Beatrice Senior Care

Type of visit: Case Management - Annual Continuation

On 8/31/2026, at approximately 9:00 AM, Licensing Program Analysts (LPAs) Reza Jamaly and Pang Lee arrived unannounced at the facility to conduct the required one-year inspection. LPAs met with the staff on duty and explained the purpose of the visit. The Licensee, Beatrice Clark, was notified and arrived at the facility shortly thereafter. Upon arrival, LPAs observed an individual (I) setting on a couch in the living room. Staff 1 (S1) identified I as a friend. LPA Pang checked Guardian and determined that I was associated with Beatrice Home Care. LPAs Jamaly and Pang conducted a physical plant inspection of the facility, including, but not limited to, the common areas, kitchen, dining area, hallways, four residents’ bedrooms, resident bathrooms, garage, and exterior courtyards, to assess compliance with applicable Title 22 regulations. LPAs inspected the kitchen and observed four cleaning products, including Palmolive, Dawn, Clorox, and Windex, stored in an unlocked cabinet accessible to residents. Photographs were taken. A deficiency was cited on LIC 809-D. Sharp knives were observed stored in a locked kitchen cabinet and were inaccessible to residents. LPAs inspected the refrigerator and freezer located in the kitchen and observed three containers of leftover food that were not labeled or dated, including cooked lentils, scrambled eggs, and macaroni and tuna. A can of Pepsi was also observed opened. Photographs were taken. A deficiency was cited on LIC 809-D. The facility was observed to have a sufficient supply of at least seven days of nonperishable food and two days of perishable food. Page 2. LPAs inspected four residents’ bedrooms. An odor of incontinence was detected in Room 3. LPAs observed three partially filled urinal containers hanging from the resident’s walker in Room 3. Based on LPAs interview it was learned that urinal container was not emptied today. A deficiency was cited on LIC 809-D. During hallway inspection, LPAs observed a container full of used glucose test strips. Per licensee, resident checked their own blood glucose and placed the used test strips in it. Deficiency cited on LIC 809-D Resident bathrooms were observed to be clean. Grab bars and nonslip mats were observed to be secure and in good condition. The hot water temperature at one resident bathroom sink was measured at 103.4°F, which is below the required range of 105°F to 120°F. A deficiency was cited on LIC 809-D. The facility temperature was measured at 71°F in the living room. No bodies of water were observed on the premises. Smoke detectors and carbon monoxide detectors were observed throughout the facility. Fire extinguishers located in the living room and hallway were observed and had a last service date of 3/11/2026. Cleaning supplies and other toxic substances were observed stored in the garage. The garage door was locked, making the substances inaccessible to residents. The Licensee unlocked the garage door to allow LPAs to conduct the inspection. Medications were observed stored in a locked cabinet located in a hallway and were inaccessible to residents. LPAs requested and inspected the medications for three residents. No Medication Administration Records (MARs) or Centrally Stored Medication and Destruction Records (CSMDR) were available for review at the time of the inspection. The Licensee stated, “I am administering residents’ medications regularly, and I am documenting on the MAR, but I cannot locate them right now.”Due to the absence of the MARs, LPAs were unable to verify whether the residents’ medications were being administered as prescribed. Deficiencies were cited on LIC 809-D. The first aid kit was inspected and contained the required supplies. LPAs inspected the facility yard and observed multiple sections of fencing with loose containing nails. Photographs were taken. The Licensee stated that the fence had recently been repaired and that the remaining old fencing would be removed and discarded. Page 3 LPAs also observed bulky items, including an old mattress, chair, desk, and Hoyer left, on the right side of the facility that obstructed access to emergency exit door. An old washing machine was also observed outside the facility in front of the garage, obstructing an exit door. Photographs were taken. A deficiency was cited on LIC 809-D. LPAs requested resident records and reviewed four out of four resident files. One of the four resident files did not have a current Care Plan. LPAs requested the administrator file The Licensee was unable to locate the staff file and stated, “I cannot find it.” A deficiency was cited on LIC 809-D. The following additional documents were requested from the facility and are to be provided to the LPA Jamaly by email no later than 5:00 PM on the requested due date of 9/7/2026. (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (4) LIC 610 Current Emergency Disaster Plan (5) Proof of Current Liability Insurance (6) LIC 500 Current Personnel Report (7) LIC 309 Administrator Organization Based on the observations made during the annual inspection, the facility was found to be out of compliance with applicable Title 22 regulations. The identified deficiencies are documented on the LIC 809-D pages. An exit interview was conducted with S1. LPAs reviewed the inspection findings with the Licensee and provided copies of the LIC 809 report, LIC 809-D pages, and Appeals Rights.the state’s words, verbatim · CDSS document, Aug 31, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87355(e)(3) · Plan of correction due date: Sep 15, 2026

87355(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance.. This was not met as evidence by: Based on observation and interview there was an individual (I) at the facility who was not associated to the facility; however, individual was fingerprint cleared.the state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Administrator/Licensee will ensure all individualls who come to facility are finger printed and associated. Administor/Licensee will provided training on criminal record clearance to all staff and send a proof of completed training that include traninee name, signature and date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463 · Plan of correction due date: Sep 15, 2026

87463 (a) The pre-admission appraisal.., shall be updated in writing as frequently as necessary or once every 12 months. This was not met as evidence by: Based on the observation and interview with Licensee 1 out of 4 residents did not have a completed LIC 625 needs and service/care plan in place in their files which poses totential health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Administor/Licensee will create Care Plan for R1 file and provide a copy of the Care Plan to LPA Reza Jamaly by due date

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Sep 7, 2026

Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105-degree F (41 degree C) and not more than 120-degree F (49 degree C) This was not met as evidence by: Based on observation the hot water was measured at 103.4 *F in the resident main bathroom sink which posess an immediate health and safety risks to resents in carethe state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Administrator/ Licensee will ensure hot water tempreture is adusted as requeired by Title 22 regulation.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(a)(6) · Plan of correction due date: Sep 7, 2026

(a) A plan for incidental medical and dental care shall be developed by each facility.. (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This was not met as evidence by: Based on records review and interview with Administrator Beatrice’s statement she does not know where the residents CSMDR records are and cannot locate them which posess an immediate health and safety risks to resents in carethe state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: The Licensee will maintain and accurately fill MAR or CSMDR on each residents file and provide completed copy of all 4 resident's MAR or CSMDR to LPA Jamaly by due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Sep 7, 2026

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This was not met as evidence by: Based on observations, the facility was not maintained in good repair or in a clean condition. LPAs also observed long wooden fence boards with exposed, protruding nails on the ground in the rear courtyard. Additionally, the facility’s refrigerator was observed to be unclean.the state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Administrator/Licensee will remove all the wooden fence containing nails and send a picture of the yeard emtied from the those fences.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87555(b)(8) · Plan of correction due date: Sep 7, 2026

