Amelia Rose Senior Care Cottage

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with caregiver Adela Armenta and explained the purpose of today’s visit. Administrator Cheryl Dallas arrived shortly. Facility is licensed to serve six (6) non-ambulatory residents, of which one (1) may be bedridden, ages 60 and over. Three (3) hospice waivers on file. Bedrooms 1-4 are approved for non-ambulatory and bedroom #5 approved for bedridden. The facility is single story house located in a residential neighborhood in the city of Lakewood. LPA toured the facilities physical plant, indoor and outdoor. The facility has five (5) resident bedrooms, three (3) bathrooms, living room, dining room, kitchen, laundry room/office, and garage used for storage. LPA toured the facility and observed the following: All resident bedrooms have the required furniture and bedding. There is extra clean linen and towels in hallway cabinets. Smoke detectors/carbon monoxide detectors were observed throughout facility. The facility has three (3) fire extinguisher which are kept in kitchen, hallway and office and are fully charged. Cleaning supplies and toxic substances are inaccessible locked in cupboards in kitchen cabinet and laundry room. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. Sufficient supply of 2 days perishable & 7 days non-perishable foods was observed in the kitchen. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the required range of 105-120 degrees F. The facility does not have a swimming pool or large body of water. There is a shaded seating area for the residents located in backyard. Passageways and exits are free of obstruction. SEE LIC 809 C Three (3) staff files were reviewed and included Criminal clearance record, required training and health screening with TB. Three (3) resident files were reviewed and R1 was missing current consent for medical treatment LIC 627 and pre appraisal form LIC 603. Last fire/earthquake drill was conducted in April of 2026. Infectious control plan and emergency disaster plan was reviewed. Residents medications were reviewed, and no errors were found. Medications are centrally stored and locked MAR log is used. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during today’s visit will be documented on LIC809-D. Exit interview was held and a copy of the report with appeal rights was given.the state’s words, verbatim · CDSS document, Jul 9, 2026

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christian Gutierrez conducted the required annual inspection. LPA arrived unannounced and met with CNA Emani Lawrence and explained the purpose of today’s visit. Administrator Cheryl Dallas arrived shortly. Facility is licensed to serve six (6) non-ambulatory residents, of which one (1) bedridden, ages 60 and over. Three (3) hospice waivers on file. The facility is single story house located in a residential neighborhood in the city of Lakewood. LPA toured the facilities physical plant, indoor and outdoor. The facility has five (5) resident bedrooms, three (3) bathrooms, living room, dining room, kitchen, laundry room/office, and garage used for storage. Bedroom #5 is approved for bedridden LPA toured the facility and observed the following: All resident bedrooms have the required furniture and bedding. There is extra clean linen and towels in hallway cabinets. Smoke detectors/carbon monoxide detectors were observed throughout facility. The facility has three (3) fire extinguisher which are kept in kitchen, hallway and office and are fully charged. Cleaning supplies and toxic substances are inaccessible locked in cupboards in kitchen cabinet and laundry room. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 40 degrees F. LPA did not observe a sufficient supply of 2 days perishable foods Administrator had food purchased at time of visit. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were not measured between the required range of 105-120 degrees F. Bathroom #2 had a reading of 102.5 degrees. The facility does not have a swimming pool or large body of water. There is a shaded seating area for the residents located in backyard. LPA observed paint and other objects on side of house. During tour of backyard a combination lock was observed on perimeter fence without waiver from this licensing agency, no approval from on fire clearance inspection sheet. Lock was removed at time of visit. SEE LIC 809 C Two (2) staff files were reviewed. Administrator uses Clipboard Agency for additional staff. Four (4) out of six (6) resident files were reviewed and included physicians’ reports with TB and appraisal needs and service plans. R2 and R4 were missing current physicians’ reports. Last fire/earthquake drill was conducted in August of 2025. Emergency disaster plan was reviewed. Four (4) residents’ medications were reviewed, and no discrepancies were found. Medications are centrally stored and locked MAR log is used. Per California Code of Regulations, Title 22, deficiencies were observed and are cited on the LIC809-D. An exit interview was held, and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 7, 2025

