Arcady Villa

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Evelin Rios arrived to this facility to conducted an Annual Required Inspection visit. When LPA arrived she was greeted by the house manager, Dulce Villeros. Staff contacted the Administrator, Jojo Cajayon and informed him LPA was at the facility. LPA explained the purpose of the visit. Administrator was not able to meet LPA at the facility but would be available by telephone for questions. At 9:23 AM LPA requested a copy of the facility's Emergency Disaster Plan (LIC610E), Personnel Report (LIC500), Register of Facility Residents (LIC9020) and a copy of the facility's Liability Insurance. LPA obtained copies for review and to update the Regional Office file. At approximately 9:33 AM, LPA initiated the physical plant tour of the facility inside and out. At the entrance, LPA observed required postings on the wall by the front door and a small table with a visitor sign-in along with hand sanitizer. The facility has an open concept layout that includes the kitchen, living area, and dining area. In the kitchen LPA observed appliances and fixtures were functional. LPA observed two refrigerators stocked with a sufficient supply of two day perishables, and the pantry and kitchen cabinets contained an adequate amount of seven day non perishable food. LPA also observed fresh fruit available in the refrigerator and on the kitchen counter. LPA observed knives and sharps were stored in a locked drawer. LPA observed the cabinet under the kitchen sink was locked and it is used to store cleaning supplies. In the living area and dining area LPA observed the furniture to be in good repair and sit the capacity of the facility. LPA observed the fire extinguisher on a wall by the dining area. LPA observed one (1) resident in the living room watching television. The fire extinguisher was fully charged and has a last serviced date of 05/16/2025. LPA did not observe tripping hazards. (Continue to LIC809-C) (Continued from LIC809) The backyard has a table with chairs for residents' use. LPA observed the passageway to the exit was clear of obstruction. The backyard has sufficient space for residents. There is no swimming pool or bodies of water. On the side of the house not leading to an exit LPA observed a mattress and other furniture piled on top of each other. According to the administrator they will schedule a bulk pick up to clear the space. LPA observed a locked shed used for storage. The facility has two (2) bathrooms. The bathrooms are next to each other by bedroom #6. LPA observed that the bathrooms were equipped with functioning plumbing fixtures, required grab bars, non-skid mats and supplied with toilet paper, hand soap and paper towels. LPA measured the hot water temperature in both bathrooms between 9:50 AM and 9:55 AM with readings of 117.2°F and 114.1°F, within regulation. LPA observed a locked cabinet where centrally stored medication and medication records are stored. leading to the bedrooms. The facility has a fully stocked first aid kit an first aid manual. There are six (6) bedrooms designated for residents. Bedrooms are private. The facility has a fire clearance (STD850) dated 09/10/2019, indicating approval for five (5) non ambulatory residents and one (1) bedridden resident for a total capacity of six (6) residents. Bedrooms designated for residents were furnished with a bed, night stand, chair, dresser, bedding, sufficient lighting and closet space. Doors leading to the outside have auditory alarms there were on and functioning properly during the visit. In bedroom #1 and bedroom #2 LPA observed open windows without a screen. The facility is equipped with dual carbon monoxide and smoke detectors that are interconnected through out the facility. LPA observed the house manager test a detector at 11:13 AM and it was working properly. The facility has no garage. The laundry room is maintained locked. In the laundry room LPA observed a washer and dryer. Detergents and cleaning supplies are kept in the laundry room. There is an office space by the laundry room that has facility, staff, and residents records and is also used for storage of emergency water. (Con. to LIC809-C) Page 2 of 3 (Continued from LIC809-C) From 11:22 AM to 1:00 PM, LPA conducted a file review of five (5) resident files to ensure licensing forms were complete and in compliance. LPA's review of resident records revealed three (3) out of five (5) residents, Resident #2 (R2), Resident #4 (R4) and Resident #5 (R5) did not have a signed and dated Resident Appraisal and had blank Appraisal/Needs and Services (LIC625) forms. Appraisals on file were completed as pre admission appraisals. Residents have been in the facility for more than 12 months. LPA's review Physician's bed rail orders do not indicate whether it is for half bed rail or full bed rail for those residents with bed rails on their bed. Administrator will obtain orders that indicate the length of the bed rials. Centrally stored medication and medication records were reviewed for proper storage and documentation. In addition, LPA also conducted a file review of two (2) staff records to insure training documents are in compliance and complete. LPA did not observed the annual training record for the house manager. According to the house manager and the administrator training had been conducted but training documentation had not been filled out. LPA’s review of the facility’s quarterly emergency drill records, along with an interview with the house manager, revealed that they had not participated in an emergency disaster drill at the facility within the past year. LPA reviewed the Pending Administrator Certification List and observed Administrator's name on the list. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were deficiencies observed during this visit. Refer to LIC809-D. LPA also provided LIC9102TV and LIC9102TA to house manager. Exit Interview was conducted with the Administrator by telephone. Copy of Appeal Rights and a copy of the report provided to the house manger. Page of 3 of 3the state’s words, verbatim · CDSS document, Mar 2, 2026