87555(b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This was not met as evidence by: Based on observation, three containers of leftover food that were not labeled or dated, including cooked lentils, scrambled eggs, and macaroni and tuna. A can of Pepsi was also observed opened.the state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Administrator/ Licensee throw out the unlabeled leftover foods. Administrator/ Licenseen will ensure foods are stored properly dated and labeled and will provide training to direct care staff to keep food in refrigerator and freezer properly.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Sep 7, 2026

87309(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects... This is not met as evidence by: Based on observation, four cleaning products, including Palmolive, Dawn, Clorox, and Windex, stored in an unlocked cabinet accessible to residents, which poses immediate health and saftey risks to residents in care.the state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Licensee/administor immediately removed the cleaning solutions. Licensee will provide training to staff to keep chemicals locked and inaccessible to residents. Provide proof of traning completed including training title, date, trainee's name and signature by due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303 · Plan of correction due date: Sep 7, 2026

(f) All waste shall be located..Syringes and needles are disposed of..concerning bloodborne pathogens. This is not met as evidence by: Based on observations and statements, it was learned that a resident checked their own blood glucose and placed the used test strips in a clear container and the container was full of used glucose stripes on the hallway counter, where they were accessible to residents in care which which poses an immediate health and saftey risks to residents in care.the state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Licensee throw out the used glucose stripts. Licensee will provide training to direct care staff to maintain facility clean and provide proof of traning completed including training title, date, trainee's name and signature by due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87625(b)(3) · Plan of correction due date: Sep 7, 2026

87625 Managed Incontenece (b) The licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This is not met as evidence by:the state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Administor/ Lencess instructed direct staff to empty out the urinal tube. Administrator/Licensee will provide training to staff on keeping residents and facility clean and provide proof of traning completed including training title, date, trainee's name and signature by due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307 · Plan of correction due date: Sep 15, 2026

(d)The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This was not met as evidence by: LPAs Pang and Jamaly observed bulky items, including an old mattress, chair, desk, and sports equipment, on the right side of the facility that obstructed access to emergency exit doors. An old washing machine was also observed outside the facility in front of the garage, obstructing an exit door.the state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Administrator/Licensee will remove all the items obstructing the exit door. Once removed the licensee will send a picture of the emergency exit being cleared. Administrator/Licensee will provide training to staff to keep the passage way and exit doors free of obstructions and provide proof of training completed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412 · Plan of correction due date: Sep 15, 2026

87412 (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This is not met as evidence by: Based on observations and interviews with the Licensee she couldn’t located the Administrator Timothy Clark and care staff files which poses potential health and safety risks to residents in carethe state’s words, verbatim · CDSS document, Aug 31, 2026

Plan of correction: Licensee/Administrator will email the Administrator and S1 required staff file documents to LPA Jamaly by due date by due date.

Allegation investigated: Staff did not assist resident(s) with their required medical care. Staff did not provide appropriate care and supervision to resident(s), resulting in repeated emergency calls.

On 08/18/26, Licensing Program Analyst (LPA) Melina Oropeza made an unannounced visit to this facility to continue a complaint investigation for the above allegations. LPA identified themselves upon arrival, stated the purpose of their vist to staff. Administrator, Betrice Clark was called and joined 15 minutes later and LPA stated the purpose of the visit. Staff did not assist resident(s) with their required medical care based on record review, R1’s required medical care needs were not consistently met, including medical appointments and follow-up care. Based on information obtained, the preponderance of evidence standard has been met; therefore, the allegation is SUBSTANTIATED. Substantiated Staff did not provide appropriate care and supervision to resident(s), resulting in repeated emergency calls based on record review, emergency response records from Cosumnes Fire Department documented approximately 19 calls to the facility from January through June 2026, including calls for medical illness, injury/trauma, lift assistance, and public health concerns. Based on information obtained, the preponderance of evidence standard has been met; therefore, the allegation is SUBSTANTIATED. Citations are being issued today per California Code of regulation Title 22 see 9099-D page. An exit interview was held, and a copy of this report and appeal rights was provided to administrator, Beatrice Clarkthe state’s words, verbatim · CDSS document, Aug 18, 2026 · control 27-AS-20260611121820

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 1, 2026

87464(f)(1) – Basic Services Basic services shall at a minimum include care and supervision as defined in Section 87101(c)(3) and Health and Safety Code Section 1569.2(c). Based on interviews and record review, the licensee did not ensure that resident(s) received care and supervision necessary to meet their identified needs. Emergency response records documented approximately 19 calls to the facility from January 2026 through June 2026, including repeated responses for medical illness, injury/trauma, lift assistance, and community public health concerns. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 18, 2026

Plan of correction: Licensee shall provide staff training on ensuring residents' medical care needs are met. Licensee to submit proof of training to LPA Oropeza @ Melina.Oropeza@dss.ca.gov by the POC due date, 09/01/26 by 5:00pm.

Allegation investigated: Staff did not notify payee of resident's death Staff did not refund payee after resident's death Staff is not answering payee's calls

On 08/18/26, Licensing Program Analyst (LPA) Melina Oropeza made an unannounced visit to this facility to continue a complaint investigation for the above allegations. LPA identified themselves upon arrival, stated the purpose of their vist to staff. Administrator, Betrice Clark was called and joined 15 minutes later and LPA stated the purpose of the visit. Staff did not notify payee of resident’s death based on records reviewed confirmed the payee was not notified by the facility of R1’s death. Based on records reviewed and information obtained, the allegation is SUBSTANTIATED. Staff did not refund payee after resident’s death based on records confirmed R1 passed away on 04/24/2026 and the facility received payment for May 2026. Documentation showed multiple attempts were made to obtain a refund; however, the refund was not issued within the required timeframe. Based on records reviewed and information obtained, the allegation is SUBSTANTIATED. Substantiated Staff is not answering payee’s calls based on records reviewed documented multiple unsuccessful attempts by the payee to contact facility representatives regarding R1 and the outstanding refund, including calls that were not answered or returned. Based on records reviewed and information obtained, the allegation is SUBSTANTIATED. Based on records reviewed, the the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Citations are being issued today per California Code of regulation Title 22 see 9099-D page. An exit interview was held, and a copy of this report and appeal rights was provided to administrator, Beatrice Clarkthe state’s words, verbatim · CDSS document, Aug 18, 2026 · control 27-AS-20260623140406

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.652(c) · Plan of correction due date: Sep 1, 2026

Health and Safety Code §1569.652(c) – Refund of Fees Paid A refund of fees paid in advance covering the period after the resident’s personal property has been removed from the facility shall be issued to the individual or entity contractually responsible for the fees within 15 days after the property is removed. Based on records reviewed, the licensee failed to issue the required refund of prepaid fees within the required timeframe following R1’s death. Records documented multiple attempts by the payee to obtain the refund; however, the refund remained outstanding. This poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 18, 2026

Plan of correction: Licensee shall issue the refund and submit proof of payment to CCLD by the POC date 09/01/26 by 5:00pm. Licensee shall also submit a written procedure describing how refunds following a resident’s death will be processed within the required timeframe to ensure future compliance.

