Blessed Homecare 3

Allegation investigated: Resident eloped from facility Facility failed to report elopement

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced to open the investigation into allegations listed above. LPA met with Baby Quintero,during today’s visit. During today's inspection LPA conducted interviews, toured the facility and reviewed records pertinent to the investigation. **Continued on 9099-C page Substantiated Resident eloped from facility Interviews conducted with staff indicated that Resident R1 turned off the front door alarm and walked out the front door of the facility on 07/25/2026 while staff were assisting another resident. R1 was found by staff across the street from the facility. Staff called emergency services for R1 as they had fallen. Documents reviewed indicated that R1 has a diagnosis of dementia and is able to ambulate with little to no assistance. R1 does not have a history of wandering or elopement. Therefore, the allegation resident eloped from facility is substantiated. Facility failed to report elopement Interviews conducted with staff indicated that an incident report was not completed and sent to the Department. Hospice services and R1’s family were notified. Therefore, the allegation resident eloped from facility is substantiated. Based on the information obtained for the allegations above, the allegations are SUBSTANTIATED- A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Exit interview conducted with Executive Director and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Aug 11, 2026 · control 59-AS-20260803111655

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 25, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (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 of any of the events specified in (A) through (D) below. This report shall include ... (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This was not met by evidenced by: R1 eloped from the facility on 07/25/2026 but it was not reported to the Departmentthe state’s words, verbatim · CDSS document, Aug 11, 2026

Plan of correction: Licensee will conduct a training on reporting requirements and submit materials to CCL by POC due date.

Allegation investigated: Staff hit resident resulting in bruising Staff handled resident in a rough manner

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Care staff Daniel Smith to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unfounded Staff hit resident resulting in bruising Interviews conducted indicated that R1 had bruises and scars on their body prior to moving in to the facility. R1 frequently sat back in their wheelchair hard which caused marks on R1’s back. Facility staff assisted R1 with one shower while R1 was residing at the facility and did not notice any new marks or bruises. Interviews with residents in care indicated that staff have never hit residents in care. Therefore, the allegation staff hit resident resulting in bruising is unfounded. Staff handled resident in a rough manner Interviews conducted with residents indicated that staff handle residents appropriately and help with each resident’s activities of daily living. Residents R2 and R3 indicated that staff do not handle them in a rough manner. Interviews conducted with Licensee and staff indicated that proper training is done and used to help with transfers and mobility throughout the facility. Records reviewed indicated that residents in care did not have any unexplained injuries or falls at the facility. Therefore, the allegation staff handled resident in a rough manner is unfounded. Based on records reviewed and interviews, LPA finds the above allegations to be UNFOUNDED- meaning that the allegations were false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. Copy of report was given to facility.the state’s words, verbatim · CDSS document, Jun 17, 2026 · control 59-AS-20260324134221

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassandra Mikkelson arrived unannounced and met with Licensee Baby Quintero to conduct an annual inspection utilizing the inspection tool. LPA conducted an inspection of the care home to ensure compliance with Title 22 regulations. LPA observed resident rooms, common area bathrooms, kitchen, common areas, and perimeter of care home. LPA observed rooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. LPA checked the kitchen area for the ability to prepare and store food. Care home has required (2) two day perishable and (7) seven day non-perishable food supply on hand. Smoke detectors and carbon monoxide detectors are operational in the care home. Fire extinguishers and first aid kit are maintained and ready for emergency use. LPA checked medication storage and found medications to be locked away and inaccessible to the residents. LPA reviewed five (5) resident files, two (2) staff files and resident medications. Facility has a current copy of certificate of liability insurance and LPA obtained a copy. As a result of this visit, a deficiency was cited pursuant to California Code of Regulations, Title 22, Division 6, Chapter 8. Deficiency is listed on 809-D pages. Exit interview was conducted with Licensee. A copy of this report and appeal rights were provided. Signatures on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Mar 11, 2026

Allegation investigated: Resident's hygeine needs are not being met.