Allegation investigated: Licensee does not ensure that staff are adequately trained. Licensee does not ensure that there is designated substitute at the facility when the Administrator is not at the facility.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint investigation visit to deliver findings regarding the above allegations. LPA met with Lakeisha Ogesby and explained the reason for the visit. LPA spoke with Cheryl Dallas (Administrator) via phone call and delivered findings. The investigation consisted of the following: On 4/22/25 LPA Mary Flores conducted an initial investigation visit, requested copies of resident/staff roster, conducted a tour of the home, interviewed 6 residents and 2 staff. LPA Flores requested copies the following documents: resident/staff roster, menu, activity calendar, training for 2 staff, designee notification, physician’s report, appraisal, identification and emergency information sheet for resident #1-2(R1-R2), and hospital discharge documents for Resident #3(R3), pest control records to be emailed by 4/23/25. On 5/6/25 LPA Flores received requested documents. On 6/28/25 LPA Herrera delivered findings for allegations. (continued on the LIC9099-C) Substantiated The investigation revealed the following: Regarding allegation: Licensee does not ensure that staff are adequately trained. It is alleged staff do not receive initial training or yearly training. Interviews conducted with residents revealed 6 out of 6 residents were unable to provide an answer due to cognitive skills. Interviews with staff revealed training is provided prior starting to work at the facility. Documents reviewed revealed; administrator provided copies of training material via pictures. However, there were no training logs that record the date and time of yearly or initial training provided to staff #2(S2). Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Regarding allegation: Licensee does not ensure that there is a designated substitute at the facility when the administrator is not at the facility. It is alleged administrator left on vacation in December 2024 and did not leave a responsible designee. Interviews conducted with residents revealed 6 out of 6 residents were unable to answer due to cognitive skills. Interviews conducted with staff revealed there is a designated person when the administrator is out. Per administrator, administrator took a vacation in December and left staff #3(S3) as the designee of responsibility and they should have submitted the Designation of Responsibility LIC 308 to the department. LPA reviewed documents submitted to the department between December 2024 and May 2025, there was no record of appointing S3 or other staff as the designee for responsibility. Administrator did not provide a copy of document submitted to the department with transmittal sheet. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Lakeisha Ogesby and a copy of this report, LIC 9099D, and appeal rights were provided. The investigation revealed the following: Regarding allegation: Staff members are not assisting residents with residents ADLs. It is alleged residents are not assisted with showers and changing their adult underwear. Interviews with residents revealed 4 out of 6 residents stated staff assist them with all activities of daily living. 2 out of 6 residents were unable to provide an answer due to cognitive skills. Interviews with staff revealed staff assist residents with changing adult underwear at least every two hours or as needed and provide showers to residents in care at least twice a week. Facility does not keep logs for showers or changing. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff member forces resident to stay in bed all day. It is alleged Resident # 1(R1) is left in bed all day without social interactions or friends. Interviews conducted with residents revealed 4 out of 6 residents stated to have activities throughout the day, staff provide care, and all residents have meals together. Interviews with staff revealed staff ensures all residents are brought to the dining and activities are provided throughout the day. During the visit conducted on 4/22/25 LPA observed all residents in the dining finishing breakfast. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff member falsified the facility MAR. It is alleged staff filled out the medication sheet without providing the medication. Interviews with residents revealed 6 out of 6 residents were unable to answer questions regarding medication due to cognitive skills. Interviews with staff revealed the staff is aware that the medication sheet (MAR) should be initial after providing the medication daily. During the visit LPA reviewed medication for 5 residents. LPA observed 3 out of 5 residents medications sheets were initialed for afternoon medication which had not been provided to residents yet. Although the facility staff made errors by initialing the MAR prior giving the medication, there is no proof that the staff is falsifying MAR sheets. Therefore, the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. (continued on LIC9099-C) Regarding allegation: Licensee is not addressing resident’s fall risk. It is alleged that Resident # 2(R2) fell from bed several times and staff did not do anything about it. Interviews with residents revealed staff assist them as needed. Residents were unable to provide additional information regarding the allegation due to cognitive skills. Interviews with staff revealed there have not been falls among the residents within the last three months. There were no incident reports to note falls. On LPA Flores observed bed rails in R2’s bed. Although the incidents may have happened there is not enough evidence to support that the staff are not preventing residents from falling from their beds. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Administrator is not present at the facility a sufficient number of hours as required. It is alleged administrator is rarely at the facility. Interviews conducted with residents revealed 6 out of 6 residents were not able to answer question due to cognitive skills. Interviews with staff revealed administrator is present throughout the week. Per administrator, administrator visits the facility each day for a few hours, is involved during celebrations, special events that take place at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff did not report an incident involving a resident in care as necessary. It is alleged that resident #2(R2) fell while taking a shower. Residents were unable to provide information regarding this allegation due to cognitive skills. Administrator and staff stated there have not been falls sustained by the residents at the facility. Administrator stated there were no incidents to report to the department as there have not been falls. Document review did not reveal any incident reports submitted to the department for R2. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. (continued on LIC9099-C) Regarding allegation: Licensee does not ensure that enough staff are present at the facility to meet the needs of the residents in care. It is alleged there is only one staff with the residents and additional staff is required as a resident with dementia wonders out to the street. Interviews with residents revealed there is staff to provide care to the residents, and their needs are being met. Interviews with staff revealed there is one staff per shift, which they believe it is sufficient as they are able to provide the care and meet the needs of the residents at the facility. Administrator stated that resident#3(R3) does tend to seek the exit. However, staff assist R3 by redirecting so R3 does not exit, and residents are not left alone. LPA observed the residents clean, dress, and care being provided at the time of the visit. Although the allegation may be true, per observation and interviews there is staff to provide care and supervision at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff administered another resident’s medication to resident. It is alleged staff made a mistake and administered medication of a resident to another resident by staff. Interviews conducted with residents revealed 6 out of 6 residents were unable to provide information due to cognitive skills for this allegation. Interviews conducted with staff revealed there have not been any errors with medication that is being provided to residents in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Lakeisha Ogesby and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 28, 2025 · control 28-AS-20250414161453