Type of visit: Case Management - Deficiencies

On 08/18/2026, Licensing Program Analyst (LPA) Melina Oropeza arrived at the facility to continue compliant investigation. Upon arriving at the facility LPA was greeted by an individual that is not associated to the facility. The individual stated they have been working at the facility for two days and does not have criminal record clearance. The individual contacted the Administrator / Licensee and was informed that they would arrive shortly. LPA informed Beatrice that the individual would need to leave immediately. Beatrice acknowledged that the person arrived at the facility yesterday and was fingerprinted but awaiting clearance. The individual stated they have not yet completed the required fingerprinting process. A Type A violation was issued today. A civil penalty for $1,000 was assessed for a repeated violation. A Type A violation was issued today. A civil penalty for $500 was assessed. LPA issued citations and civil penalties during todays visit, see 9099-D page. An exit interview was held, and a copy of this report and appeal rights was provided to administrator, Beatrice Clark.the state’s words, verbatim · CDSS document, Aug 18, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411 · Plan of correction due date: Aug 18, 2026

(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or This regulation was not met as evidenced by a uncleared indidual present alone in the facility. This presents an immediate threat to resdidents in care.the state’s words, verbatim · CDSS document, Aug 18, 2026

Plan of correction: Administrator/Licensee present in the facility working. Uncleared individual left the facility. Licensee / Administrator acknowledges that cleared individuals are to only be present

From the deficiency page — Deficiency type: Type A · Section cited: CCR87205(a) · Plan of correction due date: Aug 18, 2026

87205(a) — Accountability of Licensee Governing Body No licensee, whether an individual or an entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation and conformance with these regulations and the welfare of the individuals it serves. The licensee failed to do this as evidenced by over the past 60 days the facility being cited two times for not having individuals fingerprint cleared before caring for individuals, this presents an immediate health and safety risk to clients.the state’s words, verbatim · CDSS document, Aug 18, 2026

Plan of correction: Licensee will provide a LIC 500 for each facility that shows coverage with cleared individuals by POC date 08/18/26 by 5:00pm to LPA Oropeza @ Melina.Oropeza@dss.ca.gov.

Allegation investigated: Staff did not ensure that the resident’s wound care needs were met at the facility Staff did not ensure that the resident’s insulin care needs were met at the facility Staff did not arrange transportation for the resident to attend medical appointments Staff did not maintain resident records Staff did not meet the resident's hygiene care needs

Licensing Program Analyst (LPA'S) Kesha Lewis arrived to the facility unannounced to continue a complaint investigation into the allegations above. LPA Lewis met with Licensee Beatrice Clark, and explained the purpose of the visit. LPA Lewis interviewed Licensee Beatrice Clark, and requested to see R1'S file. Based on the licensee not being able to prudce a compleate file for review and LPA lewis interview with R1'S physican and confirming multiple appoitments were missed. The above allegations are SUBSTANTIATED. A finding of SUBSTANTIATED means the evidence standard has been met, therefore the above allegation is found to be Substantiated. Citations are being issued today per California Code of regulation Title 22 see 9099D page. An exit interview was held, and a copy of this report and appeal rights was provided to administrator. An exit interview was held, and a copy of this report was provided. Substantiatedthe state’s words, verbatim · CDSS document, Aug 4, 2026 · control 27-AS-20260605084138

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Aug 6, 2026

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the residents’ need. In providing transportation the licensee shall do so directly or make arrangements for this service. Based on interviews with S1 and S2. The licensee did not ensure R1 made it to doctors appoitments on multiple occations. This poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: The Licensee will provide a statment of understanding to LPA Lewis By COB 08/06/2026. Kesha.Lewis@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87506(b)(14) · Plan of correction due date: Aug 6, 2026

87506 Resident Records (b) Each resident’s record shall contain at least the following information: (14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services. Based on records review the licensee was not able to provide R'S file for LPA to review. Which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: The Licensee will provide a statment of understanding to LPA Lewis By COB 08/06/2026. Kesha.Lewis@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87208(a) · Plan of correction due date: Aug 6, 2026

87208 Plan of Operation (a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:the state’s words, verbatim · CDSS document, Aug 4, 2026

Plan of correction: The Licensee will provide a statment of understanding to LPA Lewis By COB 08/06/2026. Kesha.Lewis@dss.ca.gov

Type of visit: Case Management - Deficiencies

Licensing Program Manager LPM Liza KIng arrived at the facility to open complaint 27-AS-20260623140406. Upon arriving at the facility LPM was greeted by an individual that is not associated and refused to provide name. LPM contacted the Admin / Licensee and was informed that they would arrive within 10min. LPM informed Beatrice that the individual would need to leave immediately. Beatrice acknowledged that the person just started arrived at the facility an hour ago and has not been fingerprinted. The individual stated that they were not an employee and had only come to watch the house while the caregiver was out. A visual inspection of the refridgerator and freezer showed unlabled frozen food in opened ziplock bags and freezer burned. Beatrice reported having bean soup and turkey sandwiches for lunch. LPM issued citations and civil penalties during todays visit which are attached. The report was reviewed with Beatrice, appeal rights provided.the state’s words, verbatim · CDSS document, Jun 29, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411 · Plan of correction due date: Jun 30, 2026

(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or This regulation was not met as evidenced by a uncleared indidual present alone in the facility. This presents an immediate threat to resdidents in care.the state’s words, verbatim · CDSS document, Jun 29, 2026

Plan of correction: Admin/Licensee present in the facility working. Uncleared individual left the facility. Licensee / Admin acknowledges that cleared individuals are to only be present

From the deficiency page — Deficiency type: Type A · Section cited: CCR87555 · Plan of correction due date: Jun 30, 2026

(b) (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. This was not met as evidenced by open freezer burned food.the state’s words, verbatim · CDSS document, Jun 29, 2026

Plan of correction: Licenssee Admin will go dispose of freezer burned foods and lable existing foods within 24 hours and send photos to melina.oropeza@dss.ca.gov.

Allegation investigated: Staff mismanaged and mishandled resident(s) medications.