Licensed Program Analyst (LPA) Cassandra Mikkelson arrived at the facility unannounced and met with Care staff Daniel Smith to deliver findings for the above complaint allegation. During the investigation, LPA conducted interviews, conducted a tour of the facility, and reviewed documentation pertinent to the investigation. The results of the investigation are as follows: *** Report continued on 9099-C*** Unsubstantiated Resident’s hygiene needs are not being met Interview conducted with Staff member S1 indicated that Resident R1 is cognitive and able to make decisions for themselves. R1 regularly refuses any assistance with hygiene or grooming. R1 will often refuse all showers, does not want to brush their teeth or use the restroom but instead uses a commode in their room although R1 is able to walk and use the restroom with assistance. S1 tries their hardest to assist R1 with hygiene and grooming tasks but understand they cannot force R1 but only encourage when there is a denial of hygiene and grooming tasks. Interview with Licensee indicated that the facility staff have had difficulty communicating with R1 in an effective manner to encourage good hygiene practices. Licensee has made attempts to speak with R1’s family to encourage good hygiene practices but R1’s family is unable to convince R1 as well. R1 had home health services coming to assist with hygiene but R1 turned away the home health nurses on multiple occasions. Interview conducted with Resident R1 indicated that they are doing good in the home and receiving the help that they need with hygiene and grooming. Documents reviewed indicated that R1 is in need of assistance with all self care and hygiene. Staff are encouraging R1 to move about the facility but R1 wants to stay in their room. Based on interviews conducted, observations, and records reviewed, the preponderance of evidence standards have not been met. Therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that a complaint allegation 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. Exit interview was conducted. A copy of this report was provided. Signature on these forms acknowledges receipt of these documents.the state’s words, verbatim · CDSS document, Nov 3, 2025 · control 59-AS-20250923095643

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a quarterly case management visit. LPA met with caregiver and explained the purpose of the visit. Today's census is three residents in care with one on hospice services. During today's visit, LPA and caregiver conducted an inspection of the facility to ensure the health and safety of residents in care. Additionally, LPA and Caregiver conducted a medication audit for R1. LPA was unable to audit the medications to full extent as medication administration record was not at the facility during time of visit. LPA and Caregiver conducted a medication count for one of R1's medication. Administrator arrived at the facility shortly after audit was completed. As a result of today's visit, deficiencies observed. Please see LIC 809-D. Exit interview and a copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Jun 5, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jun 13, 2025

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: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on medication audit, Licensee did not comply as LPA observed R1 medication order for Vitamin D3 25mcg daily but S1 has been administering 50mcg, which poses a potential risk.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: Licensee is to conduct a medictaion training on ensuring the correct dose is given. Proof of training is due June 13, 2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87755(c) · Plan of correction due date: Jun 13, 2025

87755 Inspection Authority of the Licensing Agency (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b). This requirement is not met as evidenced by: Based on observation, Licensee did not comply as LPA arrived to conduct a medication audit but the medication administration record was not available at the facility which poses a potential risk.the state’s words, verbatim · CDSS document, Jun 5, 2025

