Anastasia

Type of visit: Case Management - Other

On 7/29/2026 at 4:00 p.m., Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit due to a capacity increase. LPA met with Caregiver, Paul Montehermoso and explained the purpose of the visit. Administrator was unavailable and approved caregiver to sign todays report over the phone. LPA toured toured the facility and observed it consistent with facility sketch submitted to CCLD. LPA advised facility to utilize a pendant system for residents due to the physical layout. Caregivers and Administrator state that they have a system available that they plan on using. No issues noted. No deficiencies cited at this time. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 29, 2026

Type of visit: Required - 1 Year

On 06/30/26 at 1PM, Licensing Program Analyst (LPA) D Panlilio arrived unannounced to conduct an annual required inspection. LPA met with staff (ADM, S1) and explained the purpose of the visit. ADM has a current administration certificate# 6077591740 which expires 12/19/27. At 1:15PM, LPA toured the facility including but not limited to the front entrance, screening station, kitchen, bathrooms, bedrooms and common areas. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, visitor’s logs, no touch thermometer, additional face masks and hand sanitizers were observed at the screening station. Emergency Disaster Plan, Complaint poster, Personal rights, Cough/sneeze etiquette, proper hand-washing signs were observed posted in common areas. Facility has a sufficient 2-day perishable and 7-day non-perishable food supply. Facility has a 30-day supply of PPEs, paper, medications locked in cabinets. Comfortable temperature is maintained at 76 deg F. Hot water temperature was measured at 115 deg F. Facility has a mitigation plan in place and the infection control leader is the administrator. Inside and outside pathways were free of obstruction and fire hazards. Smoke and Carbon monoxide detectors were operational. Fire extinguisher was observed fully charged. LPA reviewed 3 staff and 5 resident files. Updated copies of the following documents were collected for facility file:  LIC500- Personnel Report  LIC9020 - Residents Roster  LIC308- Designation of Facility Responsibility  LIC610E- Emergency/Disaster Plan including infection control plans  Evidence of Liability Insurance No deficiencies observed during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 30, 2026

Type of visit: Required - 1 Year

On 5/28/2025 at 10:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Christine Sevier and explained the purpose of the visit. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and purchased on 4/25/2025. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 115.5 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. First Aid kit is complete. The facility has a written emergency disaster plan. Last disaster drill was conducted on 5/2/2025. LPA reviewed 6 residents and 3 staff files starting at 11:40AM. LPA reviewed a sample of resident's medications during inspection. No deficiencies are being cited on this date. Exit interview conducted with Christine Sevier. A copy of this report was provided.the state’s words, verbatim · CDSS document, May 28, 2025

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff did not ensure that resident was adequately fed resulting in weight loss Staff did not assist resident in transferring out of bed.

On 9/26/2024 at 10:40AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and to deliver complaint findings for the allegations above. LPA met with caregiver, Vanesia Duhaney and explained the purpose of the visit. LPA spoke with administrator, Lacy Vincent who stated caregiver can sign CCLD reports. During the investigation, LPA interviewed 4 residents, 2 staff, witness, and complainant. LPA reviewed and obtained documents including LIC500, physician's report, preplacement appraisal, care plan, facility notes, feeding instructions, home health document, and emergency information. Staff did not ensure that resident was adequately fed resulting in weight loss Interview with staff and witness revealed that staff are feeding R2 three meals daily. Interview with residents indicated that staff is providing meals to residents. R2 stated that staff assist in feeding and R2 had an appetite in the morning. (Continue on LIC9099C...) Unsubstantiated R2's physician's report dated 10/21/2022 shows that R2's weight was168.8 pounds. However, the facility did not have records of R2's weight after admission to the facility. Staff did not assist resident in transferring out of bed. Interview with residents revealed that staff are assisting residents in transferring out of bed. R2 stated that staff would assist R2 in transferring to wheelchair when asked. Interview with staff indicated that R2 doesn't want to be transferred out of bed. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore these allegations are UNSUBSTANTIATED. No deficiencies are being cited on this date. Exit interview conducted. A copy of this report provided.the state’s words, verbatim · CDSS document, Sep 26, 2024 · control 15-AS-20230825120429

Type of visit: Case Management - Deficiencies

On 9/26/2024 at 12:15PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Caregiver, Vanesia Duhaney and explained the purpose for the visit. LPA spoke with administrator, Lacy Vincent who stated caregiver can sign CCLD reports. While LPA G. Luk was at the facility for a complaint investigation (#15-AS-20230825120429), the following deficiency was observed. After reviewing Guardian system, LPA G. Luk observed staff (S1) was not fingerprint cleared or associated to the facility. LPA spoke with Administrator, Lacy Vincent over the phone and informed her that S1 cannot be at the facility or have interactions with residents until fingerprint clearance is completed. LPA observed S1 left the licensed portion of the facility during visit. Civil penalty of $200 is being assessed. The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in civil penalties. Exit interview conducted. A copy of this report, civil penalty, and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 26, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(g)(1) · Plan of correction due date: Sep 27, 2024

Personnel Requirements - General. Obtain a California clearance or a criminal record exemption as required by law or Department regulations... This requirement is not met as evidence by: Based on record review, licensee did not comply with the section cited above by not having staff fingerprint cleared which poses an immediate health and safety risk to the persons in care.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Administrator has agreed to obtain fingerprint clearance for S1 and submit written plan or fingerprint documents to CCLD by POC date. Civil penalty of $200 is being assess.