Licensing Program Analysts (LPA) Melina Oropeza and Kesha Lewis arrived to the facility unannounced to conduct a complaint investigation visit. LPAs Oropeza and Lewis met with Licensee Beatrice Clark, and explained the purpose of the visit. LPA Oropeza reviewed medications for three out of six residents and conducted medication counts for Residents (R1) (R2) (R3). During the review, discrepancies were identified between the medication counts and medications on hand. The Administrator stated the facility does not maintain Medication Administration Records (MARs), medication audit records, or a Centrally Stored Medication record. Due to the absence of required medication records and the medication count discrepancies identified, LPA verified medications were not properly accounted for. see page C... Substantiated Based on LPA observations, interview and medication count, the the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Citations are being issued today per California Code of regulation Title 22 see 9099D page. An exit interview was held, and a copy of this report and appeal rights was provided to administrator.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 27-AS-20260611121820

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jun 17, 2026

87465(c)(2) Incidental Medical and Dental Care (c)If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. Based on observations, interview and medication count, it is not clear if R1-R3 receive or were given mediations as prescibed by physicain. Which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 16, 2026

Plan of correction: The licensee will create an excel spreadsheet for arrival medication count. The licensee will send proof of by 5:00pm on July 17, 2026. The licensee provided the excel spreadsheet during the visit. No further POC is due at this time.

Allegation investigated: Staff do not provide activities for resident.

Licensing Program Analysts (LPA) Melina Oropeza and Kesha Lewis arrived to the facility unannounced to conduct a complaint investigation visit. LPAs Oropeza and Lewis met with Licensee Beatrice Clark, and explained the purpose of the visit. LPA Oropeza toured the facility and observed residents in their bedrooms and common area. During the visit, no activities were observed being conducted and staff were not observed encouraging or assisting residents to participate in activities. LPA interviewed Resident 1 (R1), who reported not participating in activities and had not observed activities being provided. The administrator provided an activity calendar, however, activities schedule for today were not listed on the calendar. see page c... Substantiated Based on LPA observations, interview and activity calendar review, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Citations are being issued today per California Code of regulation Title 22 see 9099D page. An exit interview was held, and a copy of this report and appeal rights was provided to administratorthe state’s words, verbatim · CDSS document, Jun 16, 2026 · control 27-AS-20251113171326

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a) · Plan of correction due date: Jun 30, 2026

87219 Planned Activities (a)Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. Based on observations, interviews and documentation received. LPA did not observe residents participating in activities during this visit. Which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 16, 2026

Plan of correction: The licensee will provide any documentation of refusal of resident participating in activities. The licensee will send updated activity calendar by 5:00pm on June 30, 2026.

Type of visit: Case Management - Other

Licensing Program Analysts (LPA'S) Kesha Lewis and Melina Oropeza arrived to the facility unannounced to continue a complaint investigation into the allegations above. LPA Lewis and Oropeza met with Licensee Beatrice Clark and explained the purpose of the visit. During the visit LPA Lewis toured the facility to ensure compliance with title 22 regulations. During the tour LPA Lewis observed that there was medication in the refrigerator that was not locked, medication on the shelf in the kitchen, and the key in the door to the laundry room that had toxins on the floor. Pictures taken of all. Citations are being issued see the 809D page. Exit interview and copy of the report and appeal rights given.the state’s words, verbatim · CDSS document, Jun 16, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jun 17, 2026

87309(a) Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation, the Administrator did not comply with the section cited above. LPA Lewis observed toxins and medication unlocked and made accessible to residents in care. This poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 16, 2026

Plan of correction: Licensee removed the mecication and took the key from the door of the laundry room. A statement acknowledging review and understanding of the cited regulation will be emailed to LPA Lewis by 06/17/2026 by the end of the day.

Allegation investigated: Staff do not serve residents food of good quality

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski spoke with facility administrator Beatrice Clark over the phone and explained the purpose of the visit. During this visit, LPA Moleski inspected food storage areas. LPA Moleski observed several opened containers of food in these storage areas, including perishable foods. LPA Moleski observed an unsealed package of pancake mix, a bag of snack crackers without a twist tie or clip, an open bag of corn meal inside of an open box, an open bag of corn flour without a twist tie or clip, an unsealed bag of sweetener, an open bag of cereal inside of an open box, a bag of oatmeal without a twist tie or clip, and an unsealed plastic zip-lock bag of leftover halved onions and bell peppers. LPA Moleski also observed one half of a green bell pepper lying cut-side down in a vegetable drawer. The bell pepper was not stored in any sort of container. [continued on 9099-C] Substantiated In an interview, R6 said staff assist them with dressing, showering, and with transferring. R6 said they cannot stand on their own, but said that staff do try to help them using the Hoyer lift. When asked, R6 said that they had not received a shower within the past week, but said that staff do provide bed baths in order to meet their hygiene needs. R6 was not able to recall when they had last received a bed bath. R6 appeared clean, and did not present any odors indicating their hygiene needs were not being met. In interviews, caregivers C1 and C2 said that R6 does not always want to get up out of bed, and when R6 does get out of bed, they often want to return to bed shortly afterward. C1 said that R6 receives daily bed baths. C2 initially said that R6 receives bed baths every other day, but later said that R6 receives bed baths daily. LPA Moleski interviewed R6's responsible party (R6's RP) over the phone during this visit. R6's RP was aware that R6 receives bed baths, and expressed no concern with this accommodation. R6's RP said that R6 has numerous medical conditions which make it difficult to move around. R6's RP said they have witnessed staff transferring R6 previously. In an interview, R6's roommate, R2, did not voice concerns regarding R6's care. R2, who moved into this facility in September, said they did observe odorous residents around the time R2 moved in, but R2 said this was the choice of those residents. Per 22 CCR Section 87468.1(a)(16), residents retain the right to refuse any service, including hygiene care. R2 said that they have not observed any issues since then. R2 said they regularly observe staff transferring other residents up out of bed. The department has determined the following as it relates to the allegations that staff do not assist a resident with showering and that staff do not assist a resident with ambulating: Based on interviews and observation, the above allegations are UNSUBSTANTIATED, which 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. No deficiencies were cited regarding these allegations. An exit interview was held with Clark. A copy of this report was left with staff member Leashia Tyrell-Moore. During a visit on 10/16/25, LPA Sommer Hayes observed a child visitor accompanied by Clark. LPA Hayes observed the child roaming around the facility and touching fruit sitting on the kitchen counter. On that same date, LPA Hayes observed raw shredded cabbage without dressing served as a side salad. In an interview conducted by LPA Hayes, R2 reported that hot dog buns had been used for sandwiches, as staff had run out of sliced bread. 22 CCR Section 87555(b)(23) requires that "all readily perishable foods or beverages ... shall be stored in covered containers..." 22 CCR Section 87555(b)(28) requires that "all food shall be protected against contamination." The department has determined the following as it relates to the allegation that staff do not serve residents food of good quality: Based on interviews and observations, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Section 87555(a). This facility was previously cited per 22 CCR Section 87555(a) in response to a substantiated complaint on 06/03/2025. As this is a repeat violation, a civil penalty in the amount of $250 is hereby assessed. An exit interview was held with Clark. Appeal rights and a copy of this report were left with staff member Leashia Tyrell-Moore.the state’s words, verbatim · CDSS document, Oct 27, 2025 · control 27-AS-20251014094455

