Bella Vista

Allegation investigated: Staff did not ensure resident's information was kept confidential.

On this day, March 11, 2026, at 10:35 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with House Manager Sally Espina and informed the reason for visit. Haidie Bautista, administrator (ADM) arrived at around 11:05 am. It was alleged that staff, S1, told resident's (R1) medications to R1's roommate (R2). LPA reviewed residents' records and obtained copies of the following: LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; R1's doctor's order of medication. LPA also reviewed Unusual Incident Report (UIR) submitted by ADM. LPA interviewed staff (S1, S2, S3 and ADM) and residents (R1, R2). .......continued on 9099C Unfounded The administrator (ADM) stated she received a call from R1's case manager (CM) regarding the allegation. ADM further stated that upon knowledge, she conducted investigation. S1 denied the allegation and that R1 and R2 stated that S1 didn't share R1's medications information. S2 and S3 stated never hearing S1 disclosed personal information nor R1's medications to others. S1 denied the allegation. Both R1 and R2 stated S1 never shared nor disclosed personal or medication information to others. Based on records review and interviews, the allegation is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis, therefore, the complaint is dismissed. No deficiency cited. Exit interview conducted and copy of this report provided..the state’s words, verbatim · CDSS document, Mar 11, 2026 · control 15-AS-20260305094639

Allegation investigated: Physical abuse of resident while in care. Verbal abuse of resident while in care

On this day, March 11, 2026, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Haidie Bautista, administratot (ADM), and informed the reason for visit. During the course of investigation, LPA reviewed resident's records and obtained copies of including but not limited to LIC602A Physician's Report, Unsual Incident Reports (UIRs), hospital After Visit Summaries, SOC341. LPA interviewed the following: staff (S2, S3, S4, S5 and ADM) and resident (R3) on 10/08/25; residents (R2, R4, R5) and staff (S1, S6) on 11/04/25; staff (S7) on 12/19/25. Allegation: Physical abuse of resident (R1) while in care. Allegation: Verbal abuse of resident (R1) while in care. ....continued on 9099C Unsubstantiated On October 2025, the reporting party (RP) stated that R1 reported a staff, S1, had punched R1 in the head with closed fist two times and grabbed the neck of R1's shirt and pulled R1. R1 further reported that S1 yelled at R1 and threatened to "beat him up". The administrator (ADM) stated that one of the staff reported to her that a police officer came due to the reported abuse. S1 was interviewed by the police officer and asked if R1 went out and fell outside the facility and interviewed S1 regarding the alleged abuse which S1 denied. ADM submitted a copy of SOC341 to the Department. SOC341 also indicated that on 9/22/25, R1 was 5150'd due to pulling of the hair of one of the staff. S1 denied the allegation. He stated the police officer came and he was not aware there's a complaint by R1 against him. He was asked if R1 went out that day and he told the police officer he does not know, because the residents can leave the facility. There were times when R1 left the facility at night and tell other residents when he leaves and S1 did room check. He was also asked if he ever hit R1 and he said he never did and that he's here to assist the residents. The other staff interviewed stated not observing S1 being physically and/or verbally abusive to R1. Some of these staff stated it is them who are at times hit by residents. The 4 residents (R2, R3, R4 and R5) stated not observing staff including S1 being physically and verbally abusive to R1. They stated S1 is a good staff. Review of 3 Unusual Incident Reports (UIRs) for incidents that happened on October 2025 showed R1 had 2 unwitnessed falls and an episode of seizure where R1 was sent out to the hospital. The hospital After Visit Summaries confirmed the incidents and one of these documents showed R1 sustained laceration of the scalp Based information gathered and due to R1 was no longer at the facility when LPA began the investigation, the above allegations are unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 11, 2026 · control 15-AS-20251007084713

Allegation investigated: Staff do not ensure residents' privacy. Staff are not meeting residents' dietary needs. Staff do not ensure residents are accorded dignity.

