Angel Care Home

Type of visit: Case Management - Other

On 8/19/2026 at 2:00pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Caregiver. Bernadette Del Rosario. Administrator, Ding "Angela" Wang, arrived at 2:33pm and LPA explained reason for visit. While LPA L. Hall was conducting a complaint investigation 15-AS-20260817122139 on 8/19/2026/5/2022 LPA observed the following deficiencies: At 1:10pm, during record review LPA observed R2 was taken to the hospital on 8/8/2026 and was admitted. S1 did not notify CCLD about the hospitalization. At 1:25pm, LPA observed two (2) of R1's medication in zip lock bags. (LPA has pictures) At 1:35pm, During record review LPA observed R1 do not have a medical assessment. At 1:40pm, LPA observed pre poured medications were in an unlocked kitchen drawer. At 2:00pm, LPA observed temperature in facility was 82 degrees. Staff adjusted thermostat and at 3:44pm temperature was still 82 degrees. Continued on LIC809C. Continued from LIC809. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights and this report provided.the state’s words, verbatim · CDSS document, Aug 19, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Aug 20, 2026

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place... This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having the kitchen drawer that contained medications locked, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 19, 2026

Plan of correction: Caregiver S2 immediately locked kitchen drawer during visit. Deficiency cleared during visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(5) · Plan of correction due date: Aug 26, 2026

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container...This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having medications for R1 in it's original container, which poses a potential health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Aug 19, 2026

Plan of correction: Administrator agreed to read and review regulation 87465 and submit self-certification that the facility will abide by the regulation going forwarded to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b) · Plan of correction due date: Aug 26, 2026

(b) A comfortable temperature for residents shall be maintained at all times. This requirement was not met as evidence by: Based on observation the licensee did not comply with the section cited above in having a comfortable temperature for residents, which poses a potential personal rights issue to persons in care.the state’s words, verbatim · CDSS document, Aug 19, 2026

Plan of correction: Administrator agreed to have air condition serviced and submit a repair invoice to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Aug 26, 2026

a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement was not met as evidence by: Based on observation and record review the Licensee did not comply with the section above in submitting an incident report for R2's hospitalization, which poses a personal rights issue to person in care.the state’s words, verbatim · CDSS document, Aug 19, 2026

Plan of correction: Administrator agreed to submit a complete incident report for R2's hospitalization to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Aug 26, 2026

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement was not met as evidence by: The Licensee did not comply with the section cited above in having a medical assessment for R1 which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 19, 2026

Plan of correction: The administrator agreed to obtain a medical assessment for R1 and submit a copy to CCLD by POC date.

Type of visit: Required - 1 Year

On 07/07/2026 at 10:25am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year required inspection. LPA met with Herminio Hernandez, Caregiver, and explained the purpose of the visit. Administrator, Ding Wang, arrived at 11:35am. Administrator holds a certificate #7021570740 expires 1/29/2028. The facility’s fire clearance was approved for six (6) non-ambulatory, of which one (1) may be a bedridden resident. Facility has a hospice waiver for two (2). LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of six (6) total bedrooms two one-half (2-1/2) bathrooms. LPA observed pool in the backyard has locked gate. A comfortable temperature is maintained at 73 degrees F. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 130.9 degrees F. Staff was doing laundry during visit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of 7-day non-perishables and 2-day perishables foods. Continued on LIC809. Continued from LIC809. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 06/16/2026. Emergency Disaster Plan was last reviewed on 5/1/2025. Fire drill last conducted 06/01/2026. First aid kit was observed to be complete. LPA reviewed five (5) staff records all were complete. The six (6) resident records were current and complete. LPA observed the following deficiencies: At 10:35am, LPA observed knives unlocked in kitchen drawer. At 11:45am, LPA observed during record review none of the staff have the required training. LPA requested the following documents to be submitted to CCLD by 07/14/2026. A coy of the administrator certificate LIC308 Designation of Administrative Responsibility Liability insurance. LIC500 Personnel Report LIC610E Emergency Disaster Plan. (last page) Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights, and this report providedthe state’s words, verbatim · CDSS document, Jul 7, 2026

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.

Type of visit: Case Management - Other

On 3/19/2026 at 12:30pm, Licensing Program Analysts (LPAs) L. Hall and C. Fowler arrived unannounced to conduct a Case Management visit. LPA met with Laly Bascao, House Manger. While LPA L. Hall and C. Fowler was conducting a complaint investigation #15-AS-20260312124108 on 3/19/2026. LPAs toured facility bedrooms, shared bathrooms, kitchen, common area, and garage. LPAs observed the following deficiencies: At 9:50am, LPAs observed S4 place a pair of scissors in unlocked kitchen drawer. LPAs then checked kitchen drawer and observed scissors and knives and that kitchen drawer did not have a lock. At 10:04am, LPAs observed unlocked medications for R2, R3, and R4 in the refrigerator. At 10:10am, LPAs was informed that glucose testing and administration of insulin was being given by staff for R2, R3, and R4. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Mar 19, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a) · Plan of correction due date: Mar 20, 2026

(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing... and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement was not met as evidence by: Based on interviews the Licensee did not comply with the section cited above in having a skilled professional conduct glucose testing and administering insulin, which poses a potential health and safety risk to persons in carethe state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: House Manager agreed to implement a plan to have R2, R3, and R4 glucose tested and insulin given, and submit plan to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Mar 20, 2026

(a) ... (b), the licensee shall ensure that disinfectants, cleaning solutions... knives, matches, tools, sharp objects... are in locked storage and are not left unattended if outside the locked storage. This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having sharps inaccessible to residents, which poses a safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: Caregiver removed sharps from kitchen drawer and locked them outside in the garage during visit. Deficiency cleared during visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h) · Plan of correction due date: Mar 20, 2026

(h) The following requirements shall apply to medications which are centrally stored: This requirement is not met as evidence by: Based on observation licensee did not comply with the section cited above in having refrigerated medication for R2, R3, and R4 locked and inaccessible, which poses a possible health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Mar 19, 2026

Plan of correction: House Manager agreed to lock refrigerated medications and submit photos to CCLD by POC date.