Allegation investigated: Staff is not fingerprint cleared. Unqualified staff administered medications to residents.

On 07/16/2024 around 05:15 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to conduct an initial 10-day complaint visit and deliver the findings for the above allegations. LPA met with Anika Brown, Staff and explained the reason for the visit. S4 was telephoned and stated that her shift had just ended and she could email any documents needed. Allegations: Staff is not fingerprint cleared. Unqualified staff administered medications to residents. SUBSTANTIATED During the course of the investigation and visit, LPA toured the facility, reviewed a sample of three Staff (S1, S2 and S3) files. LPA requested the file for (S4), Medication Log, Current Personnel Report (LIC 500) and Resident Roster. Continued on LIC 9099C... Substantiated ...continued from LIC 9099. -At 5:25 PM, LPA spoke to S4 who stated that she was helping the Licensee and the Licensee was not available at this time. There is not an LIC 308 available. S4 does not have any criminal record clearance on file and is not associated to the facility in Guardian; S4 stated that she/he gave the information to the Licensee but Licensee is unavailable. -At 6:55 PM, S4 stated that he/she had been working at the facility for about two (2) weeks. -At 6:55 PM, LPA reviewed personnel records for (S1, S2, and S3); There was not a file present for S4. -At 7:07 PM, Sample review of C1's Medication Administration Record was not dated or signed by the staff who administered the medication. S2 stated that S4 gives out the medication; S4 is not associated to the facility. -At 7:00 PM, Staff (S1 and S2) New Employee Training records and Certificate of Completion did not include adequate training hours for administration of medication. There was not a file present for S4. Based on information obtained, the allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies are cited from Title 22 California Code of Regulations and listed on LIC 9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within a 12 month period may result in civil penalties. Exit interview conducted, Appeal Rights, and a copy of this report provided to Anicka Brown, Staff.the state’s words, verbatim · CDSS document, Jul 16, 2024 · control 15-AS-20240711153226

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(g)(1) · Plan of correction due date: Jul 19, 2024

87411 Personnel Requirements - General (g)...Prior to employment or initial presence...(1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations... -This requirement is not met as evidenced by: -Based on interviews and observation, the licensee did not comply with the section above by not associating S4 to the facility.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: Licensee to submit proof to CCLD by POC date by reading the regulations and self certify. Submit proof that S4 has criminal background clearance and is associated to the facility.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.629(a)(2) · Plan of correction due date: Jul 19, 2024

1569.69 Employees assisting residents with self-administration of medication; training requirements (a)...facility who assists residents...(2)...15 or fewer persons... six hours of initial training...two hours of hands-on shadowing training... -This requirement is not met as evidenced by: -Based on interviews, observation, and record review, the licensee did not comply with the section above by providing medication training to staff that assist residents with self-administration of medication.the state’s words, verbatim · CDSS document, Jul 16, 2024

Plan of correction: Licensee to submit proof to CCLD by POC of medication training for all staff that assist residents with self-administration of medication.

Type of visit: Required - 1 Year

On 6/19/2024 at 8:50AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Administrator, Octavian Mahler and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory residents, of which 6 residents may be bedridden, and 6 residents may be under hospice care. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, garage, and outdoor area. Smoke and carbon monoxide detectors were observed. Fire extinguisher was observed to be full and purchased on 6/19/2024. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 113.2 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mat in the bathrooms. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. First Aid kit is complete. The facility has a written emergency disaster plan. Last disaster drill was conducted on 5/29/2024. LPA reviewed 5 resident and 4 staff files starting at 10:00AM. LPA interviewed 2 residents and 2 staff. LPA reviewed a sample of resident's medications starting at 12:30PM. At 9:15AM, LPA observed unlocked medication in the refrigerator. Staff locked up the medication in a lockable refrigerator during inspection. LPA also observed unlocked medications in R3's room and staff locked up the medications. At 11:00AM, LPA observed S4's file was incomplete. At 1:00PM, LPA observed facility does not have MAR (Medication Administration Records) for resident's PRN medications. (Continue on LIC809C...) At 1:15PM, LPA observed doctor's order dated 6/8/2024 states that R3 has PRN orders for Chlorhexidine Gluconate and Guaifenesin. However, facility does not have the medications available for R3. At 1:30PM, LPA observed facility does not have hospice training records when R1 was admitted to hospice care. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jun 19, 2024

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.