Ageway Boarding Care #2

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds--including detached storage shed--for this 6 bed RCFE, consisting of 5 client bedrooms, full bathroom, 4 half bathrooms, shower room, kitchen, living and dining rooms, recreation room and staff bedroom. There are no accessible bodies of water or fire safety hazards observed. Hot water temperature is tested at 111 degrees in full bathroom. Food supply and first-aid kit are inspected, and hygiene items for general use are maintained. Client files are reviewed, An Emergency Disaster Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, and staff have current first-aid training. Mihael Dayeh (x11/26) and Grace Tolentino (x 8/26) are certified RCFE administrators that oversee facility operations. There are 3 clients receiving hospice services. The following information or forms are requested to be completed and returned to CCL by 11/4//25: • LIC 309 Administrative Organization (with current terms) • LIC 500 Personnel Report • Proof of control of property • Proof of current liability insurance Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages.the state’s words, verbatim · CDSS document, Oct 21, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: Oct 21, 2025

PERSONAL ACCOMMODATIONS/SVCS All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met, as unclosed padlock is observed on metal gate on east side of house, which connects backyard to street. Licensee failed to ensure that side passageway is unobstructed, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: Padlock was removed in LPA's presence, and shall not be reinstalled, to ensure that side passageways are at all times unobstructed. Deficiency corrected and cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87633(b)(1-7) · Plan of correction due date: Oct 21, 2025

HOSPICE CARE A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include...specific information. This requirement is not met, as there is no current hospice care plan for client #3. Licensee failed to ensure that hospice care plans are maintained for all residents receiving hospice services, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: Current hospice care plan for client #3 is provided during LPA's visit. Deficiency corrected and cleared

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(h)(1) · Plan of correction due date: Nov 4, 2025

REAPPRAISALS The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every12 months, either in person or by video appointment. Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. This requirement is not met, as MD report for client #3 is dated in 2023. Licensee failed to ensure that annual MD assessment report is maintained, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Oct 21, 2025

Plan of correction: Plan of correction to be sent to CCLD BY DUE DATE, which may include updated signed MD report/assessment

Type of visit: Case Management - Annual Continuation

LPA Jeung reviewed staff records to complete annual inspection of 10/10/24. There are 3 certified RCFE administrators associated to facility with active status, per CCLD Administrator Certification Unit. Copy of complete and signed lease agreement is requested to be sent to CCLD within TEN days. No deficiencies of the California Code of Regulations, Title 22 are observed.the state’s words, verbatim · CDSS document, Mar 5, 2025

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds--including detached storage shed--for this 6 bed RCFE, consisting of 5 client bedrooms, full bathroom, 5 half bathrooms, shower room, kitchen, living and dining rooms, and recreation room. There are no accessible bodies of water or fire safety hazards observed. Hot water temperature is tested at 112 degrees in full bathroom. Food supply, signal system, and first-aid kit are inspected, and hygiene items for general use are maintained. Client files are reviewed, An Emergency Disaster Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Staff records and medications will be reviewed at a later date, due to time constraints. Ana Dayeh, Mihael Dayeh (x11/24), and Grace Tolentino are certified RCFE administrators that oversee facility operations. There are 2 clients receiving hospice services. The following forms are requested to be completed and returned to CCL by 10/17/24: • LIC 308 Designation of Administrative Responsibility • LIC 309 Administrative Organization • LIC 500 Personnel Report • Facility Sketch (including dimensions) • Proof of control of property • LIC 610E Emergency Disaster Plan (9 pages, with signed and dated page 9) • LIC 9282 Infection Control Plan (page 5 signed and dated) Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. See also Technical Advisory Notes--2 pages.the state’s words, verbatim · CDSS document, Oct 10, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Oct 11, 2024

POSTURAL SUPPORTS Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met, as client #4 has full bed rails, and there is no hospice care plan. Licensee failed to ensure that hospice care plan is maintained and includes full bed rails, which poses an immediate health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Full bed rails for client #4 must be removed unless the hospice care plan is maintained and includes full bed rails. Plan/proof of correction to be faxed to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87633(b) · Plan of correction due date: Oct 17, 2024

HOSPICE CARE OF TERMINALLY ILL A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include specific information. This requirement is not met, as hospice care plans for 2 out of 2 residents receiving hospice care are not maintained. This poses a potential health, safety or personal rights risk to clients in care. Clients #3 and #4 are receiving hospice services, but hospice care plans are not maintained.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Hospice care plans for clients #3 and #4 will be sent to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Oct 17, 2024

CARE OF PERSONS WITH DEMENTIA Each resident with dementia shall have an annual medical assessment... and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met, as appraisals or Needs and Services Plans for 2 out of 5 clients are not current, which poses a potential health, safety or personal rights risk to clients in care. Clients #2 and #3 are diagnosed with dementia, but reappraisals are dated more than 12 months ago.the state’s words, verbatim · CDSS document, Oct 10, 2024

Plan of correction: Appraisals for clients #2 and #3 will be updated, signed and dated, and copies sent to CCLD BY DUE DATE.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 12/17/23 at 10:30am to conduct a Required -1 Year visit. LPA met with Grace Tolentino and stated the purpose of the visit. Grace Tolentino, administrator certificate expires 8/8/24. LPA was allowed entry into the facility that is licensed to serve 6 non-ambulatory residents of which 3 may receive hospice care services. There are 2 receiving hospice care services during this visit. Annual Fees are current. The facility staff roster provided during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. The temperature inside the facility was observed to be at 76 *F which is within the required range of 68-85*F. The hot water temperature was measured at 114.3*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), pull alarm system, smoke and carbon monoxide detectors in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. LPA observed the food supply and storage requirements of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days on the premises. LPA observed the knives and chemicals to be locked. The facility has wall heaters and a wall air conditioner. LPA observed residents engaged in individual activities during this visit. Grace Tolentino contacted Administrator Ana Dayeh regarding todays visit and inquired about the infection control plan. Ana Dayeh inquired if LPA is asking for the LIC9282. LPA did not observe an Infection Control Plan in the facility during this visit. However, at 12:55pm, Ana Dayeh provided the completed Infection Control Plan to Grace via email to print out for the facility records. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and antiseptic solution. LPA observed 2 staff, 2 resident files and conducted interviews during this visit. LPA reviewed regulations regarding food, Infection Control Plan, Staff and Resident files, and Care Tool. Upon a file review the following items were discussed to be submitted with any changes annually: Any addendums to Infection Control Plan (LIC9282), Designation of Facility Responsibility (LIC308), Control of Property, Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, Emergency Disaster Plan (LIC610E), Liability Insurance. Per CCR-Title 22, Div.6, Ch. 8, no deficiencies cited. Exit interview conducted, copy of report given.the state’s words, verbatim · CDSS document, Dec 17, 2023