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(C) · Plan of correction due date: Jul 5, 2025

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement is not met as evidence by: Based on observations and document review licensee did not ensure that S2 received, and records were maintained for training provided which poses a potential risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Jun 28, 2025

Plan of correction: Administrator will provide training to facility’s staff and will provide a copy of training logs, with date, duration of training, and staff signatures to the department by POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Jul 5, 2025

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator... When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management … Based on observation and document review licensee did not ensure to notify or appoint via LIC 308 a designee of responsibility before going on vacation which poses a potential risk to the health, safety, or personal rights of the persons in care.the state’s words, verbatim · CDSS document, Jun 28, 2025

Plan of correction: Administrator will certify in writing that will appoint and notify the department whenever is out of the facility for an extended period of time and submit a copy to the department by POC due date

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Tena Herrera conducted a case management visit to note deficiencies observed during a complaint investigation visit conducted on 4/22/25 by LPA Mary Flores. LPA met with Lakeisha Ogesby and explained the reason for the visit. LPA spoke with Cheryl Dallas (Administrator) via phone call and delivered findings. · On 4/22/25 LPA Flores conducted a complaint investigation visit. During the visit LPA reviewed 5 residents’ medication around 12:00pm and found that in 3 out of 5 residents, resident #2,#4 and #5(R2,R4,R5) staff had initialed in the PM/evening section of 4/22/25 for dose needed to be provided in the afternoon. Per administrator, staff initial medication sheet once the medication is provided and medication was still in package and not provided to the residents. · On 4/22/25 LPA Flores interview administrator and staff who stated Resident #3(R3) had gone out to the hospital in January of 2025 via emergency responders (911) as R3 had been feeling ill. Per administrator, did not submit an incident report as administrator did not know it was reportable to Community Care Licensing (CCLD). Deficiencies are noted on LIC 9099D per Title 22 Regulations. Exit interview was conducted with Lakeisha Ogesby and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 28, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Jul 5, 2025

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidence by: Based on observation and document review licensee did not ensure staff was accurately noting the medication sheets to show current medication which poses a potential risk to the health, safety, and personal rights of the persons in care.the state’s words, verbatim · CDSS document, Jun 28, 2025

Plan of correction: Administrator will provide training to staff on medication logs and create procedures to provide and record medication and provide a copy to the department by POC due date

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a) · Plan of correction due date: Jul 5, 2025