The state marks this report as 8 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Case Management - Annual Continuation

At 9:40 a.m.,Licensing Program Analyst (LPA) Evelin Rios met with caregiver Dulce Villeros. At approximately 10:15 a.m. LPA spoke to the administrator Jojo Cajayon by telephone and explained the purpose of the visit was to continue the annual visit. An entrance interview was conducted. On 01/28/2025 LPA initiated required annual visit. Due to time constraints LPA was unable to complete the annual visit. Today LPA will complete the annual visit. LPA could not locate Infection Control Plan for facility but did find records a Mitigation Plan Report was approved on 02/16/2021. On 01/28/2025 LPA started to review five (5) of five (5) resident records and did not yet review medications and medication records. On 01/29/2025 at 9:59 a.m., LPA continued to review resident records. Resident #6's (R6's), Physician's Report (LIC 602A) revealed they are bedridden. LPA's review of facility sketch on file with Community Care Licensing Division (CCLD) and sketch posted on the facility walls indicate bedroom #6 is designated as a non ambulatory room and bedroom #3 is designated as the bedridden room. On 01/28/2024 at 3:31 p.m. LPA interviewed R6 and they informed LPA they could reach for items but needed assistance to reposition to the left or right. LPAs telephone call with the administrator, revealed they believed the inspector that conducted the fire clearance visit had indicated any room in the facility with a door was cleared for a bedridden resident. LPA review of the Fire Safety Inspection Request (LIC850) indicated the facility does have a capacity for one (1) bedridden resident without indicating which room is designated to house bedridden resident and without the comment that any room may be used to house the one (1) bedridden resident. Administrator agreed to submit required documentation to change status designation of bedroom #6. LPA spoke with Administrator regarding missing bed rail orders for three (3) out of five (5) residents. Administrator indicated they would obtain orders from family members. LPA advised it must be a written order from a physician. Administrator informed LPA they would be removing bed rails until an orders were obtained. (Continue to LIC809-C) (Continued from LIC809 Case Management Annual Continuation) At 11:02 a.m. LPA reviewed medication and medication records of five (5) out of (5) five residents. LPA observed the following: Resident #1's (R1's), Medication Administration Record (MAR) did not have records indicating they were given 26 pills out of a 30 quantity PRN medication. Resident #2's (R2's), MAR for December 2024 and January 2025 did not have two medications listed. Medications were observed in resident's medication bin with other prescribed medication. Resident #4 (R4), has one medication labeled to give 2 times daily, review of Medication Administration Record (MAR) only indicated staff were providing it one time at 8 p.m. Staff stated they provide it twice daily. At 11:38 a.m. LPA spoke to the administrator by telephone and went over medication and medication record concerns. Administrator stated they did not have written orders from a physician for medication for four (4) out of five (5) residents. LPA also discussed with administrator that staff indicated they poured medication running low from one medication to the new medication bottle with start date 02/01/2025. Deficiencies cited on todays visit (refer to LIC809-D). Immediate Civil Penalty Assessed on todays visit (refer to LIC421IM). Technical Violations issued. Exit interview conducted. Appeal rights provided. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 29, 2025

The state marks this report as 10 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 01/28/2025 at 1:28 p.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct an unannounced Required Annual Inspection. LPA was greeted by caregiver Dulce Villeros who granted access. Dulce asked LPA to sign in and they sent a text message to the administrator, Jojo Cajayon letting them know LPA was at the facility. Staff #2 (S2) at the facility contacted administrator via telephone and LPA explained the reason for the visit. The administrator could not meet LPA at the facility for todays visit, and designated Dulce to sign today's report. The inspection tool was used to conduct this visit. At approximately 1:35 p.m. LPA began a physical plant tour of the facility and the following was observed: Dining / Living Area: LPA observed required postings by the facility entrance. LPA observed two residents watching tv in the living area. The dining and living area were clean and clear of clutter. Furniture appeared clean and in good repair. Dining table was clean, clear of clutter and sits the capacity of the facility. The fire extinguisher was observed by the dining table fully charged last serviced on 05/15/2024. In the hallway LPA observed the thermostat at a comfortable temperature of 77°F. Kitchen: LPA observed the kitchen to be clean and clear of clutter. Cleaning chemicals are locked under the sink. Knives and sharps are kept locked in a kitchen drawer inaccessible to residents. LPA observed a sufficient amount of 2-day perishable and 7-day non-perishable supply of food; properly stored. LPA observed a small refrigerator locked and used for storing medication requiring refrigeration and a second staff refrigerator. LPA observed smoke detectors through out the facility that are interconnected and dual carbon monoxide detectors. LPA observed caregiver test the dual smoke/carbon detector at 2:18 p.m. and it was observed to be functioning properly. (Continue to LIC809-C) Bedrooms: There six (6) bedrooms designated for resident use. One (1) out of the six (6) rooms is currently vacant. LPA observed a hole on the wall in Room labeled #3. LPA's interview with resident #3 (R3) revealed the hole has been there for at least two days and they believe they had caused it in their sleep. Interview with staff confirms the hole has been there at least a week and it may have been caused by the hospital bed when it is moved. All resident rooms were observed furnished with required lighting, chair, bed, and linens. Exit doors with auditory alarms were working properly at time of visit. Bathrooms: There are two (2) bathrooms designated for resident use. Both bathrooms are accessible to residents by the hallway. Both bathrooms were well lit, clean, had grab bars, and nonskid mats. LPA observed a sufficient supply of hand soup and paper towels. At approximately 3:40 p.m. the hot water temperature in both bathrooms was tested and read between 117.3 and 118.2 degrees Fahrenheit. Surrounding Grounds: Passageway leading to the side gate exit was free from obstruction. There is appropriate outdoor seating for residents. LPA observed one shed unlocked in the backyard. Shed is being used for facility storage. Resident, Staff and Facility files: At 2:21 p.m. LPA reviewed two (2) staff files for the staff present at time of visit for compliance with licensing forms. LPA reviewed administrator certification and found their name under the renewal pending list. At approximately 2:45 p.m. LPA contacted the administrator and discussed the LIC610E, Infection Control Plan, and Emergency Disaster Drills. At 2:50 p.m. LPA started to review five (5) out of five (5) resident records. Due to time restraints, LPA was unable to complete the annual visit at this time. LPA did not complete review of resident records or medication documentation. An unannounced follow-up visit will be conducted at a later date to complete the annual inspection. Deficiencies cited (refer to 809D). Exit interview conducted. Appeal rights provided. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 28, 2025

