Annika Grace Care Home

Type of visit: Required - 1 Year

At 10:45 AM, Licensing Program Analyst (LPA) Huma Rahimi arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by the staff Leo Macam and the Administrator was contacted via telephone. The Administrator Jozam Batuian. Arrived shortly after and LPA explained the purpose of the visit. LPA and Administrator conducted a physical plant tour and the following was observed: Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility; properly stored. Knives were stored in a locked cabinet in the kitchen. Medications: Medication and Medication Records were reviewed for proper documentation. LPA review of Centrally Stored Medication and Destruction Records (CSMDR) for residents and did not observe any discrepancies. Bedrooms: There are six (6) bedrooms of which four (4) are designated for residents' use. Three (3) of the bedrooms are currently occupied. One (1) room is currently vacant. Rooms occupied by residents were properly furnished with appropriate bedding and linens with sufficient lighting. A hallway closet by the bedroom was observed to store extra linens. Bathrooms: There are three (3) bathrooms. Two (2) are designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was noted at 106.2 degrees Fahrenheit. Continued on LIC809-C Common Areas: These included the living area and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. The smoke alarms are dual carbon monoxide detectors they are hired wired and interconnected. Administrator tested smoke/carbon detectors at 11:00 a.m. and were observed to be functioning properly. The fire extinguisher is located in the kitchen and the laundry room with purchase date 07/16/2025. Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was free of hazards and has a covered patio with outdoor furniture. LPA observed a shed used for storage. The laundry room leads to the garage and is kept locked and inaccessible to residents in care. Detergents and cleaning products are kept in the laundry room locked. Between 11:15 AM to 12:15 PM, LPA reviewed records of three (3) residents and two (2) staff. Residents and staff records appeared to be complete and updated. Administrative: LPA collected Certificate of Liability Insurance, and LIC500. No deficiency issued during today’s visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Oct 1, 2025

Type of visit: Required - 1 Year

On 09/23/24 Licensing Program Analysts (LPAs) Angelica Segovia and Evelin Rios arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPAs were greeted by the Administrator Jozam Batuian. LPA observed required postings along the entry walls. LPA explained the purpose of the visit. This is a single story home with six (6) bedrooms and two (2) and a half bathrooms. The facility has an approved fire clearance for five (5) non ambulatory and one (1) bedridden resident with a total capacity of six (6) and hospice wavier for 6. At 11:35 a.m. LPAs and administrator Jozam conducted a physical plant tour and the following was observed: Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility; properly stored. Knives were stored in a locked cabinet under the sink. Cleaning solutions and poisons where also locked in the cabinet under the sink. One (1) fire extinguisher was in the kitchen fully charged. Bedrooms: There were six (6) bedrooms of which three (3) are currently designated for residents' use. Three of the bedrooms are currently occupied. Bedrooms occupied by residents were properly furnished with appropriate beddings and linens with sufficient lighting. A hallway closet by the bedroom was observed to store extra linens. Bathrooms: There are three (3) bathrooms. Two (2) are designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was taken and was at a comfortable temperature. . (Continued on LIC809-C) Common Areas: These included the living area and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. The smoke alarms are dual carbon monoxide detectors and are hard wired and interconnected. Administrator tested smoke/carbon detectors at 12:05 p.m. and were observed to be functioning properly. Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was free of hazards and has a covered patio with outdoor furniture. LPA observed a shed used for storage. The laundry room leads to the garage and is kept locked and inaccessible to residents in care. Detergents and cleaning products are kept in the laundry room locked. Resident and Staff Files: LPA conducted a file review of resident records to insure compliance of licensing forms at 12:15 p.m. LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms at 12:46 p.m. Medications: Medication and Medication Records were reviewed for proper documentation. LPA review of Centrally Stored Medication and Destruction Records (CSMDR) for three (3) of three (3) residents revealed PRN (as needed) medications were not documented in three (3) of three (3) resident records as being given when they were. Review of three (3) residents' physician's reports revealed residents are unable to determine their own need for a prescription or nonprescription PRN medication, and are unable to communicate their symptoms clearly. According to the administrator they did not document every time an as needed medication was provided. Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiency observed during the visit. Exit Interview Conducted. Appeal Rights provided. A copy of the report Issued.the state’s words, verbatim · CDSS document, Sep 23, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Facility staff did not provide records to resident's authorized representative.