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency …the following: (1) A written report shall be submitted … within seven days of the occurrence of any of the events … Based on interviews and documents reviewed the licensee did not ensure to report R3 was taken to the hospital via emergency personnel which poses a potential risk to the health, safety, and personal rights of the persons in care.the state’s words, verbatim · CDSS document, Jun 28, 2025

Plan of correction: Administrator will submit incident report for R3 to the department and will certify in writing that will report to the department per 87211 regulations and will submit a copy to the department by POC due date

Allegation investigated: Licensee does not ensure that the facility has a sufficient quantity of food for residents in care. Staff member does not ensure that resident participates in activities while in care. Staff member do not ensure that residents are adequately fed while in care. Staff members do not treat residents with dignity and respect Licensee did not address report roach infestation at facility

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Sherie Betters and explained the reason for the visit. The investigation consisted of the following: LPA requested copies of resident/staff roster. LPA conducted a tour of the home with Sherrie . LPA interviewed 6 residents and 2 staff. LPA requested copies the following documents: resident/staff roster, menu, activity calendar, training for 2 staff, designee notification, physician’s report, appraisal, identification and emergency information sheet for resident #1-2(R1-R2), and hospital discharge documents for Resident #3(R3), pest control records. The investigation revealed the following: Regarding allegation: Licensee does not ensure that the facility has a sufficient quantity of food for residents in care and Staff member do not ensure that residents are adequately fed while in care. (CONTINUED ON LIC 9099C) Unsubstantiated It is alleged the facility does not have a lot of food on hand and residents are hungry because they have not been fed. Interviews conducted with residents revealed, 4 out of 6 residents stated to be served their meals with a variety of foods and are content with the food and 2 out of 6 residents were unable to provide answers due to cognitive skills. Interviews with staff and administrator revealed groceries are purchase once a week and there is a menu which is followed by the staff. During facility’s tour LPA observed adequate amount of food supplies. LPA observed items as follow: in the freezer there was fish, meat, chicken, frozen vegetables. In the refrigerator milk, fruits, turkey, yogurt, vegetables, tortillas, fruits were observed. In the pantry can foods, and dry goods (oatmeal, cereals) were observed. During the visit all residents were at the dining table, one of them was finishing breakfast and the staff prepared lunch which matches the lunch posted on the menu. LPA reviewed the menu posted in the kitchen’s wall. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff member does not ensure that resident participates in activities while in care. It is alleged resident lays in bed all day. Interviews with residents revealed 3 out of 6 residents stated to have activities throughout the day, like exercises. One of the residents stated all residents have meals together. 3 out of 6 residents were unable to answer due to cognitive skills. Interviews with administrator and staff revealed there is an activity calendar and the residents paint, play bingo, do arts and crafts, exercise, and do celebrations. During LPA’s visits all residents were observed in the dining room upon arrival, finishing breakfast. An activity calendar was posted in the living room and dining room. Pictures of celebrations and arts and crafts were posted around the dining room. LPA observed materials for activities stored in the a cabinet in the dining room. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Staff members do not treat residents with dignity and respect. It is alleged residents are treated rough while providing care and are being yelled at. Interviews with 4 out of 6 residents stated staff treat them well, are gentle, and respectful at all times. 2 out of 6 residents were unable to answer due to cognitive skills. (CONTINUED ON LIC 9099C) Interviews with staff revealed residents are being treated with respect and have not observed or been reports of staff mistreating the residents while in care. Per administrator staff receive initial training which includes resident rights. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Regarding allegation: Licensee did not address reported roach infestation at facility. It is alleged there is a roach infestation. Interviews with residents revealed 4 out of 6 residents stated the facility is clean and 2 out of 6 residents were unable to answer due to cognitive skills. Interviews with staff revealed there has not been a cockroach infestation at the facility. Per administrator pest control is provided at the facility once a month. During the facility’s tour LPA observed living room, kitchen, dining room, bathrooms, and each residents’ room free of cockroaches. There was no evidence of an infestation under the kitchen’s sink or bathrooms’ sinks. LPA reviewed pest control invoice dated 4/21/25. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview was conducted with Cheryl Dallas administrator and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 22, 2025 · control 28-AS-20250414161453