On this day, March 11, 2026, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation and deliver the findings for the above allegations. LPA met with Haidie Bautista, administratot (ADM), and informed the reason for visit. During the course of investigation, LPA reviewed residents’ records and obtained copies of including but not limited to LIC601 Identification and Emergency Information, LIC602A Physician's Report, LIC625 Appraisal/Needs and Services Plan. LPA also obtained copies of menu, LIC9020 Register of Clients/Residents and staff schedule, and inspected the food supplies. LPA interviewed the following: staff (S1, S2, S3, S4, S6) on 10/08/25; resident (R1) on 10/07/25 and 11/04/25; residents (R2, R3) on 10/08/25; residents (R5, R6) and staff (S5) on 11/04/25; staff (S7) on 11/04/25 and 3/11/26. ....continued on 9099C Unsubstantiated Allegation: Staff do not ensure resident’s privacy. The reporting party (RP) stated that at night around September 2025, resident (R1) was going to the big building in the facility to take a shower, and R1 observed staff (S2) giving bath to resident (R2). R2 was naked and the bathroom door was open while S2 was giving R2 a bath. All residents except R1 stated not observing any staff giving bath to residents with bathroom door open. R1 stated observing S2 giving bath to R2 one night with bathroom door open. One of the staff does not provide care giving while the other one stated not providing assistance with bathing to residents. S2 who works NOC shift stated he does not give bath to residents including R2 at night and that residents are given bath during the day. The rest of the staff interviewed indicated when they provide assistance with bathing they close the bathroom door. Due to medical condition, LPA was not able to obtain information from R2. Therefore, the allegation is close as unsubstantiated. Allegation: Staff are not meeting residents’ dietary needs. The reporting party (RP) stated R1 has been forced to eat meat but due to religion, R1 cannot eat meat or use animal products due to R1 itches when eating and/or touching animal products. Review of records showed R1 was seen by a doctor due to itching but After Visit Summary didn’t indicate to avoid and/or not eat animal products. LIC602A Physician’s Report didn’t indicate any food allergies or other type of allergies. On 10/07/25, R1 stated that when he moved-in, he told the staff that he prefers vegetarian food but he turned vegan around 10/2025, because whenever he eats something with meat and meat bi-products, he itches. At first, the staff told him 'maybe' and later was offered vegetarian diet but it's not totally vegetarian because they still put meat on it. Around first week of October 2025, the cook told him he can buy his own food and the cook will prepare for him but S7 told him that he should not be bothering the cook which S7 denied telling R1. ........continued on 9099C On 11/04/25, R1 stated the staff are good and serving him vegetarian meals. LPA conducted inspection of the kitchen and observed list of residents who are on soft diet and those with food preference but no list of residents who are vegetarian or vegan. The cook stated he does not have list but he knows because there's only 2 of them. He stated R3 is vegetarian due to religious/spiritual belief and he does not serve R3 meat. He further stated that he himself is vegetarian, so whatever he prepares for himself, he serves to R3. He also stated that R1 use to eat meat before but around September 2025, R1 transitioned to vegan. On November 2025, R1 told him that he's not eating meat so he prepared him vegetarian meals for about 5 days, but after 5 days, R1 told him that vegetarian diet is not working, so R1 started eating meat again and asked him for hot dog. When R1 told him he is vegan, he served him vegan meals. R3 stated staff do not served him meat. Based on interviews and records review, the allegation is unsubstantiated. Allegation: Staff do not ensure residents are accorded dignity. The reporting party (RP) stated that when staff (S3) was putting 'apron' on resident's (R2) thigh while in the dining room during meal, S3 touched R2's thigh and was not mindful. R1 stated it bothered him and does not think that the touching was accidental. S3 confirmed she puts an apron like a bib and ties it on R2's neck and the apron stretches up to the lap. S3 denied touching R2's thigh when placing the apron. Due to medical condition, LPA was not able to obtain information from R2. Therefore the allegation is unsubstantiated. Based on interviews, records review and inspection, the 3 allegations are unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 11, 2026 · control 15-AS-20250929145917

Type of visit: Case Management - Deficiencies

While at the facility conducting investigation of a complaint (Complaint Control # 15-AS-20260305094639) on this day, March 11, 2026, and upon review of resident's (R1) record, Licensing Program Analyst (LPA) Delmundo observed one of R1's medications which was filled on February 10, 2026 with 84 tablets and administered 3x/day, with start date of administration February 10, 2026, showed this particular medication still has one remaining tablet. Staff (S1) who administers residents medications was not able to explain what happened why there is still one remaining tablet. This was discussed with Haidie Bautista, administrator (ADM), who stated that it could be a recording error. Deficiency is cited from Title 22 California Code of Regulations and listed on 809D. Failure to submit proof of correction by plan of correction due date may result in civil penalty. Deficiency and plan and proof of correction were discussed with ADM. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 11, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Mar 25, 2026