On 10/09/2023 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced subsequent complaint visit for the above allegation. LPA arrived at the facility at 10:00 a.m. and was greeted by the administrator Jozam Batulan. LPA explained to Administrator the purpose of the visit. Entrance interview conducted. At 10:10 a.m. LPA and administrator Jozam conducted a physical plant tour to ensure the health and safety of the residents in care. No issues or concerns were observed. Allegation: Facility staff did not provide records to resident's authorized representative. It is alleged facility did not provide copies of Resident #1's (R1) facility records to R1's legal representative. To investigate the allegation LPA conducted an interview with the Reporting Party (RP) on 07/21/2023 and an interview with the facility administrator on 07/26/2023. Interview with administrator revealed person(s) listed on R1's Admission Agreement were designated representative(s) for R1. (Continued on LIC9099-C) Unsubstantiated On 07/26/2023 LPA reviewed and obtained copies of R1's records relevant to the investigation. LPA's review of R1's Admission Agreement, revealed R1 was admitted to the facility and the responsible person(s) listed on the document is different from representative mentioned in this complaint. Furthermore, LPA did not find a legally binding document on file that designates the representative mentioned in this complaint as conservator or POA. Based on record review and interviews, the allegation facility staff did not provide records to resident's authorized representative is Unsubstantiated at this time. No deficiencies issued. Exit interview conducted. Report signed and delivered.the state’s words, verbatim · CDSS document, Oct 9, 2023 · control 31-AS-20230718160426

Type of visit: Required - 1 Year

On 10/09/23 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by the Administrator Jozam Batuian. LPA observed covid-19 signs at the front door and required postings were observed in the entry area. LPA Rios explained the purpose of the visit. At 10:10 a.m. LPA and administrator Jozam conducted a physical plant tour to ensure the health and safety of the residents in care. The following was observed: Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility; properly stored. Knives were stored in a locked cabinet in the kitchen. Bedrooms: There were six (6) bedrooms of which four (4) are designated for residents' use. Three of the bedrooms are currently occupied. One (1) room is currently vacant. Rooms occupied by residents were properly furnished with appropriate beddings and linens with sufficient lighting. A hallway closet by the bedroom was observed to store extra linens. Bathrooms: There are three (3) bathrooms. Two (2) are designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was taken from one (1) of two (2) bathrooms at 11:48 a.m. and read 110.6 degrees Fahrenheit. Common Areas: These included the living area and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. (Continued on LIC809-C) The smoke alarms are dual carbon monoxide detectors they are hired wired and interconnected. Administrator tested smoke/carbon detectors at 12:00 p.m. and were observed to be functioning properly. The fire extinguisher is located in the kitchen and the laundry room with purchase date 08/22/23. Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was free of hazards and has a covered patio with outdoor furniture. LPA observed a shed used for storage. The laundry room leads to the garage and is kept locked and inaccessible to residents in care. Detergents and cleaning products are kept in the laundry room locked. Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms at 12:10 p.m. Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms at 12:47 p.m. Medications: Medication and Medication Records were reviewed for proper documentation. LPA review of Centrally Stored Medication and Destruction Records (CSMDR) for two (2) of two (2) residents revealed medication dosages were inaccurate for both residents. According to administrator medication dosage taken had been updated but he had not had a chance to update the dosage on CSDMR. LPA observed Destruction log record was missing for medication indicated discontinued on (CSMDR). Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiency observed during the visit. Exit Interview Conducted. Appeal Rights provided. A copy of the report Issued.the state’s words, verbatim · CDSS document, Oct 9, 2023