Averie Manor

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Abeye Duguma met with Abraham Joseph for a Required One (1) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 12:15 PM and the following was noted: The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The facility has a total of four (4) bedrooms for residents and two (2) bathrooms. Fire Clearance is approved for six (6) non-ambulatory of which one (1) may be bedridden in Room #1, two (2) in Room #2, two (2) in Room #3, one (1) in Room #4 and Room #5 is for staff only. The facility is currently occupying four (4) residents. The living room and dining room are neat and clean. The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. Towels and washcloths are not shared. There was enough clean linen available in the cabinets. Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. (continued on LIC 809-C) The facility maintains a comfortable temperature at 78°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located near the kitchen and observed to be fully charged and last inspected December 11, 2025. Knives and sharps are observed to be locked and inaccessible to residents. Laundry detergents, cleaning agents and other toxins are locked away. The hot water temperature was measured at 108.9°F. LPA observed medication to be locked and inaccessible to residents. Facility maintains a complete first aid kit. No health and safety hazards noted during the visit. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Aug 19, 2026

Allegation investigated: Facility staff dropped resident during a transfer resulting in injury.

Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with licensee Abraham Joseph and explained the reason for the visit. --- Facility staff dropped resident during a transfer resulting in injury. It was alleged that Resident #1 (R1) was not transferred safely and dropped to the ground sustaining multiple fractures. To investigate the allegation, on October 21, 2025, LPA requested documents at around 10:00a.m. On November 6, 2025, the department conducted interviews with two (02) staff at around 11:30a.m. On November 7, 2025, the department requested additional documents from other parties. A review of hospital X-ray records noted a fracture to R1’s left femur resulting in an acute distal femoral fracture. (CONT on LIC9099-C) Substantiated The caregivers who were interviewed gave inconsistent information as to how R1 was transferred on October 12, 2025, which resulted in their injury. The two caregivers present were previously instructed to be in front of and behind R1 to assist with transferring. One of the caregivers stated she was on the left side of R1 when assisting. The other caregiver stated he was behind R1 as he was instructed by the private caregiver and hospice nurse. Based on interviews and record reviews, there is enough information to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D): No other health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued. During interviews, staff stated all staff have completed training and background clearances. Based on interviews and record reviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. --- Staff did not follow reporting requirements. It was alleged that facility did not submit an incident report. To investigate the allegation, on April 1, 2026, the Department reviewed documents at around 11:00a.m. and interviewed one staff from 11:30a.m. – 12:00p.m. A review of the Department’s records revealed facility submitted a written report within seven (07) days of the occurrence. During interviews, staff stated the resident’s Responsible Party was at the facility within a few hours of the incident taking place. Based on interviews and record reviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No other health and safety hazards were noted during the visit. Exit interview conducted and a copy of the report was issued.the state’s words, verbatim · CDSS document, Apr 1, 2026 · control 31-AS-20251021101610

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(2) · Plan of correction due date: Apr 2, 2026

87464 Basic Services (f)Basic services shall at a minimum include…(2) Safe and healthful living accommodations and services, as specified in Section 87307, Personal Accommodations and Services. This requirement is not met as evidenced by; Based on interviews, R1 was not transferred as instructed leading to injury which poses an immediate health, safety and personal rights to resident in care.the state’s words, verbatim · CDSS document, Apr 1, 2026

Plan of correction: Licensee will provide training on safe transfer techniques and review policy. Licensee will submit a written letter stating they have reviewed regulation and going forward will adhere to it.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Abeye Duguma conducted an announced Pre-licensing visit at around 10:00 AM and met with administrator, Abraham Joseph. This is a change of ownership application from Affectionate Care Home (LIC197609968) to Averie Manor (LIC197610707). LPA conducted an entrance interview with the Administrator. At the time of this visit LPA observed two (02) additional individuals working in the facility. LPA also observed and assessed five (05) residents present in the facility. All residents appear to be clean and well groomed. With the assistance of the Administrator, LPA conducted a facility tour of both the inside and outside. The facility was inspected for Fire Safety, Personal Accommodations and Services, Medication Procedures and Food Service. This is a single-story property. Fire Clearance is approved for six (06) non-ambulatory of which one (01) may be bedridden in Room #1. Two (02) in Room #2, two (02) in Room #3, one (01) in Room #4 and Room #5 is for staff only. Facility has a total of four (04) bedrooms for residents and two (02) bathrooms. Resident bathroom has properly installed grab bars and shower has non-skid mats. Hot water temperature measured at 115.3ºF during the visit. All residents’ bedrooms were adequately furnished. The linens were stored in the storage space located in the hallway. Towels and washcloths are not shared. The common areas were appropriately furnished and had adequate furniture. The LPA observed entertainment equipment and games for activities. The resident and staff records were stored in a closet located in the hallway with medication. The first-aid kit is complete. The facility has adequate linen, water, perishable and nonperishable food supplies. LPA observed a fireplace with the appropriate screen. (CONT. on LIC9099-C) LPA inspected the kitchen and observed the stove and refrigerator to be clean and working. Facility has at least two (02) days perishable and seven (07) days non-perishable foods. Nonperishable food was stored in the kitchen pantry. Sharps are stored in a locked kitchen drawer. The facility has working alarms on all exits. Smoke detectors and Carbon Monoxide detectors were checked and function properly. Fire extinguisher located in the kitchen, observed to be fully charged and last inspected 12/10/2024. LPA Duguma observed a washer and dryer in the garage adjacent to the kitchen. All chemicals, additional personal hygiene items were stored in a vertical locked storage. There is sufficient outdoor space with seating and a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises. At the time of this visit the physical plant is meeting Title 22 requirements. The Component III completed with LPA. No health and safety hazard were noted during this visit. Exit interview was conducted and a copy of report was issued.the state’s words, verbatim · CDSS document, Aug 14, 2025

Type of visit: Office

COMP II by CAB successfully completed Method: Phone Call at CAB Applicant/administrator participated in COMP II at CAB telephone call with analyst at CAB. Identification of the applicant and administrator was verified by presenting photo ID via phone. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Control of propertythe state’s words, verbatim · CDSS document, Jun 18, 2025