Active Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nune Margaryan conducted an Annual Required visit and inspection of the facility. LPA met with Ebele Nnaji. Licensee was contacted over the phone. LPA explained the purpose of the visit. During the visit, the CARE tool was used. The facility is licensed to serve five (5) ambulatory residents and one (1) bedridden resident. Hospice waiver granted for 6 clients. At the time of visit resident was in the Day Program. The facility is a single-story home, located in a residential area, that consists of a living room, dining area, (4) resident bedrooms, (2) bathrooms, a kitchen, staff room, attached garage. LPA toured the facility. All indoor and outdoor passageways were free of obstruction. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. The kitchen was inspected. LPA observed all kitchen equipment to be clean and in working condition. LPA observed sufficient supply of perishable and non-perishable foods. Additional food supplies observed in the garage. Appliances such as a microwave, refrigerator and stove were observed to be clean and operating properly. Sharps are locked and inaccessible to residents. Cleaning supplies, sprays were observed unlocked under the kitchen sink and accessible to residents. A locked storage area in the garage for cleaning solutions and disinfectants was observed. Laundry area observed in the garage. Fire extinguisher was observed in the kitchen, and it is fully charged. Carbon monoxide / Smoke detectors were observed throughout the facility and were tested and operable. The common areas (dining room, living room) are clean and were properly furnished. Resident rooms were sanitary and had the required furniture and furnishings. There is closet space for clothing and other belongings. Extra clean linen was observed in the bedrooms. Continue 809C The resident bathrooms are clean and operational w/grab bars and non-skid surface/mats in place. The hot water temperature was tested in the bathrooms and reading was shows 120.3 degree F, 122.5 degree F. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. Last fire drill was conducted on 04/05/26. LPA reviewed resident and staff files and observed that all files are updated. LPA confirmed staff working have fingerprint clearances. LPA reviewed resident medications. Medications are documented properly and given as prescribed. Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided.the state’s words, verbatim · CDSS document, May 4, 2026

Type of visit: Case Management - Other

On 11/20/2025, Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Case Management Incident visit regarding the unexpected death of client#1 (C1) on 11/17/2025. LPA Ramirez was greeted by Awele Obuly and explained the purpose of the visit. LPA Ramirez toured facility and conducted wellness inspection. On 11/18/2025, LPA Ramirez received an Incident Report regarding the unexpected death of C1 at the facility. According to Facility/Program Special Incident Report (SGPRC 641), on 11/17/2025 at 5:40 am, staff entered C1’s room and observed that C1 was not snoring as C1 normally did. Staff called out C1’s name and did not observe C1 respond. Staff called out C1’s name several times again and C1 did not respond. Staff called 911 and began CPR until paramedics arrived. Paramedics arrived within 8 minutes and took over life saving measures. At 6:10am, paramedics pronounced C1 deceased. West Covina police officer Salgado (Badge# 510) arrived to observe C1’s body and called C1’s family. At 11:40am, C1’s body was picked up by local funeral home. LPA Ramirez requested a copy of C1's Death Certificate. LPA Ramirez obtained copies of C1’s face sheet, Death Report (LIC 624A), Medical Progress Notes from Central City Community Health Center dated 10/21/2025 and 08/19/2025, medical lab results dated 07/29/25, 08/19/25, centrally stored medications and destruction log, and medications administration record for 11/2025, 10/2025, 09/2025, and 08/2025 Individual Program Plan (IPP), and physician’s report. LPA Ramirez may return later to gather additional documents regarding this visit. No deficiencies were observed during this visit. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 20, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Nune Margaryan conducted an Annual Required visit and inspection of the facility. LPA met with Keisha Bailey. Licensee was contacted over the phone. LPA explained the purpose of the visit. During the visit, the CARE tool was used. The facility is licensed to serve five (5) ambulatory residents and one (1) bedridden resident. Hospice waiver granted for 6 clients. At the time of visit 2 residents were in the Day Program and 1 resident was at the Hospital / SNF. The facility is a single-story home, located in a residential area, that consists of a living room, dining area, (4) resident bedrooms, (2) bathrooms, a kitchen, staff room, attached garage. LPA toured the facility. All indoor and outdoor passageways were free of obstruction. The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded seating area for the residents located in the backyard. The kitchen was inspected. LPA observed all kitchen equipment to be clean and in working condition. LPA observed sufficient supply of perishable and non-perishable foods. Additional food supplies observed in the garage. Appliances such as a microwave, refrigerator and stove were observed to be clean and operating properly. Sharps are locked and inaccessible to residents. A locked storage area in the garage for cleaning solutions and disinfectants was observed. Laundry area observed in the garage. Fire extinguisher was observed in the kitchen, and it is fully charged. Carbon monoxide / Smoke detectors were observed throughout the facility and were tested and operable. The common areas (dining room, living room) are clean and were properly furnished. Resident rooms were sanitary and had the required furniture and furnishings. There is closet space for clothing and other belongings. Extra clean linen was observed in the bedrooms. Continue 809C The resident bathrooms are clean and operational w/grab bars and non-skid surface/mats in place. The hot water temperature was tested and maintained within the required range of 105-120*F. The first aid kit was observed and found to be in compliance with the Title 22 Regulations. Last emergency/ fire drill was conducted on 01/25/25. LPA reviewed clients and staff files. LPA confirmed staff working have fingerprint clearances. LPA reviewed clients medications. Medications are documented properly and given as prescribed. No deficiency was observed during today's visit. Exit interview was conducted and a copy of report was provided.the state’s words, verbatim · CDSS document, Mar 25, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Nune Margaryan conducted an announced pre-licensing visit using CARE Tool. LPA met with Licensee Joseph Jose and Operational Manager Daniel Adebisi and explained the reason for the visit. This Pre-Licensing Inspection is due to a change of ownership. The facility has an approved fire clearance to be licensed to serve five (5) ambulatory residents and one (1) bedridden resident. Hospice waiver granted for 6 clients. The facility is a single-story home, located in a residential area, that consists of a living room, dining area, (4) resident bedrooms, (2) bathrooms, a kitchen, staff room, attached garage, and shaded patio with seating in the back yard. Laundry area observed in the garage. A locked storage area for central storage of medications was observed in the dining area. A locked storage area in the garage for cleaning solutions and disinfectants was observed. Fire extinguisher was observed in the kitchen, and it is fully charged. Carbon monoxide / Smoke detectors were observed throughout the facility and were tested and operable. Doors, exits, hallways, and passageways were clear and free of obstruction. The front and back yards were observed to be clean and free of debris. No pools or bodies of water were observed in or around the home. Grab bars and non-skid mats were observed in the bathrooms. There are no firearms present at the facility. The first-aid kit was observed and is kept in the medication cabinet which included all required supplies. Appliances such as a microwave, refrigerator and stove were observed to be clean and operating properly. Adequate food supply is stored in the kitchen and consists of the following: 2-day perishables, and 7-day non-perishables. Additional food supplies observed in the garage. Sharps and cleaning solutions are kept locked in a kitchen cabinet and in the garage. Continue 809C The water temperature was tested in both bathrooms and measured at 114.1 degrees F and 114.7 degrees F, which is within the required 105-120 degrees F. Residents bedrooms have all required furniture, lighting, and bedding. There is closet space for clothing and other belongings. Extra clean linen was observed in the bedrooms. Staff and client files are maintained locked in a cabinet located in the dining room area. LPA conducted the Component III with the licensee. The Pre-licensing is complete, and the facility has no deficiencies. Exit interview conducted and a copy of this report was provided to Licensee. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.the state’s words, verbatim · CDSS document, Mar 18, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Change of Ownership (CHOW) Capacity: 6 Census (if any clients in care): 6 COMP II Participants: Jose, Joseph - Applicant; Morris, Melanie - Administrator Interview Method: Telephone interview On 01/29/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jan 29, 2024