Aging in the Bay 3

Type of visit: Required - 1 Year

At approximately 10:45am, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by staff. Charmaine Mendaros, Administrator was contacted via telephone and gave permission to begin inspection without them. Administrator arrived at facility at approximately 1:00pm. Facility is a Residential Care Facility for the Elderly (RCFE) with five (5) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for four (4), is approved for five non-ambulatory residents and three (3) bedridden residents, and is vendored with the North Bay Regional Center (NBRC). At approximately 11:30am, LPA initiated a tour of the facility with staff and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. LPA observed egress devices activated on all facility doors. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were observed unlocked. Staff locked the cabinets and secured items immediately and agreed to maintain compliance moving forward. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a shaded seating area in the backyard with outdoor space for activities. Continued on LIC809-C... Continued from LIC809C... LPA inspected a locked storage shed in the backyard which contained care equipment. LPA observed residents watching TV in their bedrooms and in the facility's common area. Facility has internet service and administrator agrees to purchase an internet access device which will be designated for resident use. The telephone was tested and was operational during inspection. Smoke and carbon monoxide detectors were tested and operational during inspection. Fire extinguisher was observed fully charged and was last inspected 11/2024. Emergency Disaster Plan was reviewed and updated 10/2023. Facility conducts quarterly disaster drills with the most recent drill conducted 07/2025. At approximately 12:30pm, LPA conducted file review of three (3) staff and three (3) resident files. Three (3) of three (3) staff files reviewed contained all the required documents, proof of training and proof of current First Aid and CPR certifications. Three (3) of three (3) resident files reviewed contained all the required documentation. Administrator states that residents' families coordinate medical and dental appointments as well as transportation to a from these appointments, but facility assists with coordinating them as needed and has resources available for transportation if needed. Medications and medication records were inspected and the logs were observed maintained in compliance with regulation. Administrator understands that facility shall submit an affidavit and surety bond to the Department for any P&I resources the facility manages for residents. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: LIC400 - Affidavit Regarding Client/Resident Cash Resources Surety Bond Emergency Disaster Plan (updated) Exit interview conducted with Administrator whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 4, 2025

Type of visit: Required - 1 Year

At approximately 9:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced to conduct a Required-1 Year inspection. LPA met with Administrator Charmaine Mendaros and explained the purpose of the visit. Administrator certificate is current. LPA toured the facility to ensure the health and safety of residents in care. Areas toured include but are not limited to resident rooms, common areas, bathrooms, kitchen, storage areas and back yard. In the areas toured no immediate health, safety, or personal rights violations were observed. Staff and resident files were reviewed. First Aid/CPR certification was current. The common areas, bathrooms and kitchen were clean and in good repair. All bedrooms had required furniture, bedding, and lighting. Cooking/dining equipment and utensils were present. Food appears to be stored and prepared properly. Facility has required seven-day non-perishable and two day perishable supply of food. Medication is locked and not accessible. The facility was observed to be at a comfortable temperature. First aid kit fully stocked and ready for emergency use. Fire extinguishers were fully charged. Smoke detectors are all operational. Carbon Monoxide Detector was present. Fire sprinklers were throughout the building. All employees requiring background checks are cleared. No pools/bodies of water are on the premises. Facility has been conducting drills every 3 months. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Lease Agreement Evidence of Liability Insurance No deficiencies were observed in the areas inspected, No citations were issued during today’s visit.the state’s words, verbatim · CDSS document, Aug 16, 2024

Allegation investigated: Staff did not provide medical attention to resident’s pressure sore. Staff did not administer resident’s medication as prescribed. Staff not assisting resident in a timely manner. Staff does not provide bell within reaching distance for resident. Staff does not provide a comfortable environment for resident.

At approximately 9:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with caregiver Angelina Manabat, toured the facility and reviewed records. Administrator Charmaine Mendaros arrived a short time later. Based on records reviewed and interviews conducted, Resident, R1, moved into this facility from the Hospital and was under the care of Solano Hospice. Based on hospice care plan and interviews conducted, a hospice aide came to the facility daily to care for R1's wound. LPA reviewed medication records and observed facility utilizes a medication administration record, MAR, and the form indicated medications were given as ordered. R1 resided in the facility for approximately seven days and based on care plan and assessment, was able to communicate their needs. There was no indication resident was not assisted in a timely manner. Continued on LIC9099-C... Unsubstantiated Based on interviews conducted, LPA was not able to verify whether resident call bell was within reach. Facility procedures are to place bell next to bed within reach. LPA observed facility to be at a comfortable temperature at each visit. LPA toured the building and observed residents had the required accommodations. LPA did not observe anything in the facility that would make for an uncomfortable environment. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.the state’s words, verbatim · CDSS document, Apr 22, 2024 · control 21-AS-20240103123250