Type of visit: Case Management - Other

On 10/16/2025 at 12:40pm, Licensing Program Analyst (LPA), L. Hall conducted an unannounced case management visit to obtain facility information for residents. LPA met with Bernadette Del Rosario, Caregiver, and explained the reason for the visit. During the visit LPA toured facility and reviewed the five (5) residents files. Facility had a non-compliance conference (NCC) on 12/16/2024. LPA obtained a copy of the resident roster and LIC500 (personnel report). No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 16, 2025

Type of visit: Case Management - Health Checks

On 8/26/2025 at 1:25pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit a request from the facility. LPA met with Bernadette Del Rosario, Caregiver and explained the purpose of the visit. LPA spoke with Administrator, Ding Wang, via telephone. LPA reviewed R1's file to confirm ambulatory status. LPA spoke with Administrator and explained the facility is only allowed one (1) bedridden resident. Administrator stated she will submit a new LIC200. No deficiencies issued during the visit. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 26, 2025

Allegation investigated: Facility staff did not contact emergency services within a timely manner. Facility staff did not provide consent documents to emergency providers. Facility staff did not notate resident's medications that were taken. Facility did not refund responsible party for reminder balance for the month.

On 7/15/2025, at 2:25pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Hermino Hernandez, Caregiver. Laly Bascao, Caregiver arrived at 2:25pm and explained the reason for the visit. During the course of the investigation the Department conducted interviews with staff, witnesses, obtained and review records. Allegation: Facility staff did not contact emergency services within a timely manner. Continued on LIC9099C. Substantiated Continued from LIC9099. During initial interview W2 stated that emergency services wasn’t called in a timely manner being S1 called R1’s responsible party first and was then instructed to call 9-1-1. W2 further stated R1 was found unconscious and there was not an attempt to resuscitate. S1 stated during interview that due to R1 expiring of natural causes the responsible party was contacted first. S1 stated she was at the facility but was not able to provide what other staff were present. Allegation: Facility staff did not provide consent documents to emergency providers. W1 stated during interview that R1 had a physician order for life-sustaining treatment (POLST). W1 stated a lady (unknown name) handed her papers. S1 stated the facility did not have any of R1’s documents and was unsure who took the documents from the facility. During record review of the physician orders for life-sustaining treatment (POLST) dated January 12, 2024, indicated to attempt to resuscitate. Allegation: Facility staff did not notate resident's medications that were taken. W1 and W2 stated the facility did not notate any of R1’s medications that were taken. Both feel some of the medications were missing, but it is unknown if R1 had taken the medications or someone at the facility. W2 stated documents were given to W1 and did not indicate that R1 had taken any medications during the time she was there. S1 stated the facility did not have any of R1’s documents. LPA reviewed the medication administration record that was dated May 1, 2025, to May 31, 2024, and there was not any date noted where the Continued on LIC9099C. Continued from LIC9099C. medication was taken. The Department reviewed pictures of medications that was submitted, however, was unable to determine if medication was taken by R1. W1 stated during interview that a staff gave documents and W1 gave a description of the staff. Allegation: Facility did not refund responsible party for the remainder balance for the month. S2 stated during interview that the facility did not refund the balance of the month’s rent. S1 stated that she had an agreement with R1 that there will not be any refund for the 1st month. Health and Safety Regulation 1569.652© states: “A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or, if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.” Based on interviews which were conducted and record reviews, 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, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. A copy of the appeal rights and this report provided. Continued from LIC9099. were in a drawer in the bedroom and some medications were in a gray bag in the closet. S1 stated that R1’s medication was no accessible to R1 during her admission, but all R1’s belongings were in the room for her responsible party. 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 conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 15, 2025 · control 15-AS-20250205174724

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(c) · Plan of correction due date: Jul 22, 2025

1569.652 Termination of admission agreement upon death of resident; removal of resident’s property... (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed... shall be issued to the individual... responsible for the fees... within 15 days after the personal property is removed. This requirement was not met as evidence by: Based on interviews the Licensee did not comply with the section cited above in refunding responsible party, which poses a potential risk.the state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: Administrator agreed to issue a refund to R1’s responsible party and submit documentation to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87469(c)(1) · Plan of correction due date: Jul 22, 2025

(c) If a resident who has an... request regarding resuscitative measures form on file experiences a medical emergency, facility staff shall do one of the following: (1) Immediately telephone 9-1-1, present... form to the responding emergency medical personnel... This requirement was not met as evidence by: Based on interviews and record review the Licensee did not comply with the section cited above in presenting documents to emergency personnel, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: Administrator agreed to read and review regulation 87469, and submit a self-certification that the facility will abide by the regulation going forward to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(g) · Plan of correction due date: Jul 22, 2025

(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis... This requirement was not met as evidence by: Based on interviews the Licensee did not comply with the section cited above in immediately contacting 9-1-1, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: Administrator agreed to implement a plan of what staff shall do when there is circumstance to a resident health including, but not limited to, an apparent life-threatening medical crisis and submit plan to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(6) · Plan of correction due date: Jul 22, 2025

(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement was not met as evidence by: Based on interview and record review the Licensee did not comply with the section cited above in have a MAR for R1, which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Jul 15, 2025

Plan of correction: Administrator agreed to complete record keeping training by an authorized vendor and submit certifications to CCLD by POC date.

Type of visit: Case Management - Other

On 7/15/2025, at 1:35pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding a POC visit dated February 13, 2025. LPA met with Herminio Hernandez, Caregiver. LPA spoke with Laly, Bascao, Caregiver, via telephone and explained the purpose of the visit. LPA arrived to deliver an amended plan of correction report (POC) that was generated on February 13, 2025, and to explain the civil penalties. An appeal was requested on February 19, 2025, for the civil penalties assessed. The response to the appeal dated May 14, 2025, indicated the Department would amend the report issued on February 13, 2025, to reflect the correct amount. The facility was assessed civil penalties for two (2) uncorrected deficiencies. The regulations cited were 87307(3)(c) and 87211(a)(1). Regulation 87211(a)(1) was previously cited on November 21, 2024, and recited on February 13, 2025. Regulation Continued on LIC809C. Continued from LIC809. 87307(3)(c) was previously cited on August 30, 2024, and recited on February 13, 2025. Therefore, when the LPA conducted the POC visit and observed the deficiencies were still not corrected civil penalties were assessed of $100.00 per day for each deficiency until corrected. The LPA amended the report to correct a typo. The typo that originally showed on the report dated February 13, 2025, that each deficiency was $100.00 x 2 = $1400.00, but should have shown each deficiency was $700.00 x 2 = $1400.00. The LIC421FC’s dated February 13, 2025, reflects the correct amount of the civil penalty, which is $700.00 for each deficiency for a total of $1400.00. No deficiencies cited during the visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 15, 2025

