23, 2025

87208 Plan of Operation The licensee shall have and maintain a current, written definitive plan of operation for the facility… (7) Sketches, showing dimensions, of the following: (A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for nonambulatory residents… This requirement is not met as evidenced by: LPA Lee observed that one of the resident’s bedrooms was switched with the staff room based on observation and facility sketch that was submitted to the department. This posed a potential risk to residents in care.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: Licensee will ensure that the submitted facility sketch is maintained and accurate at all times. Licensee will review the submitted facility sketch and ensure that residents and staff room are switched and accurate. POC will be cleared by visit. POC due by 05/23/25 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87219(i) · Plan of correction due date: May 23, 2025

87219(i) Planned Activities (a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include This requirement is not met as evidenced by: LPA Lee did not observe multiple activities, equipment and supplies for residents. LPA Lee only observed books and a guitar. This posed a potential risk to residents in care.the state’s words, verbatim · CDSS document, May 16, 2025

Plan of correction: Licensee will ensure that there are multiple activities and equipment made available to residents in care. POC will be cleared by visit. POC due by 05/23/25 end of day 5:00 PM.

Type of visit: Required - 1 Year

On 11/26/2024, Licensing Program Analysts (LPAs) Pang Lee and Holly Williams arrived unannounced to this facility to conduct an annual visit. LPAs met with care staff Marvin Tibbits. LPAs asked care staff to call Licensee Murphy Gant to informed that CCLD is present in the home. A brief interview was conducted via telephone with licensee Murphy who stated that he is not able to join the visit and that care staff Marvin can assist and sign the report. The administrator to this facility is Staci Barnes who has an expired administrator certificate. LPAs informed licensee that the facility needs a current and active administrator. It was learned that there are currently no residents residing at the facility at this time. LPAs toured the facility and observed multiple health and safety concerns. These concerns must be addressed, and licensing must be contacted for an additional inspection prior to the admittance of any residents. If licensing is not informed, and the inspection is not completed prior to admitting any residents into care, Administrative Actions may be taken. The following were addressed to the licensee Gant: • No residents will be accepted unless the Department has been notified prior to admission. • A mandatory reinspection must take place prior to accepting any residents • Licensee will remain available to the Department for contact by phone or email. • Facility must have a current administrator. The following was observed and addressed with the licensee to be corrected: • All toxins shall be locked and inaccessible to residents in care. • All sharp objects shall be locked and inaccessible to residents in care. • All resident accommodation should include the required furniture: chest of drawers, bed, night stand, lamp/lighting sufficient for reading, and a chair. [809 continued on 809-C] •The facility shall be in good repair and all debris and other discarded items shall be removed from the facility's property. • The Licensee shall remove the dried vegetation, and weeds. • The following shall be posted and visible to residents in care: The Administrator's Certificate, facility sketch, the Local Ombudsman poster, CCLD complaint poster. • The Licensee shall repair/replace any missing window screens or screens that are not fitted. • 2 days perishable and 7 days nonperishable shall be at the facility at all times. • Ramps needs to be installed for the patio deck, front door, and back door. • Licensee will ensure a telephone service is always on the premises. • The licensee will ensure that personal records are maintained on all facility staff and available upon request. • The licenses will ensure that there are activities made accessible to residents in care. • Ensure all sheds are locked at all times. • Garage will be decluttered and ensure all potential hazard are locked. No deficiencies being cited during today's annual visit, an exit interview was conducted, and a copy of this report was provided to the facility at the end of this visit.the state’s words, verbatim · CDSS document, Nov 26, 2024

Type of visit: Post Licensing

An unannounced annual inspection was completed by Licensing Program Analyst (LPA) Pang Lee on 11/16/2023. LPA identified herself and the purpose of the visit to the licensee friend, Marvin Tibbitts and a brief interview followed with both Marvin and licensee Murphy Grant (via telephone). Administrator was not present during today's visit. The census at the time was 0. The following Technical Assistance was provided during today's inspection. These concerns must be addressed, and Licensing must be contacted for an additional inspection prior to the admittance of any residents. If Licensing is not informed, and the inspection is not completed prior to admitting any residents into care, Administrative Actions may be taken. · All toxins shall be locked and inaccessible to residents in care. · All sharp objects shall be locked and inaccessible to residents in care. · All resident accommodation should include the required furniture: chest of drawers, bed, night stand, lamp/lighting sufficient for reading, and a chair. · The facility shall be in good repair and all debris, broken appliances, furniture, medical equipment, bins, trash, suitcases, and other discarded items shall be removed from the facility's property. Broken tiles in the entry need to be repair or replace. · The Licensee shall remove the dried vegetation, and weeds. · The following shall be posted and visible to residents in care: The Administrator's Certificate, the Emergency/Disaster Plan with facility sketch, the Local Ombudsman poster, and the poster of Resident Rights. ·The Licensee shall repair/replace any missing window screens or screens with holes. · The licensee shall repair/replace the emergency exit gate that is not in good condition. · The licensee shall ensure that the emergency gate is not lock at all times. · All food items in the refrigerator, freezer, and pantry will be inspected and all expired items shall be disposed. Going forward, any food item once opened shall be dated appropriately as will any leftovers. · There shall be a designated space for personal items, for example, a change of clothes, handbags, coats, meals, medications, etc. Personal items shall not be stored in multiple bedrooms, drawers, or closets. · Fire extinguishers need to be inspected annually. Last inspection date was 05/01/2021. · There is light appropriate for the use of each room and sufficient to ensure the comfort and safety of all people in the facility. Resident bedroom #4 bathroom light is not in good repair. The light does not turn on. · Resident bathrooms shall have non-skid mats at all times. · The license will ensure residents room is not used for other individuals sleeping purposes. · Licensee will ensure stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless · well lighted. · Licensee will ensure a telephone service is always on the premises. · The licensee will ensure that personal records are maintained on the licensee, and administrator available upon request. Facility did not have a designated place for files. · The licenses will ensure that there at activities made accessible to residents in care. · The licensee will ensure that an emergency and disaster plan, evacuation procedures and facility sketch, emergency exiting plans and emergency contact information is posted in the facility. There were no citations given today. A copy of this report was provided to the Licensee. Exit interview.the state’s words, verbatim · CDSS document, Nov 16, 2023

The state marks this report as 17 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.