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Oct 28, 2025

"The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents... All food shall be selected, stored, prepared and served in a safe and healthful manner." This requirement was not met as evidenced by: Based on observation, foods were not stored in a safe or healthful manner, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Oct 27, 2025

Plan of correction: Licensee agrees to conduct a staff training regarding food storage procedures by POC due date. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on a complaint investigation, but discovered an unrelated deficiency during that visit. LPA Moleski spoke with facility administrator Beatrice Clark over the phone and explained the purpose of the visit. LPA Sommer Hayes visited this facility on 10/16/25. During that visit, LPA Hayes requested several documents, including a resident roster, a staff roster, and a certain resident's (R1's) medical assessment and service plan. LPA Hayes requested these documents by 10/20/25. As of today, LPA Hayes has not yet received these documents. During this visit, LPA Moleski requested R1's medical assessment and service plan to assist in investigating the aforementioned complaint. However, Clark told LPA Moleski that she did not have immediate access to the documents, and she was planning on sending them to LPA Hayes later today. 22 CCR Section 87755(c) establishes inspection authority as follows: "(c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours." This facility is hereby cited per 22 CCR Section 87755(b). An exit interview was held with Clark. Appeal rights and a copy of this report was left with staff member Leashia Tyrell-Moore.the state’s words, verbatim · CDSS document, Oct 27, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87755(b) · Plan of correction due date: Oct 28, 2025

"(b) The licensee shall ensure that provisions are made for ... the examination of all records relating to the operation of the facility." This requirement was not met as evidenced by: Based on interview and observation, the licensee did not make provisions for the examination of records upon demand, which poses an immediate health, safety, and/or resident rights risk.the state’s words, verbatim · CDSS document, Oct 27, 2025

Plan of correction: Licensee agrees to produce these documents by POC due date. Failure to do so will result in the assessment of civil penalties. vincent.moleski@dss.ca.gov

Allegation investigated: Staff do not ensure that residents in care are provided with food that is of good quality. Staff do not provide activities for residents in care.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Beatrice Clark and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. LPA Moleski reviewed six residents’ files (R1-R2 and R4-R7). LPA Moleski interviewed two staff members (Clark and S3), six residents (R1-R2 and R4-R7), and four residents’ responsible parties (R1’s RP, R4’s RP, R5’s RP, and R7’s RP). During a visit to this facility on 10/2/24 Community Care Licensing Division (CCLD) staff observed food that was undated, leftover food covered with plates, leftover food which was uncovered, and open smoothie container. [continued on 9099-C] Substantiated During a visit to this facility on 3/7/25, CCLD staff observed food which was improperly covered, insufficient food supplies, unclean refrigerators, and freezer burned food. In recent interviews, a resident (R1) said the facility’s food had been “poor quality” several months ago, but had since improved. LPA Moleski visited this facility during daytime hours on 5/5/25 for a period of approximately 6.5 hours. LPA Moleski visited this facility a second time during daytime hours on 5/20/25 for a period of approximately 5.5 hours. During these time periods, LPA Moleski did not observe most residents engaged in meaningful activities. LPA Moleski did observe one resident with dementia playing with sensory stimulation devices, but did not observe any other group or individual activities ongoing. Residents observed during these time periods were largely either watching television or sitting outside. LPA Moleski interviewed two residents who were able to coherently respond to questions and who were not diagnosed with any sort of cognitive impairments (R2 and R7). R2 said that there are board games at the facility, but they are not played. R2 did not identify any other activities that are available for residents. R2 said that activities are not possible due to the condition of the other residents of the facility. R7 also said there are games around the facility, but they are not used. R7 had not observed other residents engaged in meaningful activities. LPA Moleski interviewed a staff member (S3) on the same date LPA Moleski interviewed R7. S3 claimed that a board game had been played with residents the day before. In an interview, R6’s RP said that there was “not a lot of stimulation” at the facility, that staff “don’t seem to engage them in activities,” and that when they visit, R6 is typically watching television. The department has determined the following as it relates to the allegations that staff do not ensure that residents in care are provided with food that is of good quality and that staff do not provide activities for residents in care: Based on interviews and observations, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Sections 87555(a) and 87219(a). An exit interview was held with Clark. Appeal rights and a copy of this report were left with Clark. During this time period, LPA Moleski did not smell any odors of urine or feces from residents or from their bedrooms. LPA Moleski did observe staff assisting residents to the bathroom in order to care for their continence needs, and otherwise observed residents being assisted with their activities of daily living (ADLs). LPA Moleski observed residents’ clothing and bed linens to be clean. LPA Moleski interviewed four residents who were able to respond verbally and coherently (R1, R2, R6, and R7). Of these, two were not diagnosed with any sort of cognitive impairments (R2 and R7). R1 voiced no concerns with their quality of care, and said they receive all assistance when needed. R2 voiced no concerns with quality of care, and said that other residents are cared for appropriately by staff, such as ensuring that they are bathed and that their diapers are changed regularly. R6 voiced no concerns with their quality of care and said they had their basic needs met. R7 said that although they did not receive showers, they do receive bed baths on a regular basis. R7 said they receive assistance with other ADLs when requested. In interviews, four residents’ responsible parties (R1’s RP, R4’s RP, R5’s RP, and R6’s RP) voiced no significant concerns with the quality of direct care at the facility. The department has determined the following as it relates to the allegations that staff do not ensure residents have clean linens, that staff do not assist residents with their ADLs, and that staff do not assist residents with toileting: Based on interviews and observations, the above allegations are UNSUBSTANTIATED, which 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. No deficiencies were cited regarding the above allegations. An exit interview was held and a copy of this report was left with Clark.the state’s words, verbatim · CDSS document, Jun 3, 2025 · control 27-AS-20240927111732

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(a) · Plan of correction due date: Jun 9, 2025

“(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.” This requirement was not met as evidenced by: Based on interviews and observations, food was not stored or prepared in a safe and healthful manner, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: Licensee agrees to provide LPA Moleski with an inservice training record by POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a) · Plan of correction due date: Jun 9, 2025