Type of visit: Required - 1 Year

On 6/5/2025 at 1:45pm, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year required inspection. LPA met with Laly Bascao, Caregiver, Caregiver, and explained the purpose of the visit. The facility’s fire clearance was approved for four (4) ambulatory, two (2) non-ambulatory, of which one may be a bedridden resident. Facility has a hospice waiver for two (2). LPA toured the facility with Caregiver including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of six (6) total bedrooms two one-half (2-1/2) bathrooms. LPA observed pool in the backyard has locked gate. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 99.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 11/23/2024. Emergency Disaster Plan was last reviewed on 5/1/2025. First aid kit was observed to be complete. Continued on LIC809. Continued from LIC809. LPA reviewed five (5) staff and all six (6) resident records. LPA reviewed a sample of three (3) residents' medication. LPA observed the following deficiencies: At 2:15pm, LPA observed during record review there was not any training conducted by staff. At 2:50pm, LPA observed R6 did not have dresser/chest of drawers in the bedroom, R1 did not have a dresser/chest of drawers in the bedroom, and R2 did not have a night stand or lamp in the bedroom. At 3:00pm, LPA observed facility has one (1) bedridden, five (5) total non-ambulatory, and one (1) ambulatory resident, which does not meet fire clearance. At 3:05pm, LPA observed a walker, hoyer lift, 7 wheelchairs, a broken table, and 4 raised toilet seats in back yard, behind and on right side of house in back yard. At 3:07pm, LPA observed exit gate locked with padlock on right side of house. At 3:13pm, LPA observed insulin unlocked in refrigerator. At 4:30pm, LPA observed facility was no conducting fire drills. *An immediate civil penalty of $1000.00 will be assessed on today's date* ($500.00 for 87705(f) for padlock and $500.00 for 87202(a)(1) fire clearance for non-ambulatory). Continued on LIC809C. Continued from LIC809C. LPA requested the following documents to be submitted to CCLD by 6/12/2025. Resident Roster LIC 308 Designation of Administrative Responsibility Liability insurance. LIC 500 Personnel Report LIC 610E Emergency Disaster Plan. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights, LIC421M, and this report providedthe state’s words, verbatim · CDSS document, Jun 5, 2025

Type of visit: Case Management - Other

On 03/19/20250:45am, Licensing Program Analyst (LPA), L. Hall conducted an unannounced case management regarding an exception request. LPA met with Mary Lorraine Adriatico, Caregiver, and explained the reason for the visit. LPA spoke with Administrator, Ding Wang, via telephone. Upon arrival LPA observed two (2) staff, one (1) resident walking around the facility, one (1) resident eating at the kitchen table, and the other three (3) resident in their rooms. LPA reviewed R1, R2, R3, and R4's file. Scanned copies of R2 and R3 physician's report. Administrator emailed a copy of R1's physician report to LPA during visit. No deficiencies cited during visit. Exit interview and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 19, 2025

Type of visit: POC

On 2/13/2025, at 1:15PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a proof of correction (POC) visit. LPA met with Rosalita Constantino, Caregiver and explained the purpose of the visit. LPA conducted a case management visit on 1/30/2025 and cited for the following deficiency that has been corrected. 87303(e)(5), LPA observed shared bathroom and private bathroom in master bedroom have non skid mats. LPA conducted a case management visit on 1/30/2025 and cited for the following deficiencies that has not been corrected. 87307(3)(c), LPA observed facility does not a sufficient supply of linen and towels for residents. LPA observed 4 flat sheets, 0 fitted, a beach towel and one (1) bath towel, five (5) comforters, a lot of pillow cases and hospital blankets. 87211(a)(1), LPA observed that incident reports for R1 and R2 was not submitted for their hospitalization. Continued on LIC809C. Continued from LIC809. *LPA arrived to amended the report to reflect $100.00 should have been $700.00* Each uncorrected deficiency is $700.00 x 2 = $1400.00. Civil Penalties in the total amount of $1400.00 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiencies are corrected. Exit interview conducted. A copy of this report, LIC421FC, and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 13, 2025

Allegation investigated: Facility staff not ensuring facility bathroom is maintained in good repair

On 1/30/2025 at 2:10pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Rosalita Constantino and explained the reason for the visit. LPA spoke with Administrator, Ding Wang, via telephone. During the course of the investigation the Department conducted interviews with staff, witnesses, and toured facility. Allegation: Facility staff not ensuring facility bathroom is maintained in good repair Based on observation the shared bathroom was in disrepair. S1, S2, and S3 stated during interviews that caregivers use the master bathroom to give baths to residents. Continued on LIC9099C. Substantiated Continued from LIC9099. Based on LPA observation and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D. Exit interview conducted. A copy of the appeal rights and this report provided. Continued from LIC9099. did not mention observation of this to R1 or any other residents. R1 was not interviewed due to diagnosis. Staff stated during interviews that no one handles any of the resident roughly. LPA was not able to interview W1. Allegation: Facility staff yells at resident(s) W1 stated during initial interview that R1 is hard of hearing and staff yells at R1. Based on LPA's observation the staff do yell in order for R1 to hear them. LPA observed R1 asking staff to speak up. Staff stated they are not yelling to be malicious, but R1 can't hear them. Allegation: Facility staff unable to communicate with residents and others due to language barrier W1 stated during in initial interview there were three (3) staff that are not able to communicate with the residents due to a language barrier. S1 stated all staff are able to communicate. Some have heavier accents than others but all can communicate. LPA interviewed the staff in question S2, S3, and S4. S2 had the heavier accent and did not understand everything LPA but was able to answer and communicate. The other two (2) staff in question did not have a communication problem. LPA observed all three (3) of the staff in question communicate with the residents. Allegation: Facility staff not ensuring adequate amount of food is stored at facility W1 stated during initial interview that there is never an adequate amount of food at facility. LPA's initial visit was 8/30/2024, and LPA observed facility had food on that date. S3 stated during interview that facility does run short of food a lot. S3 said he has Continued on LIC9099C. Continued from LIC9099C. purchased some food items before. S4 stated he doesn't do any cooking that he only cleans the kitchen. S1 stated the staff will advise and make a list of foods to purchase. On today's date LPA observed facility had a sufficient amount of perishables, non-perishables, and snacks. Based upon the information obtained during and the interviews conducted during the investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Jan 30, 2025 · control 15-AS-20240826114945

