Anne's Place II

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Robert Campbell conducted an unannounced annual required visit. Upon entry, LPA was greeted by Maria Medero Hernandez, Caregiver, and informed them of the purpose of the visit. At the time of the visit, there were three (3) staff members and six (6) residents present. Dearme Doverte, Administrator, arrived later during the visit. Facility Overview: The facility is a one-story home with four (4) bedrooms and three (3) bathrooms, including an attached garage. There are no pools or known firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility has infection control plan in file. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents. Both the smoke detector and carbon monoxide detector were operational, and the hot water temperature was 110°F. Fire extinguisher located at kitchen had current inspection tag. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Continued on LIC809-C.... Continued... Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate. Record Review and Resident/Staff Files: LPA reviewed files for five (5) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Six (6) resident files were reviewed and contained all the required documents. Health-Related Services/Incidental Medical Services: All resident medications were securely locked in kitchen closet. LPA reviewed medications for six (6) residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. Personal & Incidental Funds: Facility doesn't handle Residents Monies. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last emergency drill conducted on 4-01-2026, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided.the state’s words, verbatim · CDSS document, May 13, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abdoulaye Zerbo conducted an unannounced visit for a required annual inspection. The LPA was greeted by the Caregiver Hortencia Chamu, notified them of the purpose for the visit and was allowed to enter the facility to conduct the inspection. The Administrator Dearme Doverte joined the visit at a later time. Facility Overview: The facility is a single story building with 3 resident bedrooms, 1 staff room, 3 bathrooms, a dinning room, an office, a kitchen, a living room and a garage. There is no gated pool and there are no firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department's requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in the kitchen and inaccessible to clients. The smoke detector and carbon monoxide detector were in good working condition. LPA observed fire extinguishers to be in compliance with the department's requirements. The water temperature was tested within regulations measuring at 111.0 F Continued 809-C.... Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The Administrator holds a current Administrator’s certificate with expiration date of 12-7-25 and a CPR certification with the expiration date of 07-20-25. Record Review and Resident/Staff Files: LPA reviewed files for 2 staff members, confirming criminal clearance, updated training, and CPR/First Aid certification. 3 residents' files were reviewed and contained all required documentation. LPA observed first kit to be locked and inaccessible to the clients in care. The clients and staff files were kept locked and inaccessible to unauthorized individuals Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a cabinet and located in the kitchen area. LPA reviewed medications for 3 residents, confirming that all medications were listed and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last emergency drill conducted on 4-01-2025, which met the department's requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed, and a copy was provided to Administrator Dearme Doverte.the state’s words, verbatim · CDSS document, May 30, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs), Stephanie Martinez and Valerie Flores, conducted an unannounced visit to the facility to address a violation observed by LPA Martinez. The LPAs met with Ana Osborne, Licensee, and informed her of the purpose for their visit. LPA Martinez observed an incomplete Resident Appraisal (LIC 603A) on file for Resident One (R1). According to R1's admission agreement the resident was admitted on 05/28/2024. The LPA observed the appraisal to have some information relating to R1's health and physical disabilities; however, the form was not completed. According to Licensee Osborne, a pre-admission appraisal was completed by herself and Staff One (S1) prior to the resident moving into the facility. No additional notes relating to the pre-admission appraisal were observed on file. LPA Martinez was informed by Licensee Osborne that R1, who left the facility for a hospitalization, was observed by staff to have additional needs not reported by the health facility that placed R1. According to Licensee Osborne, no notes documenting the staff observations were completed. Therefore, a citation will be issued. An exit interview was conducted with House Manager, Dearme Doverte; this report was reviewed, and a copy was provided, along with the LIC 811 and appeal rights.the state’s words, verbatim · CDSS document, Jun 13, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87505 · Plan of correction due date: Jul 4, 2024

Documentation and Support: Each facility shall document in writing the findings of the pre-admission appraisal & any reappraisal or assessment which was necessary in accordance w/ Sections 87457 and 87463. If supporting documentation from a physician is required, this input shall also be obtained and may be the same assessment as required in Section 87458. This requirement was not met as evidenced by: Based on interviews, the Licensee did not ensure findings from R1's pre-admission appraisal were documented. This poses a potential threat to the health, safety and personal rights of the residents in care.the state’s words, verbatim · CDSS document, Jun 13, 2024