“(a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities. The activities made available shall include:” This requirement was not met as evidenced by: Based on interviews and observations, residents were not encouraged to participate in a variety of planned activities, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: Licensee agrees to provide LPA Moleski with a planned activities calendar to be used daily, with all refusals documented, by POC due date. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a case management visit. LPA Moleski met with facility administrator Beatrice Clark and explained the purpose of the visit. Upon arrival, LPA Moleski observed two staff members (S1-S2) present and working. S2 identified themselves to LPA Moleski and said they had been working at this facility for six days. LPA Moleski reviewed Guardian records and observed that S2 is not associated to this facility but has an active criminal record clearance. Clark said that S2 actually only started working here on June 1, but that S2 moved in and has been living at this facility since May 30. 22 CCR Section 87355(e)(3) requires a transfer of criminal record clearances for all individuals not only working in licensed care facilities but also for all individuals residing in licensed care facilities. If S2 has been living at this facility since May 30, as Clark stated, then days in violation should start from that date. Therefore, five days are hereby assessed at a rate of $100 per day. This facility was previously cited for criminal record clearance requirements on 5/5/25. As this is a repeat violation, an additional civil penalty of $250 is hereby assessed. LPA Moleski cleared other unrelated citations from this facility's annual inspection on 5/5/25 during this visit. LPA Moleski reviewed staff files and observed that S1's file contained only their health screening and first aid certification. S2's file was missing a completed health screening. As this is a repeat violation, a civil penalty in the amount of $250 is hereby assessed. [continued on 809-C] Clark requested additional extensions for outstanding plans of correction regarding resident records and centrally stored records. No additional extensions will be granted, and LPA Moleski will return to assess additional civil penalties if these plans of correction are not submitted by 6/9/25. This facility is hereby cited per 22 CCR Sections 87355(e)(3) and 87412(a). Assessed civil penalties total $1000. Appeal rights and a copy of this report were left with Clark.the state’s words, verbatim · CDSS document, Jun 3, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Jun 4, 2025

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Based on record review, one staff member was not associated to this facility's roster prior to starting work, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: Licensee submitted an email transfer request during this visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: Jun 9, 2025

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by: Based on record review and interview, staff files for two staff were incomplete, which poses a potential health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Jun 3, 2025

Plan of correction: Licensee agrees to provide completed staff records for S1 and S2 by POC due date. Failure to adhere to this POC will result in additional civil penalties. vincent.moleski@dss.ca.gov

Type of visit: POC

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a plan of corrections visit. LPA Moleski met with facility administrator Beatrice Clark and explained the purpose of the visit. During an annual inspection on 5/5/25, LPA Moleski issued citations per 22 CCR Sections 87412(a) for incomplete staff files, 87506(b) for incomplete and/or missing resident files, 87465(h)(6) for centrally stored medication records not being kept, and 87303(e)(2) for hot water temperature controls. LPA Moleski reviewed all of these plans of corrections with Clark. Clark requested extensions regarding these plans of correction until June 2. During this same visit, LPA Moleski observed an individual present in this facility (S2) during this visit. According to a staff member on duty (S1), S2 was a friend of theirs. S1 did not know S2's last name. S1 said that S2 stayed in their room overnight the night previous. In an interview, S2 provided their name to LPA Moleski, and said they had stayed one night. S2 said that they were not fingerprinted because they were not working as a caregiver. Title 22 of the California Code of Regulations requires that any individual who resides in the facility not receiving care must be fingerprinted and background cleared. A civil penalty in the amount of $100 is hereby assessed due to a violation of criminal record clearance requirements. An exit interview was held with Clark. Appeal rights and a copy of this report were left with Clark.the state’s words, verbatim · CDSS document, May 20, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: May 21, 2025

"1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department ..." This requirement was not met as evidenced by: Based on interviews, one individual without a criminal record clearance resided in this facility for one night, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, May 20, 2025

Plan of correction: Licensee agrees to provide LPA Moleski with a signed acknowledgement affirming that these requirements have been reviewed and will be adhered to in the future. Licensee provided LPA Moleski this signed statement during this visit. This POC will be cleared.

Allegation investigated: Injections being administered by unqualified staff. Staff not maintaining residents hygiene.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with licensee Beatrice Clark and explained the purpose of the visit. This investigation consisted of observation, record review and interviews. Interviews were conducted with six residents (R1-R6), two staff members (Clark and S1), a resident's attorney-in-fact (R1's POA), and a resident's friend. LPA Moleski reviewed a medication list for R1 from November 2024. R1 did not have a prescription for insulin or any other injections. In an interview, R1's POA said that R1 is not currently taking injections, and has not since the time of their admission to this facility. R1 was admitted in March 2024, according to their admission agreement. In an interview, R1 said they do not receive injections at this facility. In an interview, R1's friend said they had not seen R1 being given injections. [continued on 9099-C] Unsubstantiated Staff members interviewed said that R1 does not receive any injections at this facility. Other residents interviewed said they had not witnessed R1 receiving any injections. LPA Moleski inspected medication storage areas for R1's medications and observed one insulin shot with prescription instructions for it to be used in an emergency. The shot was dated July 2024 and expires this July. LPA Moleski observed all six residents during this visit to be reasonably clean and hygienic. R1 appeared to be wearing clean clothes. LPA Moleski observed no odor of urine or feces. In an interview, R1's POA said that R1 is well taken care of at this facility. In an interview, R1's friend said that R1 had never received a bath while living at this facility, although they had never smelled anything from this resident or any other. R1's friend also said that R1 not changed, although staff do clean R1. In an interview on 10/16/24, R1 said they were bathed the day prior. In that same interview, R1 said they are changed regularly. Interviews with two other residents who are able to speak indicated that residents are kept clean and are taken care of by staff. The department has determined the following as it relates to the allegations that injections are being administered by unqualified staff and that staff are not maintaining a resident's hygiene: Based on interviews, observation and record review, the above allegations are UNSUBSTANTIATED, which 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. No deficiencies were cited regarding these allegations. An exit interview was held and a copy of this report was left with Clark.the state’s words, verbatim · CDSS document, May 5, 2025 · control 27-AS-20241011104737

Allegation investigated: Facility is not keeping an adequate medication record for residents Staff do not ensure medications are properly stored.

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to follow up on this complaint investigation. LPA Moleski met with licensee Beatrice Clark and explained the purpose of the visit. This investigation consisted of observation and interviews. During an annual inspection on this same date, LPA Moleski observed medications stored alongside food items in the facility refrigerator. The medications were not maintained in locked storage, as required by Title 22 of the California Code of Regulations. Additionally, during that same annual inspection, LPA Moleski asked Clark for centrally stored medication records. Clark said that she did not have any current centrally stored medication records, as required by Title 22 of the California Code of Regulations. Citations for these observed deficiencies were issued during the annual inspection. Therefore, additional citations will not be issued presently. [continued on 9099-C] Substantiated The department has determined the following as it relates to the allegations that the facility is not keeping an adequate medication record for residents and that staff do not ensure medications are properly stored: Based on observation and interview, the above allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegations are valid because the preponderance of evidence standard has been met. An exit interview was held with Clark. Appeal rights and a copy of this report was left with Clark.the state’s words, verbatim · CDSS document, May 5, 2025 · control 27-AS-20240927111732