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Feb 6, 2025

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having the tub in the shared bathroom in repair, which poses a potential health and safety risk to person in care.the state’s words, verbatim · CDSS document, Jan 30, 2025

Plan of correction: The administrator repaired the bathtub and submitted photos to CCLD on 11/13/2024. Deficiency cleared.

Allegation investigated: Staff did not ensure that resident received medical care after sustaining an injury. Staff did not ensure resident received medication as prescribed

On 1/30/2025 at 12:25pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Rosalita Constantino, Caregiver and explained the reason for the visit. LPA spoke with Administrator, Ding Wang, via telephone. During the course of the investigation the Department conducted interviews with staff, witness, obtained and reviewed records. Allegation: Staff did not ensure that resident received medical care after sustaining an injury. Based on initial interview with W2 staff did not ensure R1 received medical care after falling and sustaining an injury. S1 stated R1 fell and sustained injuries at Continued on LIC9099C. Substantiated Continued on LIC9099C. approximately 3:35am, on November 17, 2024. On November 21, 2024, R1 had a video doctor’s appointment. S1 stated the doctor saw the injury and was not concerned. S1 stated R1’s vitals were checked, he was not bleeding, and he was still walking around, therefore, S1 felt there was not a need for medical attention. S3 stated while doing rounds she observed R1 on the floor and that R1 possibly hit his drawer. S3 stated she did not see any blood and monitored R1’s blood pressure. S3 also stated she contacted S1 but no one else. LPA observed a bruised eye and a cut above R1’s eye during visit on November 21, 2024. LPA also obtained a photo of R1 from S1 of R1’s eye. S1 stated the cut above R1’s eye occurred at another facility. Both S1 and S3 stated that R1 did not receive any medical care after sustaining an injury. Allegation: Staff did not ensure resident received medication as prescribed During initial interview with W1 it was indicated that R1 had a medical/phone appointment on November 15, 2024. A new prescription was prescribed on the day of the medical/phone appointment and as of November 20, 2024, the medication had not been picked up by staff to ensure R1 was receiving medication as prescribed. S1 stated during video appointment on November 21, 2024, she asked who will be delivering the medication for R1 and was told the facility needs to pick up the medication. On November 25, 2024, S1 sent an email to LPA with a picture showing three (3) prescriptions that had been picked up for R1. Continued on LIC9099C. Continued from LIC9099D Based on LPA observations, interviews which were conducted, and record reviews, 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, Chapter 8) are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Jan 30, 2025 · control 15-AS-20241120130942

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Jan 31, 2025

(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidence by: Based on interviews and record review the Licensee did not comply with the section cited above in contacting 9-1-1 after R1 sustained an injury which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2025

Plan of correction: Licensee completed a mandated report training by an authorized vendor on 12/23/2024, per the non-compliance meeting held 12/16/2024. Deficiency cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(d) · Plan of correction due date: Jan 31, 2025

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration provided... This requirement was not met as evidence by: Based on observation and record review the Licensee did not comply with the section cited above in obtaining and administering prescriptions as ordered, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2025

Plan of correction: Administrator submitted a photo of medication to CCLD on 11/25/2024. Deficiency cleared.

Allegation investigated: Financial abuse Family is not notified of incidents involving resident.. Facility increased resident's fees without proper notification.

On 1/30/2025 at 1:30pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Rosalita Constantino and explained the reason for the visit. LPA spoke with Administrator, Ding Wang, via telephone. During the course of the investigation the Department conducted interviews with staff, witnesses, obtained and reviewed records. Allegation: Financial abuse Based on initial interview with W1, R1 had completed two withdrawal transactions of Continued on LIC9099C. Unsubstantiated Continued from LIC9099. $250.00 each at Wal-Mart, yet when R1 expired the money was not found. W1 also stated there was conversation regarding money for incontinence products between R1 and S1. S1 stated during interview there was a conversation to pay more for incontinence products and R1’s cat, but S1 stated she never received any additional money. S1 stated R1 and S2 had went to the bank and obtained cash. S1 also had knowledge that R1 had bought candy and clothes. S2 stated during interview that he went with R1 to Wal-Mart two days. S2 recalled R1 had obtained money during the outing and bought candy. S2 stated that R1 had given him $100.00, and he gave $20.00 back to R1. Based on interviews R1 handled her own money, furthermore there is not enough evidence to prove any financial abuse. Allegation: Family is not notified of incidents involving resident. W1 stated during initial interview that a witness was told by the Pittsburg Police Department that R1 had recently been discharged from a hospital in Modesto. W1 stated the facility did not notify the family about any hospitalization. W1 was not able to give an exact date, but it was approximately two weeks prior to R1 expiring. W3 stated there was an after-summary visit document dated May 7, 2024, along with medications sitting on the dresser of R1’s room. During record review of the after-summary visit from Pittsburg Health Center Family Medicine it indicated the visit was a follow-up visit from a hospital. The summary did not specify when R1 visited the hospital or which hospital was visited. S1 stated she was not aware of R1 going to a hospital in Modesto. S1 did not have any documentation for R1. Continued on LIC9099C. Continued on LIC9099C. Allegation: Facility increased resident's fees without proper notification. During initial interview W1 stated S1 admitted a conversation was held between S1 and R1 regarding paying more money to the facility for extra services being provided. W1 stated R1 was not given the proper notification for the increase of fees. W1 also stated that R1 was responsible for signing her own paperwork. S1 stated during interview that R1 wanted to pay more money to the facility because of the incontinent products and R1’s cat. S1 also said the facility never received any additional money for any fees, and it was only a conversation. Based upon the interviews conducted and the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview conducted and a copy of report was given.the state’s words, verbatim · CDSS document, Jan 30, 2025 · control 15-AS-20240513172348