Plan of correction: Licensee is to submit a statement of understanding that the medication administration record should not leave the facility. POC is due June 13, 2025.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct an annual continuation visit. LPA met with staff and explained the purpose of the visit. Licensee was contacted who stated she is stuck in traffic and is unable to make it. During today's visit, LPA ensure the facility was safe, sanitary and in good repair for residents in care. LPA reviewed and completed the CARE tool from visit conducted on March 25, 2025. LPA and staff completed CARE tool together and no further deficiencies was cited. At this time, LPA is requesting a copy of facility liability insurance to be emailed to LPA by Friday April 18, 2025. Exit interview conducted and a copy was provided.the state’s words, verbatim · CDSS document, Apr 16, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Proof of Correction visit. LPA met with caregiver and explained the purpose of the visit. LPA spoke with Licensee on the phone. LPA was informed corrections has been made and submitted to LPA. At this time, LPA is requesting the following Plan of Corrections by April 17, 2025. If not received, LPA will return at a later date to cite $100 per day Failure to Correct civil penalties. Licensee will create a drill schedule to be in compliance and provide a copy. Licensee is to conduct an audit of staff files to ensure all caregivers have a first aid certification. Licensee is to provide proof of S1 and S2's first aid. Licensee is to provide LPA a statement of compliance of the following regulation 87307 Personal Accommodations and Services (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. No deficiencies cited at this time. Exit interview was conducted and a copy of report was provide to staff.the state’s words, verbatim · CDSS document, Apr 16, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a required annual visit utilizing the care tool. LPA met with Licensee and explained the purpose of the visit. Today's census is five residents in care with two residents on hospice services. Facility is in compliance to licensure. LPA and Licensee conducted a tour of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: four residents bedrooms, kitchen, garage, backyard and the common areas. LPA observed the garage to have beddings and personal belongings. LPA was informed the garage is occupied as a "resting" space for staff when they are on break. Licensee denied any live in staff at the facility. During inspection of the exterior, LPA observed pathway to be obstructed with gardening tools and recycling boxes. LPA informed Licensee pathways cannot be obstructed. LPA provided Licensee a copy of CCR 87307. File review was conducted. Emergency Disaster Plan was reviewed, LPA informed Licensee plan should be reviewed and/or updated every year along with signature. LPA provided Licensee a copy of LIC 610E. Fire Drill was reviewed, LPA observed fire drills conducted for October and November 2024. LPA informed Licensee fire drills need to be conducted quarterly with all staff in every shift. File review of personnel files, LPA observed S1 and S2 to have no first aid certification. LPA informed Licensee that all caregivers are to have first aid and at least one person per shift needs CPR certification. LPA was unable to complete full care tool today. LPA will return at a later date to complete the inspection. Deficiencies cited. Exit interview and a copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Mar 25, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a Plan of Correction (POC) visit. LPA met with Licensee and explained the purpose of the visit. During complaint investigation conducted November 5, 2024, facility was cited 87555 General Food Service Requirements with POC due date of November 12, 2024. LPA received an email of the requested POC on November 18, 2024. POC has been cleared and letter was generated. $600 failure to correct by due date civil penalty assessed. Additionally, LPA cleared the following deficiencies that was issued during a case management visit conducted on November 5, 2024 and corrected in a timely manner, POCs has been cleared and letter was generated for the following: - 87355 Criminal Record Clearance - 87458 Medical Assessment LPA and Licensee discussed the following POCs that is still accruing as POC has not been received and has exceeded its due date: - §1569.312 Basic services requirements Type A violation POC due date of November 6, 2024 which facility is to submit a plan of how facility will ensure residents in care will not leave the facility unassisted/unnoticed. $1,300 failure to correct civil penalty has been assessed and will continue to accrue $100 per day until plan is received. - 87405 Administrator - Qualifications and Duties Type B violation POC due date of November 15, 2024 which Licensee and Administrator are to review the provided handouts of CCR 87458 Medical Assessment and CCR 87506 Resident Records and notify LPA once it has been completed. $400 failure to correct civil penalty has been assessed and will continue to accrue $100 per day until notification is received. Exit interview, a copy of the report and civil penalty appeal rights provided.the state’s words, verbatim · CDSS document, Nov 19, 2024

Type of visit: Case Management - Other

On November 19, 2024, Licensing Program Analyst (LPA) Cassie Yang arrived to the facility to conduct a case management visit. LPA met with Licensee and explained the purpose of the visit. Today's visit, LPA returned to the facility to provide Licensee all printed documents as visit conducted earlier in the day, there was technical difficulties with printer. LPA provided Licensee physical copies of two (2) LIC809s, three (3) LIC 421FC's and four (4) Letter of Deficiency Citations Cleared. At this time, Facility does not have any more plan of corrections (POC) due as pending POC has been received. Exit interview.the state’s words, verbatim · CDSS document, Nov 19, 2024