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with licensee Beatrice Clark and explained the purpose of the visit. Upon entry, LPA Moleski observed two caregivers working in the facility (S1-S2). LPA Moleski reviewed Guardian records and observed that neither S1 nor S2 were associated to this facility. Clark said S1 had been working at this facility for just under one month. S2 said they had been working at the facility for one month. LPA Moleski asked to review this facility's centrally stored medication records. Clark said she did not have any current centrally stored medication records. LPA Moleski reviewed five resident files (R1-R5) and two staff files (S1-S2). Resident files were missing several required forms. R1 had a blank PRN authorization on file, and had no needs and services plan. R2's appraisal was dated 8/1/23, which is more than one year old. R2 also had a blank PRN authorization form on file. R3 had a needs and services plan on file, but it was not complete and was missing significant pertinent information regarding R3's needs. R4's admission agreement was unsigned, and they did not have an appraisal, personal rights form, consent form, PRN authorization form, or needs and services plan on file. R5 did not have a needs and services plan or PRN authorization form on file. R6 did not have a file present at the facility. Clark emailed LPA Moleski a medical discharge form to LPA Moleski for R6, but could not produce further documentation regarding R6, such as a medical assessment. LPA Moleski asked for S1 and S2's file. Clark said that S2 did not have a file at this facility. S1's file was missing an LIC 501. [continued on 809-C] LPA Moleski toured the facility with Clark and inspected common areas, the kitchen, bedrooms, bathrooms and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 77 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 135 degrees Fahrenheit, which is not within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies and carbon monoxide/smoke detectors. While touring, LPA Moleski observed medications in the refrigerator which were not kept in locked storage. LPA Moleski also observed cleaning solutions, including some containing bleach, which were left unlocked in a cabinet under the kitchen sink and under a sink in a resident bathroom. LPA Moleski observed fire extinguishers which had not been serviced within the last year, as required. The fire extinguishers were last serviced on April 15, 2024. This facility is hereby cited per 22 CCR Sections 87202(a), 87303(e)(2), 87309(a), 87355(e)(3), 87465(h)(2), 87412(a), 87506(b), 87465(h)(6). Due to a violation of criminal record clearance requirements, a civil penalty of $100 per day worked by both S1 and S2, with a maximum of five days each, is hereby assessed. An immediate civil penalty in the amount of $500 is also assessed due to a violation of fire clearance requirements. Civil penalties assessed during this visit total $1500. An exit interview was held with Clark. Appeal rights and a copy of this report were left with Clark.the state’s words, verbatim · CDSS document, May 5, 2025

Allegation investigated: Staff does not have required first aid training

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 12/19/24 at 12:30pm to conduct an investigation of the above mentioned allegation. Upon arrival LPA met with Administrator Beatrice Clark and stated the purpose of the visit. LPA requested to review staff #1 (S1) file during this visit. LPA provided a copy of the LIS printout for staff clearances. LPA observed that S1 is finger print cleared and associated to the home. Upon a file review LPA observed that S1 has a CPR/First Aid certificate dated 4/5/24 which is valid for 2 years. LPA also observed other documented trainings that S1 has completed and a Nursing Assistant certificate valid until 8/19/25 for Washington State Department of Health. Based on interview, documentation, and that there was no incident that occurred which warranted S1 to provide CPR/First aid, the allegation is deemed Unfounded. "The allegation is UNFOUNDED, meaning that the allegation was false, could not have happened and/or was without a reasonable basis. This Department has therefore dismissed the complaint." Per California Code of Regulations, no deficiencies were observed or cited. Exit interview held, and a copy provided. Unfoundedthe state’s words, verbatim · CDSS document, Dec 19, 2024 · control 27-AS-20241218125105

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 6/17/24 at 8:45am to conduct a Case Management - Health Checks visit. LPA met with Joan Young, Caregiver then Beatrice Clark and stated the purpose of the visit. The Administrator certificate for Beatrice Clark expires 10/30/25. LPA observed the facility is licensed to serve 6 non-ambulatory residents in rooms 3-5 and the master bedroom of which 2 may receive hospice care services. There is 1 residents receiving hospice care services at this time. During LPA visit the temperature inside the facility measured to be at 73*F which is within the required range of 68-85*F. LPA observed caregiver(s) performing other duties during this visit. LPA observed fire extinguisher, smoke alarm, carbon monoxide detector in the home. LPA observed 2 day perishables. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA Observation during visit: *License fees not paid that was due on 5/3/24. Pin number was given as an option to pay online to become current. *Flies in the facility. *Did not have non-perishables fruits *The water temperature measured at 143.7*F which is within the required range of 105-120*F. *LPA observed the centrally stored medications area to be unlocked and accessible to residents, on table in room 1 with 2 residents present in bed *Facility is using 7 day pill boxes *Medications are stored with chemicals in garage *Resident #1 (R1) was requesting to be dressed and staff #1 (S1) stated you are not going anywhere and that R1 always ask for the pants. *S2 does not have a file available for review during the visit *Administrator/S2 does not have fingerprint clearance or association documentation Per California Code of Regulations (CCRs) - Title 22, Div.6, Ch. 8, deficiencies are being cited on the attached 809D during this visit. If any deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 17, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87156(a) · Plan of correction due date: Jun 18, 2024

Licensing Fees An applicant or licensee shall be charged fees as specified in Health and Safety Code section 1569.185. This requirement has not been met by: Based on the file review conducted by LPA VBrown the license fees are not current. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Licensee/Administrator shall pay license fees by POC due date and fax confirmation to the CCL office.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87555(b)(27 · Plan of correction due date: Jun 18, 2024

General Food Service Requirements All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement has not been met by: Based on the observation of LPA VBrown the Licensee/Administrator did not keep facility free of flies in the kitchen and common bathroom of the facility. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Licensee/Administrator shall submit a plan to rid the home of flies by POC due date and fax confirmation to the CCL office.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Jun 18, 2024

Maintenance and Operation Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement has not been met by: Based on water temperature measured by LPA VBrown the licensee/Administrator did not ensure water was within required range. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Licensee/Administrator shall turn down water heater by POC due date and fax confirmation to the CCL office. Also keep a water log for 1 week to be submitted by fax.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87555(b)(26) · Plan of correction due date: Jun 18, 2024

General Food Service Requirements Supplies of nonperishable foods for a minimum of one week...shall be maintained on the premises. This requirement has not been met by: Based on observation by LPA VBrown the licensee/Administrator did not ensure a variety of fruits were present on premisis. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Licensee/Administrator shall purchase nonperishable fruits and receipt to be faxed by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jun 18, 2024

Personal Rights of Residents in All Facilities To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement has not been met by: Based on observation by LPA VBrown the licensee/S1 did not ensure R1 received dignity by assisting with clothing. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Licensee/Administrator shall submit a plan on when an inservice to provide personal rights training to all staff will occur by POC due date and fax confirmation to the CCL office. Completion of in-service with signature shall be faxed to the office.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Jun 18, 2024