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

**This is a corrected version of previous report dated 9/1/24. 809-D page was cited incorrectly. 87355(e) has been corrected to 87355(e)(1).** Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit and was greeted by Administrator Cherly Dallas. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: LPA Ramirez observed a post-it note indicating the doorbell was in disrepair, however, licensee has a motion sensor to notify when visitors are at the front door. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected five (5) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. Showers were observed to be wheelchair accessible. 1 out of 3 light bulbs in bathroom#1 and bathroom#2 were in disrepair. LPA Ramirez did not observe posted facility license in prominent location of the facility. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). Planned Activities: LPA Ramirez observed coloring activities, game boards and magazines in living room area. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed a facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. No documented proof of emergency drills was observed. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply. Residents with Special Needs: No large bodies of water were observed. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be accessible to residents with Dementia in bathrooms#1 and #2. Auditory devices were observed to be in working order. LPA Ramirez observed perimeter fence gate to contain combination lock. LPA Ramirez did not observe waiver for use of locked perimeter gates. Health Related Services/Incidental Medical Services: The medications are centrally stored in staff office and in bubble packs and/or original containers. Centrally stored medication record was not observed for R5. The facility provides incidental medical services. Staffing: Administrator Certificate for Cherly Dallas is currently being renewed and LPA Ramirez verified its status. LPA Ramirez observed S1 & S2 providing care and supervision to residents in care upon arrival to the facility. It was later discovered S1 is not a regular employee of the facility or from Home Care Aid Registry. Interview of S1 and Administrator Dallas, revealed S1 did not obtain prior criminal clearance prior to beginning their employment at the facility. Per Administrator Dallas, S1 began their employment on 9/1/24 at 8am. LPA Ramirez confirmed S2 was hired through a Home Care Aide registry and LPA Ramirez was able to confirm S2’S staff file and criminal clearance due to S2 providing the documents on their phone. It was later discovered S1’s first name was different then Administrator Dallas originally believed it to be, and Administrator Dallas was unable to provide S1’s last name after personnel records were reviewed. An immediate civil penalty was assessed for this violation in the amount of $100.00 per day from 9/1/24 through 9/1/24. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required CPR and First Aid for three (3) out of the three (3) personnel records reviewed. S3 and S4 were missing required annual training. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel records reviewed. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for six (6) non-ambulatory residents, of which one (1) may be bedridden. This facility may retain no more than three (3) hospice residents. There are zero (0) residents under hospice care. Bedrooms#1-4 are approved for non-ambulatory & bedroom#5 is approved for bedridden. Resident Records/Incident Reports: LPA reviewed Resident files for five (5) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed for four (4) out of the five (5) records reviewed. R1 was missing medical assessment. LPA Ramirez did not observe physician’s order for full bed rails in R2’s file. Deficiencies were cited during inspection. Civil penalty was assessed during inspection. Exit interview was NOT conducted as Administrator Dallas was unavailable and refused to send designee to sign report or conduct exit interview. LPA Ramirez attempted to document deficiency with photo and was asked to leave the facility via phone by Administrator Dallas. A copy of this report, LIC 421BG, 809-D and appeals rights was provided via email.the state’s words, verbatim · CDSS document, Nov 22, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Sep 9, 2024

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or This requirement is not met as evidenced by: S4 did not have proof of criminal clearance prior to gaining employment at the facility.the state’s words, verbatim · CDSS document, Nov 22, 2024

Plan of correction: *24HR CORRECTION met due to S4 removing herself from the facility until criminal clearance is submitted.* Licensee will retrain staff on this regulation and send proof of re-training by 9/9/24 via email.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(f)(2) · Plan of correction due date: Sep 9, 2024

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: 1 bottle of laundry sanitizer and 1 spray bottle of disinfectant spray was observed in bathrooms#1 and 2.the state’s words, verbatim · CDSS document, Nov 22, 2024

Plan of correction: *24HR CORRECTION met due to Administrator Dallas removing the chemicals and securing in staff office.*Licensee will retrain staff on this regulation and send proof of re-training by 9/9/24 via email.

