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Type of visit: Required - 1 Year

On 04/15/2025 at 10:00 AM, Licensing Program Analyst (LPA) David Doidge arrived unannounced to conduct Required 1 Year Annual inspection. Upon arrival LPA was greeted by caregiver, Phillip Go and explained the purpose of the visit. Administrator Monique Robinson joined the visit at approximately 10:16 AM. The facility’s fire clearance was approved for 5 Non-Ambulatory and 1 Bedridden. LPA toured facility with including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 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 bathrooms were measured 116 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 11/01/2024 . First aid kit was observed to be complete. Emergency disaster drill was last conducted on 01/27/2025.. LPA reviewed five (5) staff files and six (6) resident files. All were current and complete. Continued on LIC809-C Continue from LIC 809 No deficiencies were cited during this inspection. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 15, 2025

Allegation investigated: Staff does not ensure facility is kept in clean sanitary conditions Licensee does not ensure facility is kept free of rodents

On 01/24/25 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced visit, met with staff (S1) and spoke with administrator (ADM) on the phone who authorized S1 to act on her behalf and sign the reports. LPA explained the purpose of the visit with ADM and S1. LPA gathered information on the allegations and delivered the investigation findings to ADM and S1. At 12:15PM, LPA obtained the following documents from S1: Personnel record (LIC 500), Resident roster, Emergency/Disaster/Infection Control plans, Pest control records. Continued on next page, LIC 9099-C Unsubstantiated Allegation: Staff does not ensure facility is kept in clean sanitary conditions Investigation Finding: Unsubstantiated On 01/24/25 at 12:30PM, LPA toured the facility and observed the kitchen & counter tops, bathrooms, floors, living rooms, bedrooms, hallways and dining areas clean and odor free. Staff (S1) stated they clean, dust and disinfect facility's kitchen, counter tops, bathrooms, common hallways, dining areas, living room as well as residents' bedrooms twice a day (AM & PM). LPA observed facility to be in good repair, clean and odor free. Allegation: Licensee does not ensure facility is kept free of rodents Investigation Finding: Unsubstantiated On 01/24/25 at 1PM, LPA inspected facility and grounds with S1. LPA checked all residents’ bedrooms, kitchen, bathrooms, living room, dining room, hallways, laundry room and did not observe an rodent feces/droppings inside the facility. Review of Orkin Pest Control service report dated 12/23/24 showed that rodent traps were placed in the living & dining room areas and outside overgrown vegetation cut to eliminate the migration of any pest into the facility. LPA observed no rodents present during visit. Based on records review, interviews conducted, and observations made, the department has investigated the above allegations and found them to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the above allegations are unsubstantiated. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 24, 2025 · control 15-AS-20250121135027

Type of visit: Required - 1 Year

On 05/01/2024 at 10:20 AM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct Required 1 Year Annual inspection. Upon arrival LPA was greeted by caregiver, Rizza Bantigue. LPA spoke to Sabrina Crowder, on the phone and explained the purpose of the visit. House Manager Monique Robinson will be joining the visit at approximately 1:00PM. The facility’s fire clearance was approved for 5 Non-Ambulatory and 1 Bedridden. LPA toured facility with including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 68 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 bathrooms were measured 142.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum 7 day supply of nonperishable and 2 day of perishable foods. Centrally stored medication were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 12/21/2023 . First aid kit was observed to be complete. Emergency disaster drill was last conducted on 06/14/2023 . Report continues on 809 C Continue from LIC 809 LPA reviewed 3 of 6 residents records. LPA reviewed 4 of 5 staff records and of 4 have first aid training and associated to the facility. LPA reviewed a sample of 6 of 6 resident’s medications. LPA observed the following deficiencies: · At 10:30am, LPA observed S2 is not associated to the facility nor finger print cleared. · At 10:39am, LPA observed kitchen and dining room floor buckling. · At 10:51am, LPA observed fabreeze in an unlocked cabinet located in the hallway. · At 11:08am, LPA observed knives, scissors and lighter in a unlocked drawer located in the kitchen. · At 11:10am, LPA observed medication in an unlocked drawer located in the kitchen. · At 11:13am, LPA observed hot water temperature at 142.2 degrees F. · At 11:22am, LPA observed screen door large box, bed frames and rails, washing machine, mattress pads located in the back and side yard. · At 11:23am, LPA observed the fence located in the back yard has planks missing and on both sides fence is leaning. · At 11:31am, LPA observed facility using residents closets for storage, mattresses and boxes behind the sectional in the common area, the hallway and resident bathroom. Continue on LIC 809C Continue from LIC 809C LPA requested the following documents to be submitted to CCLD by 5/10/2024. · Resident Roster · LIC 308 Designation of Administrative Responsibility · LIC 309 Administrative Organization · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan (9 pages) · Liability Insurance Copy of Current Administrator Certificate 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. *An immediate $100.00 civil penalty will be assessed on today's date for associations.* Exit interview conducted. A copy of the LIC421BG, this report and appeal rights providedthe state’s words, verbatim · CDSS document, May 1, 2024

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.