Type of visit: POC

On November 18, 2024, an office meeting held at the Sacramento North Regional Office located at 9835 Goethe Road, Suite 100, Sacramento CA 95827. LPA met with Licensee and explained the purpose of the visit. During Proof of Correction visit on November 5, 2024, LPA observed that when activating the smoke detector in the common area next to the fire door, fire door does not automatically close. LPA informed Licensee that all smoke detectors in the facility should trigger the fire door to close for installation to be successful. LPA informed Licensee that plan of correction is not completed, and Licensee will need to submit a video of completion to LPA as $100 per day until corrected will accrue. On November 13, 2024, LPA received a text message from Licensee of correction. Licensee explained that video was sent prior on November 11, 2024 but it was not delivered. Based on the video time stamp of video, LPA observed it to be taken on November 10, 2024 at 8:18PM. LPA has agreed to clear the POC for the following date the video was taken. $500 civil penalty for failure to correct by POC due date was assessed. Exit interview and a copy of the report and civil penalty appeal rights provided.the state’s words, verbatim · CDSS document, Nov 18, 2024

Type of visit: Office

On 11/18/2024 at 10:30 AM, a Non-Compliance Conference was held at the Sacramento North Regional Office located at 9835 Goethe Road Suite 100, Sacramento CA 95827. The purpose of this meeting is to discuss the high volume of citations and a substantiated complaint. The following facilities are involved because they are owned by Licensee: BLESSED HOMECARE #342700911; BLESSED HOMECARE 2 ROSEVILLE # 315002812; and BLESSED HOMECARE 3 # 345920062. Present in the meeting was Licensee, Baby Quintero, Facility Representative, Leriza Arambulo, Regional Manager (RM) Alycia Rayner, Licensing Program Manager (LPM) Anthony Perez, LPM Troy Ordonez, Licensing Program Analyst (LPA) Cassandra Mikkelson, LPA Cassie Yang, LPA Cheyenne Ratajczak, and LPA Kerry Hiratsuka. Issues discussed during the meeting were: • High volume of Type A and Type B citations • Substantiated Complaint • Fire Safety issues • Supervision issues • Administrators lack oversight. • Reporting requirements • Communication breakdown • Criminal record clearance • Resident files are incomplete • Food Service • Licensee not completing Plan of Correction correctly and timely • Licensee/Administrator accountability The licensee was in agreement with the drafted non-compliance plan as outlined in LIC 9111. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Nov 18, 2024

Allegation investigated: Staff are not providing adequate food service to residents

Licensing Program Analyst (LPA) Cassie Yang arrived uannounced at the facility to open a complaint the Department received. LPA met with Licensee and explained the purpose of the visit. Allegation: Staff are not providing adequate food service to residents The Department conducted an inspection of the kitchen and pantry. Based on observation, it revealed there is a jar of instant coffee with expiration date of August 31, 2024. As a result of this investigation, the Department finds the allegation above to be Substantiated. A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. LIC 9099-C Allegation: Resident fell sustaining injury due to staff neglect The department conducted interviews and observation. Based on interview conducted with R1, it revealed R1 is unsure if they had a fall recently. Interview conducted with R1's family member revealed R1 has not had a fall and/or any suspicious bruising. Based on LPA's observation, LPA did not observed any discoloration and/or injury on R1's feet. Therefore, the allegation is unfounded. Allegation: Staff did not ensure laundry was not in disrepair The department conducted interviews. Interview conducted with Licensee revealed facility washer and dryer has been operable and in good repair. LPA had S1 turn on the dryer and turn on the washer which LPA observed both machine to be running. Therefore, allegation is unfounded. Based on information obtained, the allegation, resident fell sustaining injury due to staff neglect, and allegation, staff did not ensure laundry was not in disrepair, listed above are UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Nov 5, 2024 · control 59-AS-20241029091620

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555a · Plan of correction due date: Nov 12, 2024

87555 General Food Service Requirements (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 is not met as evidenced by: Based on LPA and S1's food inspection, Licensee did not comply as there was a jar of instant coffee in the pantry with expiration date of August 31, 2024, which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Nov 5, 2024

Plan of correction: Coffee was disposed. Licensee is to conduct an audit of food pantry and refrigerator with documentation of expiration dates. Licensee is to submit the proof of the audit to LPA by Tuesday November 12, 2024. Failure to correct in a timely manner may result to $100 civil penalty until corrected.