Type of visit: POC

Licensing Program Analyst (LPA) Kimberly Ramirez and LPA Luis De Leon conducted a Case Management Visit-POC (Plan of Correction) on 09/17/2024, stemming from annual inspection conducted on 09/01/2024. LPA’s were greeted by Caregiver Adela Armenta and explained the purpose of the visit. LPA’s gained entry into the facility at 9:30 am. Caregiver Arnenta contacted Administrator Dallas and initially agreed to meet with LPA's. At 9:34 am, Administrator Dallas telephoned Caregiver Armenta to advise her she was no longer on her way but LPA's could leave any reports at the facility. LPA Ramirez attempted to contact Administrator Dallas and left a voicemail. Case Management-POC findings: On 9/1/24, LPA Ramirez conducted a required annual inspection, and nine (9) violations were observed and documented. All nine (9) violations had a correction due date of 9/9/24. As of 9/17/24, LPA Ramirez has not received corrections for the violations listed below or a request for an extension before the due date. 1. 87355(e) - Criminal Record Clearance – Type A 2. 87705(f)(2) – Care of Persons with Dementia – Type A 3. 87113 – Posting of License – Type B 4. 87303(a) - Maintenance and Operation – Type B 5. 87465(a)(6) – Incidental Medical and Dental Care – Type B 6. 87456(a)(3) – Evaluation of Suitability for Admission – Type B 7. Health & Safety Code – 1569.695(c) – Type B 8. 87608(a)(5)(B) – Postural Supports – Type B 9. 87705(I)(1)(2)(3) – Care of Persons with Dementia – Type B As a result of the violations not being cleared by 9/9/24, LPA Ramirez will issue civil penalties in the amount of $100 per day from 9/10/24 through 9/17/24, for each violation listed above. $7,200.00 in total civil penalties were assessed today for failure to correct the violations issued on 9/1/24. Civil penalties in the amount of $100 per day, per violation, will continue to be assessed until the licensee confirms to the satisfaction of the Department that the violation has been corrected. SEE 809-C Caregiver Armenta did not feel comfortable signing the report. No exit interview was conducted. Administrator Dallas was unavailable during visit. A copy of this report, LIC 421FC and appeals rights was provided.the state’s words, verbatim · CDSS document, Sep 17, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit and was greeted by Administrator Cherly Dallas. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: LPA Ramirez observed a post-it note indicating the doorbell was in disrepair, however, licensee has a motion sensor to notify when visitors are at the front door. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected five (5) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez observed no-slip mat in showers. Showers were observed to be wheelchair accessible. 1 out of 3 light bulbs in bathroom#1 and bathroom#2 were in disrepair. LPA Ramirez did not observe posted facility license in prominent location of the facility. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). Planned Activities: LPA Ramirez observed coloring activities, game boards and magazines in living room area. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed a facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. No documented proof of emergency drills was observed. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply. Residents with Special Needs: No large bodies of water were observed. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be accessible to residents with Dementia in bathrooms#1 and #2. Auditory devices were observed to be in working order. LPA Ramirez observed perimeter fence gate to contain combination lock. LPA Ramirez did not observe waiver for use of locked perimeter gates. Health Related Services/Incidental Medical Services: The medications are centrally stored in staff office and in bubble packs and/or original containers. Centrally stored medication record was not observed for R5. The facility provides incidental medical services. Staffing: Administrator Certificate for Cherly Dallas is currently being renewed and LPA Ramirez verified its status. LPA Ramirez observed S1 & S2 providing care and supervision to residents in care upon arrival to the facility. It was later discovered S1 is not a regular employee of the facility or from Home Care Aid Registry. Interview of S1 and Administrator Dallas, revealed S1 did not obtain prior criminal clearance prior to beginning their employment at the facility. Per Administrator Dallas, S1 began their employment on 9/1/24 at 8am. LPA Ramirez confirmed S2 was hired through a Home Care Aide registry and LPA Ramirez was able to confirm S2’S staff file and criminal clearance due to S2 providing the documents on their phone. It was later discovered S1’s first name was different then Administrator Dallas originally believed it to be, and Administrator Dallas was unable to provide S1’s last name after personnel records were reviewed. An immediate civil penalty was assessed for this violation in the amount of $100.00 per day from 9/1/24 through 9/1/24. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required CPR and First Aid for three (3) out of the three (3) personnel records reviewed. S3 and S4 were missing required annual training. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel records reviewed. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for six (6) non-ambulatory residents, of which one (1) may be bedridden. This facility may retain no more than three (3) hospice residents. There are zero (0) residents under hospice care. Bedrooms#1-4 are approved for non-ambulatory & bedroom#5 is approved for bedridden. Resident Records/Incident Reports: LPA reviewed Resident files for five (5) residents. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent For Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed for four (4) out of the five (5) records reviewed. R1 was missing medical assessment. LPA Ramirez did not observe physician’s order for full bed rails in R2’s file. Deficiencies were cited during inspection. Civil penalty was assessed during inspection. Exit interview was NOT conducted as Administrator Dallas was unavailable and refused to send designee to sign report or conduct exit interview. LPA Ramirez attempted to document deficiency with photo and was asked to leave the facility via phone by Administrator Dallas. A copy of this report, LIC 421BG, 809-D and appeals rights was provided via email.the state’s words, verbatim · CDSS document, Sep 1, 2024