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. -This requirement is not met as evidenced by: -Based on record review, the licensee did not comply with the section when R1 has 1 remaining tablet for 1 of the medications which does not match what should have left based on the recorded start date on LIC622 which poses a potential health and/or personal rights risks to person in care.the state’s words, verbatim · CDSS document, Mar 11, 2026

Plan of correction: Administrator to do the following and submit POC by 3/25/26: 1. Review the record and submit corrected LIC622. 2. In-service the staff and submit copy of in-service training,

Allegation investigated: Staff did not prevent residents in care from engaging in inappropriate behaviors.

At 10:25 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with staff, Sally Espina. LPA called and spoke over the phone with Haidie Bautista, administrator (ADM), who arrived at 11:10 am. It was reported that there were residents harassing other residents asking for money and cigarettes and residents exposing their private parts to others and walk naked. It was also alleged that a resident urinates outside the facility. LPA obtained copies of resident roster and staff schedule, and reviewed resident record. LPA also reviewed the Unsual Incident Report and SOC341 submitted by ADM to LPA on 12/15/25. LPA interviewed 3 staff and 3 residents. ....continued on 9099C Unsubstantiated All of the staff and residents interviewed including administrator stated not observing resident exposed self nor walk naked. They did not observed anyone urinates outside the facility. All 3 residents stated no one borrow money from them. One of these residents stated a resident borrowed cigarettes from him but it was his fault giving that resident. Two of the staff stated not hearing residents borrowed money from other residents while the other staff stated it is the residents' behavior borrowing money and cigarettes from each other. If this staff hears a resident borrows money from other resident, she tells the resident to wait for their money which comes every two weeks. ADM stated residents borrow money and cigarettes and does not think they feel harassed because it's their mutual behaviors. Based on information obtained, the allegation is unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. No deficiency cited. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 19, 2025 · control 15-AS-20251215105533

Type of visit: Required - 1 Year

On this day, November 4, 2025, at 10:15 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection. LPA met with House Manager Sally Espina and informed the reason for visit. LPA called and spoke over the phone with Haidie Bautista, administrator (ADM). ADM arrived at around 11:22 am. LPA started the inspection with house manager and continued with ADM. LPA inspected the 2 buildings (Bldg A and Bldg B) including but not limited to common areas, kitchens, dining areas, receiving room, library, bathrooms, shower rooms, porch, toilets, front, side and backyard. LPA selected for inspection 4 residents rooms in Bldg B and 5 in Buiding A. Fire extinguishers were observed fully charge with tags showed serviced May 12, 2025. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked. Hallways, common areas, yards and porch were observed free of obstructions. Facility has smoke and carbon monoxide detectors that were tested and observed in operating condition. Hot water temperature in one of the bathrooms in Bldg A was tested and measured at 105 degrees Fahrenheit. Facility conducts disaster drills at least every quarter and records showed last conducted October 6, 2025. .....continued on 809C LPA reviewed 5 residents and 5 staff files, and interviewed 3 residents. Medications were checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources. LPA observed the following: -at 10:55 am, saline solution in night stand drawer without lock in one of the residents' rooms. -at 11:08 am, chest rub in the night stand in another residents' room. -at 11:17 am, nail polish remover in other residents' room. -at 11:29 am, shovels and rakes in Bldg B's yard. -at 3:00 pm, resident (R2) has After Visit Summary dated 6/2025 with change in dosage of 1 medication but facility still administers the previous dosage. Also on the list are new/added medications but the facility does not have those medications. LPA received updated copies of the following documents: 1. LIC308 Designation of Facility Responsibility 2. LIC610E Emergency Disaster Plan 4. $3M liability insurance certificate Administrator to submit a copy of updated LIC500 Personnel Report by November 18, 2025. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalty.. Deficiencies and plan and proof of corrections were discussed with ADM. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Nov 4, 2025