Type of visit: POC

On November 5, 2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct a proof of correction visit as during office meeting held on October 18, 2024 it was requested due by end of month, October 31, 2024 for Licensee to install a magnetic door opener as facility wants fire door to be open at all times. LPA met with Licensee and explained the purpose of the visit. During today's visit, smoke detectors were activated in the common areas, hallway and residents room. LPA and Licensee observed that when activating the smoke detector in the common area next to the fire door, fire door does not automatically close. LPA informed Licensee that all smoke detectors in the facility should trigger the fire door to close for installation to be successful. LPA contacted Sacramento Metro Fire Inspector, Ryan Ono, to confirm the following deficiency. Administrator stated when magnetic door opener was installed, smoke detectors from the common areas were not tested by Licensee and contractor. Result of today's inspection, failure to correct civil penalty for of fire safety violation was accessed as installation was not correctly done. Exit interview and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Nov 5, 2024

Type of visit: Case Management - Incident

On November 5, 2024, Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident reported to the Department on November 4, 2024. LPA met with Licensee and explained the purpose of the visit. The incident occurred on November 4, 2024 when R1 wanted to speak to their family member who was currently unavailable. R1 became agitated and was walking back and forth from room to dining room. Staff then observed front door to be open at 9:38AM. S1 stated R1 was not observed in sight near the facility, S1 then contacted 911 to report missing persons. Local Law Enforcement then observed R1 to be a block away from the facility. LPA requested R1's LIC 602 for review but facility does not have the following. As a result of today's visit, please see LIC 809-D. Exit interview conducted an a copy of the report and appeal rights was provided. Due to Licensee no longer being at the facility, S1 has signed the following report, signature on this form acknowledges receipt.the state’s words, verbatim · CDSS document, Nov 5, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(e) · Plan of correction due date: Nov 6, 2024

§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (e) Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being. This requirement is not met as evidenced by: Based on file review of the incident report and interview, Licensee did not comply as R1 left the facility through the front door without staff seeing which poses an immediate health and saftey risk.the state’s words, verbatim · CDSS document, Nov 5, 2024

Plan of correction: Licensee shall provide a plan to LPA of hoe facility will ensure residents in care will not be absent without leave. Plan is to be provided to LPA by 11/6/2024. Failure to correct may result to $100 per day until received and/or corrected.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility and observed the following deficiencies. LPA met with S1 and Licensee and explained the purpose of the visit. At entrance, S1 opened the door for LPA. When asked how long has S1 been working at the facility S1 stated "about two months". Based on LIC 500 provided on October 31, 2024 dated October 29, 2024, it listed S1 as a caregiver. Based on LPA's file review of Guardian, S1 does not have a criminal clearance association to the facility. Based on file review of LPA's emails, it revealed Licensee had sent an email to CDSS CCL SAC ACS TRANSFER REQUEST corresponding LPA on September 6, 2024, Licensee sent a photo of S1's DOJ Applicant Fingerprint Response. File review observed on September 9, 2024 LPA responded "Please send all the required documents in order for the regional office to assist with the association." File review, there was no additional response from Licensee. Criminal Clearance Transfer Request LIC 9182 and S1's driver license/proof of identification for S1 has not been received by the Department. Note: facility has been cited for Criminal Record Clearance violation during LPA's visits conducted on 7/18/2024 and 8/20/2024. LPA provided a copy of the following Title 22 regulations for Licensee to review: CCR 87355 Criminal Record Clearance CCR 87458 Medical Assessment CCR 87506 Resident Records Please continue report on LIC 809-C. LIC 809-C Additionally, during file review of resident files, facility did not have LIC 602 and/or any medical assessment conducted for R1. When asked, Licensee provided LPA a copy of R1's Skilled Nursing Discharge form. Licensee stated "this is all that they gave me when he came here." LPA and Licensee discussed that prior to admission for residents in care, LIC 602 is required in order for needs and service to be assessed. Licensee stated she did not know it was not the LIC 602. The following form did not have physician's primary diagnosis and secondary diagnosis, Documentation of prior medical services and history and current medical status including, but not limited to height, weight, and blood pressure, Identification of physical limitations of the person to determine his/her capability, determination whether the person is ambulatory or nonambulatory and Information applicable to the pre-admission appraisal. As a result of the inspection, deficiencies were observed and cited. Please see LIC 809-D, additionally, civil penalties accessed. Exit interview conducted and a copy of report and appeal rights provided. Due to Licensee no longer being at the facility, S1 has signed the following report, signature on this form acknowledges receipt.the state’s words, verbatim · CDSS document, Nov 5, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(c) · Plan of correction due date: Nov 6, 2024