Type of visit: Case Management - Other

On 1/30/2025 at 10:00am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding an text message that was sent to LPA on 1/14/2025. LPA met with Rosalita Constantino, Caregiver and explained the purpose of the visit. LPA spoke with Administrator, Ding Wang, via telephone. The text message was from Administrator, and stated there were only three (3) residents and one (1) staff in the day and at night. LPA arrived to find there were four (4) residents and one (1) caregiver. LPA L. Hall requested the after-summary visits for R1 and R2 to be sent to CCLD by 2/1/2025. LPA observed the following deficiencies. At 10:20am, LPA observed the facility did not have a sufficient quantity of towels for residents. LPA observed beds missing top sheet, mattress pads, and bedspread. At 10:35am, LPA observed shared bathroom did not have a slip-resistant mat. At 11:15am, LPA observed during record review that R1 and R1 was hospitalized and CCLD was not notified. Continued on LIC809C. Continued from LIC809. *A civil penalty of $500.00 total ($250.00 each) will be assessed on today's date for repeat violations of regulations 87307(3)(c) and 87211(a)(1).* The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the LIC421FC, this report and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 30, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(3)(c) · Plan of correction due date: Feb 6, 2025

(3) Equipment and supplies necessary for personal care... shall be readily available to each resident. (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often... clean linen is in use by residents at all times. This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having suffiencient linen for residents, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2025

Plan of correction: Administrator agreed to purchase towels and enough linen for each resident. Administrator will submit photo to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(e)(5) · Plan of correction due date: Feb 6, 2025

(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Slip-resistant mats, strips, or flooring shall be used in all bathtub and shower floors. This requirement was not met as evidence by: Based on observation the Licensee did not comply wiht the section cited above in having a non slip mat in the shared bathroom tub, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2025

Plan of correction: Administrator agreed to purchase non skid mat and submit photo to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Feb 6, 2025

(a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section above in reporting incidents for R1 and R2 to CCLD, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2025

Plan of correction: Administrator agreed to submit incident reports for R1 ad R2 to CCLD by POC date.

Type of visit: Case Management - Other

On 11/21/2024 at 4:35pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Ding Wang, Administrator, and explained the reason for the visit. While LPA L. Hall was conducting a complaint investigation 15-AS-20241120130942 on 11/21/2024. During tour of facility LPA observed the following deficiencies. LPA observed, a reverse door knob on room # 5 was locked and R1 was inside. LPA observed room #6 door was locked, when open LPA observed (S4) male sitting on the bed in room LPA observed during record review R1 did not have an admission agreement, consent for medical treatment, and emergency contact and identification. LPA observed during record review facility did not report hospitalization for R1. LPA observed during review of R1's medication that three (3) medication was missing. *An immediate civil penalty of $250.00 will be assessed on today's date for a repeat violation and $200.00 for fingerprint. A total of $450.00. Continued on LIC809C. Continued from LIC809. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights, LIC421FC, LIC421BG, and this report.the state’s words, verbatim · CDSS document, Nov 21, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Dec 2, 2024

(a) Residents... shall have all of the following personal rights: (6) To... not be locked into any room... by day or night. This does not prohibit a licensee... locking doors at night to protect residents... This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in R1 having a reversed door knob and being locked inside bedroom, which poses a potential health and safety risk for persons in cae.the state’s words, verbatim · CDSS document, Nov 21, 2024

Plan of correction: Administrator agreed to have a new door knob placed without a lock or reverse the door knob with the lock being inside the room for resident.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(b) · Plan of correction due date: Dec 2, 2024

(b) Each resident’s record shall contain at least the following information: Based on LPA record review the licensee did not comply with the section cited above in having R1's file completed, which poses a potential health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Nov 21, 2024

Plan of correction: Administrator agreed to obtain admission agreement, consent for medical treatment, emergency contact and identification, and submit forms to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(d) · Plan of correction due date: Nov 25, 2024

(d) If the resident is unable to determine his/her own need for a prescription or nonprescription... and is unable to communicate... facility staff ... shall be permitted to assist the resident with self-administration provided all of the following requirements are met: This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having 3 prescribed medications available for R1 for administration which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 21, 2024

Plan of correction: Administrator agreed to obtain medication for and submit a copy of the prescription and the bottle of medication to CCLD by POC date

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1) · Plan of correction due date: Nov 25, 2024

(a) Each licensee shall furnish to the licensing agency such reports as the Department may require...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement was not met as evidence by: Based on record review and interview the Licensee did not comply with the section cited above in report R1's hospitalization, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 21, 2024

Plan of correction: Administrator agreed to submit an LIC624 for R1's hospitalization to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(d) · Plan of correction due date: Nov 22, 2024

(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement was not met as evidence by: Based on record review and interview the Licensee did not comply with the section cited above in have a S4 residing in facility with a clearance, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 21, 2024

Plan of correction: Administrator agreed to get S4 fingerprinted or submit document stating S4 will not be residing in the facility to CCLD by POC date.

Allegation investigated: Facility accepted a resident with a higher level of care need.

On 11/1/2024 at 11:05am, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegation above. LPA met with Wilfredo Bacani, Caregiver and explained the purpose of the visit. Administrator, Ding Wang, arrived at 11:55am. During the investigation the LPA interviewed staff, witness, obtained and reviewed records. Allegation: Facility accepted a resident with a higher level of care need. Based on review of Kaiser medical records R1 was discharged on 4/22/2024. W1 stated during interview that R1 was discharged to Angel Care Home on 4/22/2024 with the Continued on LIC9099C. Substantiated Continued from LIC9099. intentions that staff would be able to assist R1 with conditions that required a skilled professional to handle. W1 stated S1 affirmed that S1 was licensed to aid R1. W1 further stated home health was to begin on 4/23/2024 for R1 but being that the staff was not trained to assist R1 with the level of care that was needed home health denied R1’s admittance to services. W1 stated there was a conversation with S1 and S1 sent R1 to the emergency room. S2 stated during interview that R1 came and left the same day but did not give a date. S1 stated during interview that R1 was discharged to facility on 4/24/2024, on hospice services. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Based on LPA’s interviews which were conducted and record reviews, 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, Chapter 8), are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Nov 1, 2024 · control 15-AS-20240424150504

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Nov 2, 2024

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidence by: Based on interviews and record review the Licensee did not comply with the section cited above in providing care and services to meet the resident needs, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Nov 1, 2024

Plan of correction: Administrator agreed to implement a plan to ensure when accepting a resident that requires a higher level of care, supervision, and services the facility will be able to meet their needs and submit plan to CCLD by POC date.