The state marks this report as 9 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Deficiencies on 09/01/2024, stemming from annual inspection conducted on 09/01/2024. LPA Ramirez was greeted by Home Care Aide Registry Staff- Tyra R. Case Management-Deficiencies findings: LPA Ramirez returned to the facility to conduct exit interview of earlier annual inspection conducted on 9/1/2024. At approximately 5:10:pm, LPA Ramirez was greeted by Registry Staff- Tyra R. Tyra advised LPA Ramirez that Administrator Dallas had left the facility and requested LPA Ramirez call Administrator Dallas once LPA Ramirez arrived. Tyra confirmed to LPA Ramirez she was the only staff at the facility and no other staff was available to conduct exit interview. LPA Ramirez telephoned Administrator Dallas and advised her LPA was ready to conduct the exit interview. Administrator Dallas stated she was unable to meet LPA Ramirez due to feeling ill. LPA Ramirez again asked Administrator Dallas if any other staff was available to discuss deficiencies and inspection report. Administrator Dallas advised LPA Ramirez no other staff were available and began to express her disapproval with LPA Ramirez conducting an annual inspection at the facility on a Sunday; expressed that due to LPA’s unexpected weekend arrival and deficiencies discussed earlier, Administrator Dallas was now ill. LPA Ramirez advised Administrator Dallas that the report will indicate her refusal to conduct exit interview via phone or in person and will indicate “REFUSE TO SIGN” on the report. Administrator Dallas advised LPA Ramirez that she was not coming or sending anyone to meet LPA and LPA could proceed forward with any course of action. At 5:16pm, LPA Ramirez attempted to make way to the backyard to take a picture of the facility perimeter gate that earlier was observed to be in noncompliance. LPA Ramirez advised Tyra that the facility is being cited and LPA was going to take a picture for documentation purposes. Tyra called Administrator Dallas to notify her of LPA’s intent to take a picture of the perimeter gate. Tyra advised LPA Ramirez that Administrator Dallas said to “leave now!”. LPA Ramirez could hear Administrator Dallas shouting “TELL HER TO GET OUT NOW! LEAVE RIGHT NOW!” LPA Ramirez asked Tyra to put the call on speaker so LPA Ramirez could advise Administrator Dallas of the consequences of not allowing LPA Ramirez to enter and inspect the entire premise even after proper identification and stating my purpose. LPA Ramirez could hear Administrator Dallas shout “I DON’T CARE! I DON’T WANT TO TALK TO HER! GET OUT!” LPA Ramirez collected her belongings and left the facility at 5:18pm. An Immediate Civil Penalty of $500 was assessed due LPA Ramirez being denied entry to backyard and being asked to leave the facility by Administrator Dallas during annual inspection of facility. A copy of this report, 809-D, LIC 421IM and appeals rights was provided via email.the state’s words, verbatim · CDSS document, Sep 1, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87755(a) · Plan of correction due date: Sep 2, 2024

(a) Any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter and inspect the entire premise of any place providing services at any time, with or without advance notice. This requirement was not met as evidenced by: LPA Ramirez was denied entry to backyard to complete inspection.the state’s words, verbatim · CDSS document, Sep 1, 2024

Plan of correction: Licensee will allow any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter and inspect the entire premise of any place providing services at any time, with or without advance notice. Licensee will certify a plan to address how the facility plans to comply with the above regulation. Due via email by 9/2/24.