Type of visit: Case Management - Deficiencies

While at the facility investigating a complaint (Control # 15-AS-20251007084713) and upon review of resident's (R1) file, Licensing Program Analyst (LPA) Delmundo observed 3 Hospital Discharge Summaries showing R1 was seen in the hospital due to fall incidents that happened this October 2025. LPA interviewed Haidie Bautista, administrator (ADM), who stated she sent Unusual Incident Reports (UIRs). LPA checked the Department's e-faxed documents and facility's e-fax folder and didn't see UIRs for the said incidents. LPA also learned from ADM that local law enforcement came to the facility October 2, 2025 due to an alleged abuse, and LPA has not receive the SOC341 nor the UIR from the facility. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Deficiencies were discussed with the administrator, and informed that any repeat violations within 12 month period may result in civil penalty. Exit interview conducted. Appeal Rights and copy of this report provided.the state’s words, verbatim · CDSS document, Oct 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 22, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence ......... -This is requirement is not met as evidenced by: -Based on records review and interview, the licensee did not comply with the section above for not sending report for R1 for fall incidents and alleged abuse.the state’s words, verbatim · CDSS document, Oct 8, 2025

Plan of correction: Corrected. Administrator provided the incident reports while LPA was at the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(c) · Plan of correction due date: Oct 22, 2025

87211 Reporting Requirements: (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required...... --This is requirement is not met as evidenced by: -Based on records review and interview, the licensee did not comply with the section above for not sending the SOC341 while posed a potential safety and personal rights risks to person in care.the state’s words, verbatim · CDSS document, Oct 8, 2025

Plan of correction: Corrected. Administrator provided copy of SOC341 while LPA was at the facility.

Allegation investigated: Staff (S1) sexually abused resident (R1).

On this day, July 10, 2025, at 2:30 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegation. LPA met with Haidie Bautista, administrator (ADM), and informed the reason for visit. The reporting party (RP) stated that on 4/15/2025, resident (R1) told RP that on 4/15/2025, staff (S1) assisted R1 with showering. Afterwards, while R1 was naked, S1 rubbed down R1’s back, turned R1 around, French kissed R1 and put his erect private part against R1’s body. ...........continiued on 9099C Unsubstantiated During the course of investigation, the Department obtained copies of LIC9020 Register of Facility Clients/Residents, staff roster and LIC624 Unusual Incident Report concerning resident (R1). Copies of R1’s following documents were also obtained: LIC602A Physician's Report; Preplacement Appraisal; LIC625 Appraisal/Needs and Services Plan; LIC9172 Functional Capability Assessment. Local law enforcement was also involved in the investigation and copy of police report was obtained and reviewed. The following were interviewed: RP on 6/09/25; staff (S2, S3, S4) and administrator (ADM) on 6/10/25; residents (R2, R3, R4) on 6/10/25; resident (R1) on 6/16/25; staff (S1) on 6/19/25. RP confirmed what R1 reported to RP. RP stated that R1 told RP about S1 telling R1 not to tell anyone what had happened. S1 asked R1 for R’s phone number as S1 said he was leaving the facility and wanted to keep in contact with R1 but R1 did not provide S1 with R1’s phone number. R1 was inconsistent with her statement to the Department. R1 stated that S1 gave R1 “a quick kiss” only and that there was no other inappropriate touching, and no part of S1’s body parts touched R1’s back. The Hayward Police Department closed their case due to R1 not wanting to make a statement. S1 denied all allegations of inappropriate touching. S1 stated he has showered and dried R1 multiple times without incident. S1 further stated that he has never said or done anything to upset R1 that would prompt this type of allegation, did not notice any changes in R1’s behavior during the week of the alleged incident, and R1 has never indicated that R1 was uncomfortable around him. The staff and residents interviewed said they never saw S1 act unusual or inappropriate around residents or R1. There were no staff or residents who could have witnessed the incident. The information gathered during investigation did not confirm the allegation, therefore the complaint is closed as unsubstantiated. A finding that a complaint is unsubstantiated means that there is not a preponderance of evidence to prove that the allegation and violation occurred. No deficiency cited. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jul 10, 2025 · control 15-AS-20250417163152

Allegation investigated: Due to lack of supervision, resident eloped from the facility