Allegation investigated: Staff did not prevent a resident from sustaining a pressure injury while in care Staff did not apprise the resident's family of the resident's pressure injury while in care.

On 9/6/2024 at 1:20pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Wilfredo Bacani, Caregiver, and explained the purpose of the visit. LPA spoke with Administrator, Ding Wang, via telephone. The Department concluded a complaint investigation and substantiated the following two (2) allegations: staff did not prevent a resident from sustaining a pressure injury while in care, and staff did not apprise the resident’s family of the resident’s pressure injury while in care. Based on the investigation, it was revealed that staff neglect resulted in R1 developing pressure injuries. Continued on LIC9099C. Substantiated During the investigation the Department interviewed the reporting party (RP), staff, a witness (W1), obtained and reviewed R1’s medical records from Contra Costa Regional Medical Center. R1 was admitted to this facility from Contra Costa Regional Medical Center (CCRMC) on 10/6/2023. R1’s discharge diagnosis was major neurocognitive disorder, due to vascular disease, with mild behavioral disturbance. No pressure injuries were noted but the plan of care notes dated 10/6/2023, listed R1 as “at risk for skin impairment”. Interviews and Contra Costa Regional Medical Center records indicated that on 1/2/2024, R1 was admitted to CCRMC with a chief complaint of a wound check. R1 was assessed and was diagnosed with a stage four pressure injury on his right hip, an unstageable pressure injury on his left buttocks, a stage one pressure injury on his right knee, and a deep tissue pressure injury on his left hip and left heel. On 6/4/2024, interviews with facility staff (S2 and S3) stated, R1 had one pressure injury on his buttocks /coccyx area. S2 described it as a “small wound, that was kind of open”. S2 added that she reported this to the administrator (S1) when she saw the wound and that wound “needs treatment”. S1 was interviewed and she made inconsistent statements about what happened with R1. S1 initially stated she only saw one pressure injury on R1’s right hip, but during a follow-up interview admitted to seeing the other pressure injuries. S1 did not consider the “wounds” as pressure injuries because they were not “open” but referred as “black spots bruises”. Based on the investigation, staff did not apprise the resident’s family of the resident’s pressure injury while in care. Continued on LIC9099C. Continued from LIC9099C. During interview with W1 on 03/27/2024, it was stated that she was not aware that R1 had any pressure injuries. W1 was notified by the hospital that R1 was admitted. Furthermore, the facility did not furnish to the licensing department a report of a serious injury as determined by the attending physician and occurring while the resident was under facility supervision. This will be addressed separately on a case management visit. Deficiencies are cited under the California Code of Regulations, Title 22, Division 6, follows on LIC9099D. *A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to injury of client is pending. * Exit interview conducted. A copy of the appeal rights, LIC421M, and this report provided.the state’s words, verbatim · CDSS document, Sep 6, 2024 · control 15-AS-20240212113726

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Sep 7, 2024

87468.2 (a) In addition to the rights listed in Section 87468.1... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not as evidence by: Based on interview and record review the Licensee did not comply with the section cited above in preventing resident from having pressure injury, which poses an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 6, 2024

Plan of correction: Licensee agrees to attend the mandatory noncompliance conference (NCC). Date to be sent later. *A civil penalty of $500.00 was assessed on today's date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Sep 7, 2024

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes... or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidence by:the state’s words, verbatim · CDSS document, Sep 6, 2024

Plan of correction: Licensee agrees to attend the mandatory noncompliance conference (NCC). Date to be sent later.

Type of visit: Case Management - Other

On 9/6/2024 at 02:05pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Wilfredo Bacani, Caregiver, and explained the purpose of the visit. While LPA L. Hall was investigation complaint (15-AS-20240212113726) and delivered findings on 9/6/2024. During record review LPA observed R1’s file was not available for review and facility did not report R1's incident to CCLD. *An immediate civil penalty of $500.00 will be assessed on today's date* 87211(a)(1) = 1x $250.00 87506(a) = 1x $250.00 Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, Sep 6, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Sep 13, 2024

87211 (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement was not met as evidence by: Based on observation and record review the Licensee did not comply with the section cited above in submitting an incident report for R1, which poses a potential health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Sep 6, 2024

Plan of correction: Administrator agreed to review regulation 87211 and submit self-certification that facility will abide by regulation going forward to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Sep 13, 2024

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 was not met as evidence by: Based on observation, interview, and record review the Licensee did not comply with the section cited above in having R1's file available for review, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 6, 2024

Plan of correction: Administrator agreed to review regulation 87506 and submit self-certification that facility will abide by regulation going forward to CCLD by POC date.

Type of visit: Case Management - Other

On 8/30/2024 at 03:10pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Wilfredo Bacani, Caregiver. While LPA L. Hall was conducting a complaint investigation 15-AS-20240826114945 on 8/30/2024, LPA observed the following during visit: Residents do not have mattress pads, top sheets, and some do not have bedspreads. LPA observed two (2) clean face towels, no hand towels, and three (3) bath towels. LPA observed unlocked kitchen drawer containing knives. LPA observed S3 file was not available for review. Facility will be assessed at $250.00 civil penalty for a repeat violation for 87705(f)(1). Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of the appeal rights and this report provided.the state’s words, verbatim · CDSS document, Aug 30, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(3)(C) · Plan of correction due date: Sep 6, 2024

(3) ...supplies necessary for personal care and maintenance... shall be readily available to each resident. ...if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall... at least once per week or more often... This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having sufficent linen for residents, which poses a possible health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 30, 2024

Plan of correction: Administrator agreed to purchase additonal linen including towels and submit receipt and photo of new items to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(f) · Plan of correction due date: Sep 6, 2024

87412 Personnel Records (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement was not met as evidence by: Based on observation and record review the Licensee did not comply with the section cited above in having S3's file available for review, which poses a potential health and safety risk to persons in care..the state’s words, verbatim · CDSS document, Aug 30, 2024

Plan of correction: Administrator agreed to have S3's file readily for review at facility ad submit a self certification to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1) · Plan of correction due date: Aug 31, 2024

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having knives locked and inacessible to residents, which poses a health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Aug 30, 2024

Plan of correction: Caregiver locked kitchen drawer containing knives. Deficiecency cleared.