Plan of correction: The House Manager stated in-service training relating to appraisals will be completed for managerial staff by a third party and proof will be submitted to the Department.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA), Jacqueline Shaw Ross, made an unannounced visit to the facility to conduct an annual inspection. LPA met with Stefan Rudolph, Operations Manager, who was informed of the purpose of the visit. Administrator Anna Osborne and House Manager Dearme Doverte arrived shortly. At the time of visit there were 2 staff and 5 residents present. An overall tour of the facility was conducted inside and out. The facility is licensed for six elderly non-ambulatory residents, and has an approved hospice waiver for four residents. There is approved bedridden fire clearance for one resident. There are currently three residents on hospice. LPA conducted staff and resident interviews. Tour included: Physical Plant: The facility is one story with five bedrooms and three bathrooms. The tour of the front entrance, interior and exterior surroundings were observed to be in good repair with no pathway obstruction and facility's water temperature measured at 110 degrees Fahrenheit. LPA inspected all of the residents bedrooms and observed them to be clean, and odor free. The inspection also revealed sufficient lighting and mattress pads in residents bedrooms. Furthermore, smoke and carbon monoxide detectors were also inspected and found to be in working order. All cleaning solutions were observed in a locked secure area. The facility does not house firearms and/or ammunition on grounds. Emergency drills are conducted on a quarterly basis. The last drill was conducted on 4/5/2024. Fire extinguishers were observed to be fully charged. Food Services: 7 day non-perishable and 2 day of perishable food supply were observed, and all food was properly stored and available to residents. Staff records were reviewed and contained criminal record clearance, CPR/First Aid training, Health Screening Reports, and annual training. Resident records were reviewed and had a current Physician's Report, Resident Appraisal, Identification and Emergency Information, Admission Agreement, and Centrally Stored Medication and Destruction Records. Medications were stored in a locked cabinet and were labeled and maintained in compliance with label instructions. No deficiencies were observed during today's visit. An exit interview was conducted and a copy of this report along with LIC 811 was provided to House Manager Dearme Doverte.the state’s words, verbatim · CDSS document, May 22, 2024

Allegation investigated: Licensee is resident #1's payee

Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced complaint investigation visit to deliver findings. The LPA introduced himself and disclosed the purpose of the visit to Caregiver Alexandra Leon. House Manager Dearme Doverte and Licensee Ana Osborne arrived during the visit and assisted the LPA. Throughout the investigation, the Department secured pertinent records and conducted interviews with external and internal sources, including staff and clients. It was alleged the Licensee was the assigned payee for a resident. On 12/02/2020, it was reported to the Department that the Licensee was assigned to be Resident #1’s (R1) payee. Review of records along with multiple interviews, including the Licensee, confirmed the Licensee was R1’s payee. The records did not reveal any written documented consent from R1, nor R1’s guardian. It was also revealed R1’s guardian was actively working with the Licensee to re-assign R1’s guardian as the payee for social security benefits. (See LIC 9099C for continuation of report.) Substantiated Based on evidence obtained, the allegation was Substantiated. The deficiency was cited in accordance with California Code of Regulations, Title 22, and listed on the LIC 9099D. A plan of correction was jointly formulated with Licensee Odborne. An exit interview was conducted with Doverte and Osborne, to whom a copy of this report, LIC 9099D, and Licensee/Appeals Rights (LIC 9058), were provided. The investigation did not yield enough evidence to prove the facility staff were not following this diet. It was alleged the Licensee violated a resident's personal rights. It was reported to the Department a resident was not allowed to have private telephone conversations and that the resident was not allowed to seek a new facility. Interviews with internal and external sources revealed conflicting statements regarding the resident’s desire to leave the facility, and the resident’s conservatorship status. An interview with the resident did not reveal any concerns with the facility not allowing the resident to relocate, nor the facility not allowing the resident to have private phone conversations. Interviews with the resident’s responsible party and the facility administrator revealed there had been concerns regarding a third party contacting the resident, encouraging the resident to relocate. Records obtained by the Department confirmed the resident had a guardian appointed prior to the resident being admitted. It was alleged the Licensee did not maintain accurate record keeping of the administration of medication. It was reported to the Department the facility did not document the administration of insulin for a resident. Interviews with a source revealed the resident in question was diabetic but was not prescribed insulin. Review of records, including medication records, and interviews of sources did not reveal any concerns regarding lack of documentation. Additionally, interviews along with the resident’s physician’s report revealed the resident had a history of refusing medication. An exit interview was conducted with Doverte and Osborne, to whom a copy of this report, and Licensee/Appeals Rights (LIC 9058), were provided.the state’s words, verbatim · CDSS document, Mar 29, 2024 · control 08-AS-20201202152956

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(26)(B) · Plan of correction due date: Mar 28, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (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:(26)To manage their financial affairs. A licensee shall not require residents to deposit their personal funds with the licensee. Except as provided for in approved continuing care agreements, a licensee, or a spouse, domestic partner, relative, or employee of a licensee, shall not do any of the following: (B) Become or act as a representative payee for any payments made to a resident, without the written and documented consent of the resident or the resident’s representative. This requirement was not met as evidenced by: Based on review of records and interviews, the licensee did not ensure the Licensee had prior written consent to be assigned as R1's payee, which posed a potential health, safety, and personal rights risk to 1 of 5 residents in care.the state’s words, verbatim · CDSS document, Mar 29, 2024

Plan of correction: Licensee agreed to review personal rights regulations. Resident is no longer residing at the facility, therefore, the Plan of Correction was cleared on today's date.