Type of visit: Required - 1 Year

On 01/22/2024 at 9:20 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct a Required Annual Inspection. LPA was greeted by caregiver Jenny Franoso who granted access. Jenny asked LPA to sign in. Jenny called the administrator Jojo Cajayon and LPA explained the reason for the visit. Jojo could not meet LPA at the facility for todays visit, Jojo designated Jenny to sign today's report. The inspection tool was used to complete this visit. At the facility LPA observed two caregivers Jenny and staff #1 (S1). At 9:35 a.m. LPA began a physical plant tour of the facility and the following was observed: Dining / Living Area: LPA observed required postings by the facility entrance. The dining and living area were clean and clear of clutter. Furniture appeared clean and in good repair. A fireplace located in the living area was not in use and secured with a glass screen. In the hallway by the dining area, LPA observed the thermostat at a comfortable temperature of 76°F. Dining table was clean, clear of clutter and sits the capacity of the facility. The fire extinguisher was observed by the dining table fully charged last serviced on 05/26/2023. Kitchen: LPA observed the kitchen to be clean and clear of clutter. Cleaning chemicals are locked under the sink. Knives and sharps are kept locked in a kitchen drawer inaccessible to residents. LPA observed a 2-day perishable and 7-day non-perishable supply of food; properly stored. LPA observed a small refrigerator locked and used for storing medication requiring refrigeration and a second refrigerator by the dining table. LPA observed smoke detectors through out the facility that are interconnected and dual carbon monoxide. LPA observed S1 test the smoke/carbon detectors at 11:07 a.m. and it was observed to be functioning properly. (Continued to LIC809-C) Bedrooms: There are seven (7) total bedrooms six (6) bedrooms are designated for resident use. One (1) out of the six (6) rooms is currently vacant. All resident rooms are furnished with required lighting, chair, bed, and linens. Exit doors with auditory alarms where working properly. Bathrooms: There are two (2) bathrooms designated for resident use. Both bathrooms are accessible to residents by the hallway. Both bathrooms were well lit, clean, had grab bars, had hand washing signs, nonskid mats and trash bins with lids. LPA observed a sufficient supply of hand soup and paper towels. At approximately 11:07 a.m. the hot water temperature in one (1) out of two (2) bathrooms was tested and read 113.1 degrees Fahrenheit. Surrounding Grounds: Passageways were free from obstruction. Side gate was observed closed but unlocked. There is appropriate outdoor seating for residents with no shade. LPA observed one shed unlocked in the backyard. Shed is being used for storage and has a third refrigerator. LPA observed a hospital bed in the backyard according to administrator bed is scheduled to be picked up for removal. Resident and Staff files: At 10:15 a.m. LPA reviewed two (2) staff files for the staff present at time of visit and observed both files missing LIC 503 - Health Screening with TB screening. LPA contacted administrator at 11:50 a.m. according to administrator staff have required documentation, however it could not be provided to LPA at time of visit. LPA reviewed five (5) out of five (5) resident records and Resident #4 (R4) was missing a Medical Assessment/ Physician's report and admission agreement was not signed by the facility. Resident #3 (R3) was missing an updated annual medical assessment/ physician's report due to their dementia diagnosis. LPA contacted administrator at 11:50 a.m. to discuss missing and incomplete records. According to administrator they are working with resident's responsible parties to thoroughly complete records. Medications: LPA observed, resident medications locked in a small refrigerator in the kitchen and looked in a hallway cabinet inaccessible to residents. Medication and Medication Records were reviewed for proper documentation. Deficiencies cited (refer to 809D). Exit interview conducted. Appeal rights provided. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 22, 2024