Type of visit: Case Management - Other

On 5/21/2024 at 1:00pm Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Administrator, Ding Wang, and explained the purpose of the visit. While LPA L. Hall was conducting a complaint investigation (15-AS-20240513172348) on 5/21/2024. LPA requested R1's file for review and S1 stated someone took R1's binder. The following deficiencies were observed during visit. LPA observed R1's binder was not available for review. LPA observed S1 did not submit death report for R1. LPA observed each resident MAR (Medication Administrative Record) was not accurate. Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights providedthe state’s words, verbatim · CDSS document, May 21, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e) · Plan of correction due date: May 28, 2024

87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement was not met as evidence by: Based on observartion the Licensee did not comply with the section cited above in having R1's records available for review, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 21, 2024

Plan of correction: Administrator agreed to implement a plan on how and where records will be retained following termination of a resident to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(A) · Plan of correction due date: May 28, 2024

(a) Each licensee shall furnish to the licensing agency such reports... including, but not limited to... (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven day... This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment... A) Death of any resident from any cause regardless of where the death occurred...This requirement was not met as evidence by: Based on observation the Licensee did not comply with the seciton cited above in reporting R1's death to CCLD, which poses a potential health and safety risk to person in care.the state’s words, verbatim · CDSS document, May 21, 2024

Plan of correction: Adminstrator agreed to submit a complete death report for R1 to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(c)(3) · Plan of correction due date: May 28, 2024

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. Based on observation and record review the Licensee did not comply with the section cited above in having an accurate MAR for each resident, which poses a potential health and safety risk for persons in care.the state’s words, verbatim · CDSS document, May 21, 2024

Plan of correction: Administrator agreed to have an in-service training regarding record keeping for medication and submit complete training to CCLD by POC date.

Type of visit: Required - 1 Year

On 4/30/2024 at 10:30am, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Mary Lorraine Adriatico, Caregiver, and explained the purpose of the visit. Ding Wang, Administrator arrived at 11:05am. The facility’s fire clearance was approved for four (4) ambulatory, one (1) non-ambulatory, and one (1) bedridden resident. Facility has a hospice waiver for two (2). LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of six (6) total bedrooms two one-half (2-1/2) bathrooms. LPA observed pool in the backyard has locked gate. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 100.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last purchased on 04/24/2024. Emergency Disaster Plan was last posted on 9/1/2023. First aid kit was observed to be complete. Continued on LIC809. Continued from LIC809. LPA reviewed four (4) staff files. All five (5) residents' file were reviewed and a sample of resident's medication. LPA observed the following deficiencies: At 11:45am, LPA observed Comet can powder, Comet spray disinfectant in unlocked cabinet underneath kitchen sink. At 11:45am, LPA observed knives and scissors in unlocked drawer next to stove. At 12:00pm, LPA observed bathroom disinfectants and fabuloso in unlocked shared bathroom cabinet underneath sink. At 12:03pm, LPA observed R5 in a non-ambulatory room. At 12:05pm, LPA observed Comet underneath sink and toilet cleaner tablets in unlocked drawer in master bathroom. At 2:10pm, LPA observed closet doors, bed rails, shower doors, wooden planks, 2 wheelchairs, 2 walkers, and 3 commodes located on right side of facility in back yard. At 12:25pm, LPA observed facility has hospice waiver for two (2), but have three (3) hospice residents. At 3:00pm, LPA observed Administrator did not have a current administrator certificate. At 3:15pm, LPA observed R4 with full-bed rail and no doctor's order. Continued on LIC809C. Continued from LIC809C. LPA requested the following documents to be submitted to CCLD by 5/7/2024. Resident Roster LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. *An immediate civil penalty of $500.00 for two (2) repeat violations will be assessed on today's date* Exit interview conducted. A copy of appeal rights, LIC421FC, and this report provided.the state’s words, verbatim · CDSS document, Apr 30, 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 - Health Checks

On 2/13/2024 at 12:20pm, Licensing Program Analyst (LPAs), L. Hall and T. Syess-Gibson arrived unannounced to conduct a health and safety check as a result of the department receiving a complaint (15-AS-20240212113726). LPAs met with Ding Wang, Administrator and explained the reason for the visit. During the health and safety check LPA toured the facility with the Administrator including but not limited to common areas, bedrooms, back yard, and kitchen. Upon arrival LPA observed S3 was not associated to the facility. A bottle of medicine was sitting on the table and the medicine cabinet was unlocked. The following deficiencies were observed during the check: At 9:40am, LPAs observed S3 was not associated and during record review that R3 was not fingerprint cleared. At 9:40am, LPAs observed medicines were in unlocked closet and there was a bottle of Tylenol sitting on the kitchen table. At 9:55am, LPAs observed unlocked kitchen drawer containing knives, a bottle of S2 medication in unlocked kitchen cabinet, and a pair of scissors sitting on kitchen counter top in utensil dryer. At 10:05am, LPAs observed rotting fruit sitting on kitchen table and rotting vegetables in refrigerator. Facility did not have a 7-day supply of non-perishables and 2-day of perishables for the residents. Continued on LIC809C. Continued from LIC809. 10:40am, LPAs observed R2, R3, and R4 resided in ambulatory rooms per fire clearance. At 10:45am, LPAs observed hot water temperature in residents' shared bathroom measured at 133.5 degrees F. and Ajax and Windex under unlocked bathroom cabinet. At 10:50am, LPAs observed via interview and record review S1 did not report any deaths, hospitalization's, or positive COVID incidents. At 10:50am, LPAs observed during via interview and record review that S1 did not notify CCLD of hospice residents. At 10:50am, LPAs observed facility did not obtain a hospice care plan for R3 and R4. At 10:50am, LPAs observed during record review that staff files were incomplete and not current. At 10:50am, LPAs observed during record review that resident files were incomplete and not current. At 11:00am, LPAs observed during record review that there were not any training records for staff in files. At 11:30am, LPAs observed during record review that the medication administration record (MAR) did not match the medications that were given to R2. MAR for R3 has not been updated since 2/3/2024. There was not a MAR for review for R4. At 11:40am, LPAs observed Administrator was not meeting the qualifications and duties of an Administrator as specified in the regulation 87405. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Continued on LIC809C. Continued from LIC809C. An immediate $2000.00 civil penalty will be assessed on today's date for the following: Exit interview conducted. A copy of the LIC421FC, LIC421M, LIC421BG, this report, and appeal rights providedthe state’s words, verbatim · CDSS document, Feb 13, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(1) · Plan of correction due date: Feb 14, 2024