On 7/03/2025, at 4:15 PM, Licensing Program Analysts (LPAs) James Sampair and Andrew Christy arrived unannounced to investigate the allegation above. Upon arrival, the LPAs informed House Manager (HM) Sally Espina of the purpose of the visit. The complaint alleges due to lack of supervision, Resident R1 eloped from the facility. The LPAs were unable to interview Witness W1 because no phone number was provided to the Department. At the facility, the LPAs interviewed HM and R1. The LPAs confirmed that he was the resident whom W1 described. The LPAs reviewed R1's Physician's Report, which stated that he is able to leave the facility unassisted. The data collected and analyzed by the LPAs shows that the staff were providing the appropriate supervision for R1, which does not confirm the allegation. Continued on LIC 9099-C . . . Unsubstantiated . . . Continued from LIC 9099 Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 3, 2025 · control 15-AS-20250703103028

Type of visit: Case Management - Health Checks

On 4/21/2025, at 12:45 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to conduct a case management health and safety check as a result of a complaint (15-AS-20250417163152) received by the Department. The LPA met with Administrator Haidie Bautista and informed her of the reason for the visit. The LPA toured the interior and exterior of the facility with the House Manager (HM) Sally Estina. During the tour, the LPA observed the kitchens, dining rooms, living rooms, bedrooms, bathrooms, smoking area, and shared yard for both houses at 1641 and 1659 D Street. No citations were issued during the inspection. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 21, 2025

Allegation investigated: -Facility staff are not providing quality meals to residents. -Facility staff are restricting resident's telephone use. -Facility staff are restricting resident's leisure time activities.

On this day, 3/25/25, Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegations. LPA met with House Manager Sally Espina. LPA called and spoke with Haide Bautista, administrator (ADM), and informed the reason for visit. ADM arrived after about 30 minutes. During the course of investigation, LPA conducted inspection with staff and ADM, obtained copies of menu and LIC9020 Register of Facility Clients/Residents. LPA interviewed staff (S1, S2, S3, S4, S5 and ADM) and residents (R1, R2, R3). Residents (R4 and R5) refused to be interviewed. Allegation: Facility staff are not providing quality meals to residents. Reporting party (RP) stated observing nutritional foods being prepared by staff like chickens, vegetables, etc, but the meals that are given to the resident are as follows: Breakfast: a bowl of cold cereal. Lunch: cold hotdog or corn dog and a small bowl of soup. Dinner: ramen with vegetables ..........continued on 9099C (page 2) Unsubstantiated Page 2 All 5 staff interviewed provided information on food/meal serve which were of different varieties. They serve corn dog only once or 2x a week. One out 3 residents interviewed provided information consistent with the information provided by the staff. One of the other resident stated food served is always good while the other one does not remember but not have issues/problems on the meals provided. Two other residents refused to be interviewed. ADM stated she does the grocery shopping online of different varieties from different grocery chains and whatever is not available she asks one of the staff to do in-person grocery shopping. LPA inspected the food supplies and copies of menus showed different varieties. Based on inspection and interviews and LPA unable to obtain information from 2 residents, the allegation is closed as unsubstantiated. Allegation: Facility staff are restricting resident's telephone use. LPA conducted inspection and observed both buildings with land line telephones. All 5 staff stated the residents are allowed to use the facility telephone. Two of these staff and ADM stated that for courtesy to other residents who also want to use telephone, they tell the residents to limit their calls to 10 minutes but they can come back to use the telephone again. One of the 5 staff and ADM also stated that the facility also gets incoming calls and at times may need to make emergency calls. One of the 3 residents stated not using the facility telephone because this resident has cell phone. The other 2 residents stated they are allowed to use and not told to limit their calls. The other 2 residents refused to be interviewed. Based on interviews, the allegation is unsubstantiated. Allegation: Facility staff are restricting resident's leisure time activities. RP stated that all electrical devices such as TV, radio, etc, have to be off at 9:00 p.m. to save electricity, even if they are used with a headset. .....continued on 9099 (page 3) Page 3 During inspection, LPA observed residents in both buildings watching TV, while others doing activities coloring book in the dining area. All 5 staff interviewed stated residents are allowed to watch TV as they want. The TV is turned off at night when observed no resident is watching. ADM denied telling the residents to turn off the TV, radio or other electrical device at 9:00 pm to save on electricity. She only tells them to turn down and/or use headset. One out of 3 residents stated they are allowed to watch tv and staff ask to turn off at 8:00 pm but this resident stated still watches TV after 8:00 pm. One of these 3 stated residents are required to turn off the TV at 8:00 pm which is okay with this resident. The other resident stated staff allow them to watch as they want. LPA tried to interview the other 2 residents but they refused. Therefore, the allegation is unsubstantiated. Based on interviews and observation during investigation, the allegations are closed as unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. No deficiency cited. Exit interview conducted, and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 25, 2025 · control 15-AS-20250317093549