Incidental Medical and Dental Care Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement has not been met by: Based on observation by LPA VBrown the licensee/Administrator did not ensure medications were locked and inaccessible. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Licensee/Administrator shall submit confirmation that medications are inaccessible to residents by POC due date and fax confirmation to the CCL office.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465 · Plan of correction due date: Jun 18, 2024

Incidental Medical and Dental Care Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement has not been met by: Based on observation by LPA VBrown the licensee/administrator did not ensure medications were not in its orignal container until medication pass was to occur. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Licensee/Administrator shall submit a letter stating medication are not stored in 7 day pill boxes by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(b) · Plan of correction due date: Jun 18, 2024

Storage Space Medicines which are centrally stored shall be stored as specified in Section 87465 and separately from other items specified in (a) above. This requirement has not been met by: Based on observation by LPA VBrown the licensee/administrator did not ensure medications are disposed of properly. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Licensee/Administrator shall submit a letter stating medication are not stored with chemicals in the garage by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87412(a-h) · Plan of correction due date: Jun 18, 2024

Personnel Records The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee... This requirement has not been met by: Based on observation by LPA VBrown the licensee/Administrator did not ensure a file was created for S2. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Licensee/Administrator shall ensure a file is created and maintained for all staff. A letter of confirmation shall be submitted by fax to the office by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(g)(1-3) · Plan of correction due date: Jun 18, 2024

Personnel Requirements - General Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: This requirement has not been met by: Based on observation by LPA VBrown the licensee/Administrator did not ensure S2 was fingerprint cleared and associated to the facility. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Licensee/Administrator shall submit a plan to ensure S2 is cleared and associated to the facility by POC due date and fax confirmation to the CCL office.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87305(b) · Plan of correction due date: Jun 18, 2024

Alterations to Existing Building or New Facilities The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists. This requirement has not been met by: Based on observation by LPA VBrown the licensee/Administrator did not ensure staff was not sleeping in the shed in the backyard. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 17, 2024

Plan of correction: Licensee/Administrator shall submit a plan to seek confirmation from the Fire Dept on the approval of the shed being used as a living space or ensure it is used for its proper use by POC due date and fax confirmation to the CCL office.

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 3/25/24 at 8:30am on a subsequent visit. This visit is to conduct a health and safety check of the residents residing in the home. LPA met with Beatrice Clark and stated the purpose of the visit. The Administrator certificate for Beatrice Clark expires 10/30/25. LPA observed the facility is licensed to serve 6 non-ambulatory residents in rooms 3-5 and the master bedroom of which 2 may receive hospice care services. There is 2 residents receiving hospice care services at this time. LPA observed fire extinguisher, smoke alarm, carbon monoxide detector in the home. LPA observed 2 day perishable and 7 days of non-perishables during this visit. During LPA visit the temperature inside the facility measured to be at 68*F which is within the required range of 68-85*F. The water temperature measured at 116.5*F which is within the required range of 105-120*F. LPA observed caregiver(s) performing other duties during this visit. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA did not observe any hazards for residents at this time. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.the state’s words, verbatim · CDSS document, Mar 25, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 3/25/24 at 8:30am to conduct a Required - 1 Year visit. LPA met with Beatrice Clark and stated the purpose of the visit. The Administrator certificate for Beatrice Clark expires 10/30/25. LPA observed the facility is licensed to serve 6 non-ambulatory residents in rooms 3-5 and the master bedroom of which 2 may receive hospice care services. There is 2 residents receiving hospice care services at this time. LPA observed fire extinguisher, smoke alarm, carbon monoxide detector in the home. LPA observed 2 day perishable and 7 days of non-perishables during this visit. During LPA visit the temperature inside the facility measured to be at 68*F which is within the required range of 68-85*F. The water temperature measured at 116.5*F which is within the required range of 105-120*F. LPA observed caregiver(s) performing other duties during this visit. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 1 staff and 1 resident files and conducted interviews during this visit. Upon a file review the following items were discussed to be submitted with any changes annually: Licensing fees-Current Criminal Record Clearances LIS536-Current Administrative Organization LIC309-Current Designation of Administrative Responsibility LIC308-Submit Personnel Report LIC500-Submit Affidavit Regarding Client/Resident Cash Resources LIC400-NA Surety Bond LIC402-NA Facility Floor Plan/Plot Plan LIC999-Current Fire Clearance (consistent with terms and limitations of license)-NA Qualifications of Administrator/Facility Manager-Submit Articles of Incorporation/Organization, Constitution and bylaws-NA Partnership Agreement-NA Control of Property-Submit Emergency Disaster Plan LIC610-Submit Plan of Operation (Restricted Health Care Plan)-NA Admission Policies and Procedures-NA Health Screening Report-Facility Personnel LIC503-NA Bacteriological Analysis of Private Water Supply-NA In-service Training Program-NA Medication Procedures-NA Transportation Procedures-NA Job Description/Personnel Policies-NA Exemptions/Waivers and Exceptions-Current First aid/CPR certificates-Current Liability Insurance-Submit Infection Control Plan-Submit Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.the state’s words, verbatim · CDSS document, Mar 25, 2024

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) arrived unannounced on 12/7/23 at 3:45p to conduct a health and safety check of the residents residing in the home. LPA met with Beatrice Clark, Administrator and stated the purpose of the visit. LPA observed the facility is licensed to serve 6 non-ambulatory residents in rooms 3-5 and the master bedroom of which 2 may receive hospice care services. There is 1 residents receiving hospice care services at this time. LPA observed residents preparing for dinner during this visit. LPA observed fire extinguisher, smoke alarm, carbon monoxide detector in the home. LPA observed 2 day perishable and 7 days of non-perishables during this visit. LPA observed caregiver(s) performing other duties during this visit. LPA did not observe any health and safety hazards during this visit. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.the state’s words, verbatim · CDSS document, Dec 7, 2023

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) arrived unannounced on 11/2/23 at 3p to conduct a health and safety check of the residents residing in the home. LPA met with Caregiver Talitha Smith who contacted the Administrator Beatrice Clark regarding todays visit. Beatrice Clark arrived within 15 minutes to assist with todays visit. The Administrator certificate for Beatrice Clark expires 10/30/25. LPA observed the facility is licensed to serve 6 non-ambulatory residents in rooms 3-5 and the master bedroom of which 2 may receive hospice care services. There is 0 residents receiving hospice care services at this time. LPA observed residents preparing for dinner during this visit. LPA observed fire extinguisher, smoke alarm, carbon monoxide detector in the home. LPA observed 2 day perishable and 7 days of non-perishables during this visit. During LPA visit the temperature inside the facility measured to be at 77*F which is within the required range of 68-85*F. The water temperature measured at 110.8*F which is within the required range of 105-120*F. LPA observed caregiver(s) performing other duties during this visit. LPA did not observe any health and safety hazards during this visit. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given.the state’s words, verbatim · CDSS document, Nov 2, 2023