87202(a) All facilities shall maintain a fire clearance approved by the city, county... department, or district providing fire protection services... Prior to accepting or retaining... licensee shall notify the licensing agency and obtain an appropriate fire clearance... (1) Non ambulatory persons. This requirement was not met as evidence by: Based on observation and record review the Licensee did not comply with the section cited above in have 3 non-ambulatory residents in ambulatory rooms, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 13, 2024

Plan of correction: Administrator agreed to either move residents to non-ambulatory or submit updated facility sketch and LIC200 to have a new fire clearance to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(d)(3) · Plan of correction due date: Feb 14, 2024

87355 (d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement... (3) The licensee shall submit these fingerprints... for the purpose of searching the records... prior to the individual's employment, residence, or initial presence in the facility. This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having S3 fingerprinted before working at facility which poses a potential immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 13, 2024

Plan of correction: Administrator agreed to get S3 fingerprinted and submit proof to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(1) · Plan of correction due date: Feb 14, 2024

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in having knives and scissors accessible to residents, which poses/posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 13, 2024

Plan of correction: Administrator locked knives away making them inaccessible to residents. Deficiency cleared during visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303( · Plan of correction due date: Feb 14, 2024

87303 (e)Water supplies and plumbing fixtures shall be maintained as follows: (2)Faucets used by residents... Hot water temperature controls shall be maintained... to attain a temperature of not less than 105 degree F and not more than 120 degree F. This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in have hot water between 105-120, which poses/posed an immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 13, 2024

Plan of correction: Administrator agreed to adjust water temperature between 105 - 120 and submit photo to CCLD by POC date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Feb 14, 2024

87465 (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited in have medications locked and inaccessible, which poses/posed a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 13, 2024

Plan of correction: Caregiver locked put away medication and locked closet immediately during visit. Deficiency cleared during visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Feb 20, 2024

87211 (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement was not met as evidence by: Based on interview and record review the Licensee did not comply with the section cited above in reporting incidents to CCLD, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 13, 2024

Plan of correction: Administrator agreed to submit incident reports/death report for R1, R4, and R5 to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87632 · Plan of correction due date: Feb 20, 2024

87632 (d) ...a hospice care waiver it shall stipulate terms and conditions of the waiver... to ensure the well-being of terminally ill residents... which shall include..., the following requirements: (2)The licensee shall notify the Department in writing within five working days of the initiation of hospice care... or within five working days of admitting a resident already receiving hospice care services... This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in notifying CCLD about hospice residents, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 13, 2024

Plan of correction: Administrator agreed to submit a hospice notification for R3 and R4 to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 877405(a) · Plan of correction due date: Feb 20, 2024

87405 (a) All facilities shall have a qualified and currently certified administrator...The administrator shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility... When the administrator is not in the facility, there shall be coverage by a designated substitute... This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above by not having adequate attention to the management and administration of the facility , which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 13, 2024

Plan of correction: Administrator agreed to review regulation 87405 and submit a self-certification that the regulation have been reviewed and the facility will abide by the regulation going forward to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: Feb 20, 2024

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having all personnel records complete and current, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 13, 2024

Plan of correction: Administrator agreed to complete all personnel files and have them available for review, and will submit Health screenings, First aid, and TB test to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Feb 20, 2024

87506 (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 was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in have complete and current records for residents, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 13, 2024

Plan of correction: The administrator agreed to complete all resident files and submit a copy of the physician's report, admission agreement, and the appraisal needs and services plan for each resident to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(26) · Plan of correction due date: Feb 20, 2024

87555 (b) The following food service requirements shall apply: (26)Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidence by: Based on observation the Licensee did not comply with the section cited above in have 1 week perishable and 2-day non perishable foods for residents, which poses a potential health and safety risk to persons in carethe state’s words, verbatim · CDSS document, Feb 13, 2024

Plan of correction: Administrator agreed to purchase food and submit photo and receipts to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Feb 20, 2024

87411 (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 was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having annual training for staff, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 13, 2024

Plan of correction: Administrator agreed to have all staff with required training and submit certifications to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87633(a)(4) · Plan of correction due date: Feb 20, 2024

87633 (a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon... to reside in the facility and receive hospice services from a hospice agency... (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident... This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having a hospice plan for R3 and R4, which poses a potential health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Feb 13, 2024

Plan of correction: Administrator obtain the hospice care plan for R3 and R4 during visit. Deficiency cleared during visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: Feb 20, 2024

87465 (h) The following requirements shall apply to medications which are centrally stored: (6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement was not met as evidence by: Based on record review the Licensee did not comply with the section cited above in having the medication administrator record (MAR) current and aligned with resident's medication, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 13, 2024

Plan of correction: Administrator agreed to review and correct the MAR for each resident for the month of February and submit a copy to CCLD by POC date.

Type of visit: POC

On 9/29/2023 at 3:30pm, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct proof of correction (POC) visit. LPA met with Mary Lorraine Adriatico, Caregiver, and explained the purpose of the visit. LPA spoke with Administrator, Ding Wang, via telephone LPA conducted a case management visit on 9/14/2023 and cited facility for the following: 87506(a) Resident records - LPA observed during today's visit both client records are complete. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 29, 2023