Type of visit: Required - 1 Year

On this day, October 24, 2024, at 1:15 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection. LPA met with House Manager Sally Espina and Haidie Bautista, administrator, and informed the reason for visit. LPA started the inspection with house manager and continued with administrator. LPA inspected the 2 buildings (Bldg A and Bldg B) including but not limited to common areas, kitchens, dining areas, receiving room, library, bathrooms, shower rooms, toilets, front, side and backyard. LPA selected for inspection 4 residents rooms in Bldg B and 7 in Buiding A. Fire extinguishers were observed fully charge with tags showed serviced May 21, 2024. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications and medication carts were locked. All residents rooms, dining and common areas were equipped with electric fans. Hallways, common areas, yards and porch were observed free of hazards. Facility has smoke and carbon monoxide detectors that were observed functional. Hot water temperature in one of the bathrooms in Bldg A was tested and measured at 118.4 degrees Fahrenheit. Facility conducts disaster drills every quarter and records showed last conducted October 14, 2024. LPA reviewed 5 residents and 5 staff files, and interviewed 4 residents. Medications were checked and compared with doctor's orders and LIC622 Centrally Stored Medication and Destruction Records. Facility does not handle residents' cash resources. .......continued on 809C LPA observed the following: -at 1:30 p.m., greasy cooking range and grease deposits in the corner of flooring in the kitchen in Bldg A. -at 1:38 p.m., vinyl flooring tiles in Bldg B coming off. -at 1:40 p.m., mildew in the shower and broken faucet in Bldg B. -at 1:56 p.m., chipped electrical outlet plate in one of the resident's rooms in Bldg A. -at 5:15 p.m., resident's (R1) medications filled on 10/02/24 & 10/21/24 has no LIC622. R1 has doctor's order for Ferrous Sulfate but facility does not have this medication. -at 5:50 p.m., staff crossed-out one of resident's (R2) medications on the label. LPA received updated copies of the following documents: 1. LIC308 Designation of Facility Responsibility 2. LIC610E Emergency Disaster Plan 3. LIC9282 Infection Control Plan 4. $3M liability insurance certificate Administrator to submit a copy of updated LIC500 Personnel Report by 11/07/24. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties. Deficiencies and plan and proof of corrections were discussed with the administrator. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Oct 24, 2024

Type of visit: Required - 1 Year

On this day, November 10, 2023, at 10:15 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual inspection. LPA met with staff, Efren Moreno, Sally Espina, Nangtin Lwin. LPA called and spoke over the phone with Haidie Bautista, administrator, and informed the reason for visit. Administrator arrived after several minutes. Facility has LIC9282 Infection Control Plan. LPA started the inspection with Sally Espina and continued with Haidie Bautista. LPA inspected the 2 buildings (Bldg A and Bldg B) including but not limited to common areas, kitchen, dining areas, receiving room, library, staff room, bathrooms, shower rooms, toilets and yard. LPA selected for inspection 3 residents rooms in each in Bldg A and Bldg B. Fire extinguishers were observed fully charge with tags showed serviced March 16. 2023. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications and medication carts were locked. All residents rooms, dining and common areas were equipped with electric fans. Hallways, common areas, yards and porch were observed free of hazards. Facility has smoke and carbon monoxide detectors that were observed functional. Hot water temperature in bathrooms in Bldg A and Bldg B was tested and measured at 119 and 120 degrees Fahrenheit. Facility conducts fire drills every quarter and records showed last conducted October 1, 2023. .......continued on 809C LPA reviewed 5 residents and 3 staff files, and interviewed 3 staff and 3 residents. Medications were checked and compared with records. Facility does not handle residents' cash resources. Administrator to submit a copy of updated LIC500 Personnel Report by 11/24/23. Deficiencies are cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates, and any repeat violation within 12 month period may result in civil penalties. -at 10:43 am, medications in unlocked staff room. -at 12:51 pm, staff S3 has no first aid and 4 hours postural support/restricted health/hospice care training. Deficiencies and plan and proof of corrections were discussed with the administrator. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Nov 10, 2023