Allegation investigated: FIRE CLEARANCE VIOLATIONS

Licensing Program Analyst (LPA) Alviso conducted a complaint visit, on 11/16/23 at approximately 11:00am, and met with caregivers Angelina Manabat, and Romeo Manabat. Caregiver Angelina contacted the Administrator and notified them that the LPA was at the facility. The Licensee/Administrator Charmaine Mendaros spoke with the LPA, stating they were in a training, and not able to come to the facility. The Department obtained iinformation of the facility having serious fire clearance violations; The Department was provided fire clearance inspection documentation of 11/9/23, including pictures of the observed violations. The facility had a flip latch, and a hasp staple on the front door from the inside, these are fire clearance violations per fire code. The hallway door/fire door was observed to be held all the way open against the living room wall by the living room couch, this hallway door must be kept closed at all times, this is a fire clearance violation. Licensee is aware the hallway door is to remain closed at all times, due to choosing to not install a fire door that closes automatically if there's a fire. Continued on LIC9099C... Substantiated LPA arrived to the facility today, 11/16, and observed the hallway door all the way open, held against the the wall by the living room couch. This is a fire clearance violation, per fire inspection report of 11/9/23. LPA obtained pictures. Based on LPA review of fire inspection on 11/9/23, obtained photos, interviews with staff, and LPA's observations on 11/16, the investigation has revealed that the allegation of "FIRE CLEARANCE VIOLATIONS" is substantiated. Due to the substantiation of the allegation, a citation, 87203 Fire Safety- All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic, this will be cited today. Deficiency on LIC9099D. This deficiency citation will have an immediate civil penalty fine assessed today, in the amount of $500, see LIC421IM. The preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited. Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed. Appeal Rights left, with written report, for the Administrator Charmaine Mendaros. Exit interview conducted with caregiver Angelina Manabat, and left voice message of report findings to Licensee/Administrator Charmaine Mendaros.the state’s words, verbatim · CDSS document, Nov 16, 2023 · control 21-AS-20231109110436

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Nov 17, 2023

87203 Fire Safety-All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by: Based on LPA review of fire inspection on 11/9/23, obtained photos showing a flip latch, a hasp staple on the inside of the front door, and the hallway door being held open by the living room couch, including LPA observing on 11/16, the couch holding the hallway door open against the wall. All the above are fire clearance violations. This is an immediate risk to Health and Safety of residents in care. CP Fine assessed in te amount of $500, see LIC421IM.the state’s words, verbatim · CDSS document, Nov 16, 2023

Plan of correction: The facility to immediately ensure the hallway door is kept closed at all times to ensure the facility is in compliance with their fire clearance. Licensee to submit a written plan of how the facility will maintain compliance at all times with the fire clearance approved by the Local Fire Department. Licensee to ensure no other locks are installed on the front door, and that the hallway door is kept closed at all times as required by fire code. Fire Department is requesting that a fire door be installed that will close automatically if there's a fire. Pease notify Licensing if you are installing a fire door, you may add this as part of your corection plan, POC due by 11/17/23.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alviso conducted a Required- 1 Year visit, on 10/2/23 at approximately 10:20am, and met with caregivers Angelina Manabat, and Romeo Manabat. Caregiver Angelina contacted the Administrator and notified them that the LPA was at the facility. The Administrator Charmaine Mendaros arrived within an hour of being notified that the LPA was at the facility. Facility has an infection control plan as required. Facility has an emergency and disaster plan as required. The facility does have emergency food and supplies to meet the "72 hour shelter in place" requirements. Fire clearance is approved for one (1) ambulatory, and five (5) non-ambulatory, of which three (3) may be bedridden; 1 bedridden in room #5, 2 bedridden in room #4, 1 non-ambulatory in room #2, 1 non-ambulatory in room #3, and 1 ambulatory in room #1. Fire extinguisher expires soon, one(1) scheduled to be serviced and tagged this Thursday,10/5/23. Facility was found to be clean, orderly,and at a comfortable temperature with all exits free from obstruction. Hot water was checked at 117.F which is within regulation. Medications were stored and locked making them inaccessible to residents. All toxins and cleaners were stored in locked cabinets, and inaccessible to residents in care. There was a sufficient supply of hygiene products, cleaning supplies, and paper products for use as needed. All bathrooms had grab bars, and non-slip mat/flooring for bathing/showering as needed. Facility has a sufficient supply of personal protective equipment(PPE) for use as needed. LPA observed sufficient supply of food, perishable and non-perishable. The LPA reviewed five (5) resident files. LPA reviewed five(5) of five(5) staff files. All five (5) staff have criminal record clearance as required. Per record reviews, three (3) staff are associated as required. Continued on LIC809C LPA is requesting the following documents be updated and submitted by 11/2/2023: LIC308 - Designation of Administrator Responsibility LIC500 - Personnel Report LIC610E-Emergency Disaster Plan (ensure to provide all information in all boxes as required) Copy of LIC400 Handling of Client Cash Resources, complete form and submit Copy of Surety Bond (if handling resident cash) Copy of Current Liability Insurance Copy of current Administrator Certificate Per LPA's file reviews, staff lack current First Aid, S2, S3, and S4. This deficiency will be cited, Personal Requirements-General 87411(c )1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross, see LIC809D. Per LPA's file reviews, direct care staff lack current CPR certification as required, S2, S3, S4, and S5. This deficiency will be cited, H&S 1569.618(c)(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR, see LIC809D. Per LPA's file reviews, staff S4, and S5 are not associated to the facility as required. This deficiency will be cited, Criminal Record Clearance 87355(e)(3) Request a transfer of a criminal record clearance as specified in Section 87355(c), see LIC809D. Per LPA's file review, staff, S2, S3, S4, & S5, files were found to be incomplete. This deficiency will be cited, Personnel Records 87412(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain all required records, see LIC809D. Continued on LIC809C... Per LPA's file review, staff, S2, S3, S4, and S5, have proof of required 40/20 hrs of required annual training. This deficiency will be cited, H&S 1569.625(b)(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training initially, and 20 hours annually, see LIC09D. Per LPA's review of files, staff S2, S3, S4, and S5 lack medication training as required, his deficiency will be cited, Personnel Records/Staff Training -1569.69(a)(2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment, see LIC809D. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. . Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties being assessed. Exit interview conducted with the Administrator Charmaine Mendaros. Appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 2, 2023