87355 Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: This requirement is not met as evidenced by: Based on observation, file review and interview, the licensee did not comply with the section cited above as S1 was observed to be working but are not associated to the facility roster which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 5, 2024

Plan of correction: Licensee is to submit paperwork required for criminal clearance transfer for the facility and/or associate S1 on Guardian immediately or S1 is to vacate the facility. Proof of association is due to LPA on 11/6/2024. Failure to provide POC by due date may result to civil penalty of $100 per day until received. Civil penalty and repeated violation civil penalty assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(a) · Plan of correction due date: Dec 5, 2024

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by: Based on file review, Licensee did not comply as R1 did not have a LIC 602 / Medical Assessment present on file which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Nov 5, 2024

Plan of correction: Licensee is to obtained an updated LIC 602 / Medical Assessment for R1. Licensee is to notify LPA once completed - POC is due by December 5, 2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d)(3) · Plan of correction due date: Nov 15, 2024

87405 Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (3) Ability to maintain or supervise the maintenance of financial and other records. This requirement is not met as evidenced by: Based on file review and interview, Licensee did not comply as R1's skilled nursing facility discharge paperwork was mistaken for LIC 602 which R1 has no current LIC 602 on file, which poses a potential risk for residents in care.the state’s words, verbatim · CDSS document, Nov 5, 2024

Plan of correction: Licensee and Administrator are have a training of 87458 Medical Assessment and 87506 Resident Records . Notification of completion is to be submitted to LPA by November 15, 2024. Failure ot correct in a timely manner may assessed to civil penalty of $100 per day.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to open a complaint the Department received. LPA met with Licensee and explained the purpose of the visit. When conducting the exit interview at approximately 1:15 PM, LPA and Licensee were interrupted by residents in care. R1 was sitting on the couch near the dining room, when became agitated. Licensee then gave R1 an apple to eat which R1 then mumbled words to Licensee and threw the apple onto the floor towards Licensee. Caregiver attempted to redirect R1 and gave R1 the apple again. LPA observed R1 throwing the apple again, breaking apart onto the floor. R1 then walked into the kitchen forcing cabinets and drawers to open. When Licensee attempted to redirect R1, R1 then punched the wall and informed Licensee to stay away. In midst of R1's behavior, R2 was in the common area watching television. LPA observed R2 yelling at staff to change the channel. When dismissed, R2 became upset and walked towards the front door attempting to escape. LPA observed R2 shouting profanity and refusing to stay at the facility. Once R2 saw R1 was having behavioral issues, R2 walked to the dinning room to observe. At this time when LPA, Licensee, S1, R1 and R2 were all present in the dining room, R1 walked around the table and hit Licensee with a closed fist. Due to safety precaution, LPA gathered her belongings and informed Licensee LPA will be in the car until the situation is handled. LPA advised Licensee to contact 911 as R1 is not on baseline. Licensee stated R1 is on hospice and she did not know if R1 can go to the hospital. LPA again informed Licensee that 911 should be contacted immediately for the health and safety of other residents in care as R1 should be evaluated. LPA then vacated the facility to notify Licensing Program Manager of the following. Please continue on LIC 809-C LIC 809-C Upon LPA's return to the facility, Licensee was no longer at the facility. LPA observed R1 to still be at the facility with hospice nurse. LPA and Hospice Nurse discussed R1's change of condition. Hospice nurse stated at this time, it is strongly recommended for direct 1:1 care supervision as R1 can be erratic until R1 is further assessed. The following incident will be under reviewed and further discussed by the Department. Exit interview conducted and a copy of the report was provided. Due to Licensee no longer being at the facility, S1 has signed the following report, signature on this form acknowledges receipt.the state’s words, verbatim · CDSS document, Nov 5, 2024

