Applegate @ Berkshire

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 10:35AM. LPA met with facility staff upon entry. Licensee Irma Carmona and Administrator Cynthia Alvarez arrived shortly thereafter. Entrance interview conducted. Beginning at 10:42AM, the LPA, along with staff, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN/LAUNDRY/GARAGE: Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility had a sufficient supply of perishable and non-perishable food. Cleaning supplies are located in a locked under-sink cabinet. Knives are in a locked kitchen cabinet. Laundry room contains locked storage for cleaning chemicals. The LPA observed the garage to be locked and contained an office area, extra food, emergency water supply, and additional storage. BEDROOMS: There are eight (8) total bedrooms in the facility; two (2) are designated as staff rooms; which were observed to be locked. There are six (6) private resident bedrooms, all with private bathrooms and exits to the exterior. Auditory exit alarms were tested and functioned properly. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. RESTROOMS: There are six (6) private resident restrooms and one (1) visitor/staff restroom. Restrooms were clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Hot water temperature was measured in five (5) restrooms and were between 105.3-107.4 degrees Fahrenheit, which is within the required range. Report Continued on LIC 809-C. COMMON AREAS: This includes the living room and dining room areas. LPA observed common areas to be clean and properly furnished. Exit doors contain alarms and were functional at the time of the visit. LPA observed required postings in the entrance hallway. Fire extinguishers were fully charged and last purchased on 03/17/2026. Hardwired combination smoke and carbon monoxide detectors were tested at 11:09AM and all were functional at the time of the visit. No fire clearance concerns observed. OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear and free of obstruction. There were no bodies of water on the premises. RECORD REVIEW: Beginning at 11:13AM, LPA reviewed six (6) out of six (6) resident files and four (4) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training, first aid certification, and fingerprint clearance. All resident and personnel files were in order. MEDICATION REVIEW: Beginning at 12:10PM, LPA reviewed medications for two (2) of six (6) residents. Medications were centrally stored and locked inaccessible in a hallway closet. All medications reviewed were properly documented and no deficiencies were observed during medication review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control policy and emergency disaster plan. Emergency disaster plan is updated annually as required and emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 04/16/2026. All documents reviewed were updated and in compliance. Staff member Cerilla Valderrama was designated to sign the report as Licensee and Administrator were unable to remain for the rest of the visit. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Jul 9, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 10:30AM. LPA met with facility staff and Administrator Cynthia Alvarez who arrived at 11:15AM. Entrance interview conducted. Beginning at 10:33AM, the LPA, along with staff and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN/LAUNDRY/GARAGE: LPA inspected the kitchen at 10:33AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility had a sufficient supply of perishable and non-perishable food. At 10:40AM, LPA observed three (3) cans of jelled cranberry sauce expired on 04/03/2025 and three (3) dented cans of evaporated milk. Staff discarded the cans immediately. Cleaning supplies are located in a locked under-sink cabinet. Knives are in a locked kitchen cabinet. Laundry room contains locked storage for cleaning chemicals. The LPA observed the garage to be locked and contained an office area, extra food, emergency water supply, and additional storage. BEDROOMS: There are eight (8) total bedrooms in the facility; two (2) are designated as staff rooms; both staff rooms were observed to be locked. There are six (6) private resident bedrooms, all with private bathrooms and exits to the exterior. Auditory exit alarms were tested and functioned properly. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Report Continued on LIC 809-C RESTROOMS: There are six (6) private resident restrooms and one (1) visitor/staff restroom. Restrooms were clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. The restrooms were sufficiently stocked with supplies and paper towels. Hot water temperature was measured in three (3) restrooms and were between 105.3-108.7 degrees Fahrenheit, which is within the required range. COMMON AREAS: This includes the living room and dining room areas. LPA observed common areas to be clean and properly furnished. Exit doors contain alarms and were functional at the time of the visit. LPA observed required postings in the entrance hallway. Fire extinguishers were fully charged and last serviced on 04/03/2025. Hardwired combination smoke and carbon monoxide detectors were tested at 11:08AM and all were functional at the time of the visit. No fire clearance concerns observed. OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear and free of obstruction. There were no bodies of water on the premises. MEDICATION REVIEW: Beginning at 11:10AM, LPA reviewed medications for two (2) of six (6) residents. Medications were centrally stored and locked inaccessible in a hallway closet. All medications reviewed were properly documented and no deficiencies were observed during medication review. RECORD REVIEW: Beginning at 11:45AM, LPA reviewed six (6) out of six (6) resident files and three (3) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training, first aid certification, and fingerprint clearance. All resident and personnel files were in order. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control policy and emergency disaster plan. Emergency disaster plan is updated annually as required and emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 05/20/2025. All documents reviewed were updated and in compliance. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Jul 3, 2025

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: Staff are not properly trained Staff are mismanaging residents' medication

Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct an initial complaint visit at 10:32AM. LPA initially met with facility staff. Licensee Irma Carmona arrived shortly after the visit began. Entrance interview conducted. During today's visit, LPA interviewed two (2) staff members beginning at 10:33AM, interviewed Licensee, conducted a medication review for two (2) residents at 10:55AM, reviewed records and obtained copies of pertinent documents, and interviewed residents beginning at 11:39AM. The following was then determined: It was alleged that the Licensee did not provide proper medication training to facility staff. Interviews revealed that staff are trained on medication administration, including education, quizzes, and shadowing training prior to administering medications. LPA reviewed three (3) staff files and verified that all staff handling medications are trained both initially and annually on medication administration per regulation. Report Continued on LIC 9099-C. Unsubstantiated The information obtained during the investigation did not include evidence sufficient to corroborate the allegation related to proper medication training. One (1) staff file for Staff #1 (S1) observed was missing 20 hours annual training and was cited on a Case Management – Deficiencies visit during today’s visit. However, S1 does not handle or prepare medications. Interviews with staff, Licensee, and residents confirmed that S1 does not administer or prepare medications. LPA observed the remaining two (2) staff files to be complete and have no missing documents or trainings. Records confirmed that all staff handling medications receive proper medication training annually. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation that Licensee did not provide proper medication training is deemed Unsubstantiated at this time. The complaint also alleges that the facility is mismanaging residents' medications, including improper preparation and documentation of medications administered. LPA reviewed medications for two (2) residents, which were observed to be administered as ordered and documented on both the Centrally Stored Medication and Destruction Record (CSMDR) and the Medication Administration Record (MAR) in accordance with regulation. LPA observed no discrepancies during the medication review. The MAR form was not pre-filled out or signed and is updated daily as medications are administered. LPA observed the MAR forms for two (2) residents with last documented medication administered yesterday 01/15/2025 at 05:00PM. Residents interviewed confirmed their medications are administered by the staff and are given as prescribed. Staff indicated that morning medications are prepared the night before and that during the day they prepare the rest of the day's medications, as time permits. Staff indicated that at no time are medications prepared more than one (1) day in advance. During medication review, LPA observed medications for today's 05:00PM, tomorrow’s 08:00AM, and tomorrow’s 05:00PM medication passes were pre-prepared. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation "Staff are mismanaging residents' medication" is deemed Unsubstantiated at this time. Licensee was unable to stay for the remainder of the visit and designated staff Patrick Sangalang to sign the report. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Jan 16, 2025 · control 29-AS-20250113113032

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Angela Barutyan conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20250113113032). The purpose of the visit is to issue a citation for a deficiency observed during the initial complaint investigation. During the visit on 01/16/2025, LPA reviewed three (3) personnel files and observed Staff #1’s (S1) file missing 20 hours annual training for 2024. S1 does not handle medications and interviews with staff, residents, and Licensee Irma Carmona confirmed that S1 does not administer or prepare medications. However, S1 was missing annual training for subjects including, but not limited to: dementia, aging, food preparation, and residents rights. Licensee stated they will create a training schedule for S1 to complete their 20 hours of annual training. The remaining two (2) personnel files observed were in order and had no missing documents or training. The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Administrator was informed that failure to correct deficiency may result in civil penalties. Exit interview was conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 16, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Jan 30, 2025

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above as Staff #1 (S1) was missing 20 hours of annual training which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 16, 2025

Plan of correction: Licensee agreed to create a training plan for S1's 20 hours of annual training and send proof of the plan to CCL by 01/30/2025.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 02:28PM. LPA initially met with facility staff. Administrator arrived shortly after LPA's arrival. Entrance interview conducted. Beginning at 02:42PM, the LPA, along with Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguishers are fully charged and recently serviced on 03/19/2024. Hardwired combination smoke and carbon monoxide detectors were tested at 05:20PM and all were functional at the time of the visit. No fire clearance concerns were observed. BEDROOMS: There are 8 (eight) total bedrooms in the facility; 2 (two) are designated as staff rooms; both staff rooms were observed to be locked. There are 6 (six) private resident bedrooms, all with private bathrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. BATHROOMS: There are 6 (six) private resident bathrooms and 1 (one) guest/staff bathroom. Restrooms were observed to be equipped with nonskid surfaces. Grab bars were observed in the bathrooms. The water temperature was measured in various resident bathrooms and measured within the required range. COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. Exit doors contain alarms and were functional at the time of the visit. OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs Report Continued on LIC 809-C for resident use. All passageways were observed to be clear. There were no bodies of water on the premises. . KITCHEN/LAUNDRY ROOM/GARAGE: Kitchen was observed to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Cleaning supplies are located in a locked under-sink cabinet. Knives are in a locked kitchen cabinet. Laundry room contains locked storage for cleaning chemicals. The LPA observed the garage to be locked and contain an office area, extra food, emergency water supply, and additional storage. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill conducted on 06/05/2024. RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All 5 (five) resident files and all 5 (five) staff files observed contained all required documents. MEDICATION REVIEW: Medications were observed to be in a locked hallway closet. Medications for 2 (two) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit. INTERVIEWS: During today's visit, LPA interviewed 2 (two) staff and 6 (six) residents. No concerns were identified. During today's visit, LPA requested a copy of the facility's liability insurance and a copy of the annual sprinkler inspection be emailed to the LPA. No citations issued. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Jul 25, 2024