Type of visit: Office

On 10/18/2024 at 10:30AM, an informal conference was conducted virtual via Microsoft Teams Meeting. The purpose of this informal conference meeting is to discuss the pending open investigations. Present in the meeting is, Licensing Program Manager (LPM) Anthony Perez, Licensing Program Analyst (LPA) Cassie Yang, and Facility Administrator , Leriza Arambulo, and Licensee, Baby Quintero. The informal conference process was explained during this meeting. Topic discussed: - Criminal Background Clearance violations - Fire Safety violations At this time, the Department agreed to monitor facility. Additionally, Facility will provide the Department a copy of LIC 500 Personnel Roster and install a magnetic door opener. Proof of installation is due to LPA Yang by Thursday October 31, 2024. No deficiencies cited. Exit interview conducted. Informal meeting concluded and a copy of report will be emailed. Facility Representative Signature is expected to be signed and returned to LPA by close of business,10 /18/2024.the state’s words, verbatim · CDSS document, Oct 18, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding an incident Sacramento Metro Fire had observed during their inspection conducted on 8/16/2024. LPA met with Caregiver and explained the purpose of the visit. Licensee then arrived to the facility shortly afterwards. During Sacramento Metro Fire's inspection, it was observed that the fire door was defective and cannot self latch. Additionally, it was observed the smoke alarm in the hallway was disconnected. During LPA's visit, fire door was again hooked open against fire regulation. LPA informed Licensee that Metro Fire had highly advised that fire door should additionally install a magnetic door opener as this is LPA's second time observing the following deficiency. Licensee informed LPA smoke alarm has been ordered as the old smoke alarm did not fit. During LPA's visit today, LPA observed S1 to be working at the facility with no criminal clearance association to the facility. LPA informed Licensee that all individuals working, residing and/or volunteering at the facility needs to have a fingerprint clearance and associated to facility roster. LPA was informed that S1 has started shadowing and/or orientation last week. LPA was additionally informed S2 has been working "here and there" and moved their personal belongings to the facility on Saturday August 17. This is a repeated violation as the following deficiencies was cited during post-licensing inspection on 7/18/2024. Deficiencies cited, civil penalties assessed. Exit interview and a copy of the report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 20, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(c) · Plan of correction due date: Aug 21, 2024

87355 Criminal Record Clearance (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: This requirement is not met as evidenced by: Based on observation and interview, the licensee did not comply with the section cited above as one staff was observed to be working and one staff was residing at the facility but are not associated to the facility roster which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 20, 2024

Plan of correction: S1 and S2 is to leave the facility until cleared and associated to the facility roster. Informal meeting will be held to discuss this matter. Failure to provide POC by due date may result to civil penalty of $100 per day until received.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87203 · Plan of correction due date: Aug 21, 2024

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above as LPA observed facility fire door to be hooked open and smoke alarm to be removed which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 20, 2024

Plan of correction: Licensee unhooked fire door immediately. Licensee will input fire alarm up immediately and provide proof to LPA. Licensee wil fix fire door to ensure it can self-latch. Licensee will install a magnetic door opener as facility has the tendency to keep fire door opened. Failure to provide POC by due date may result to civil penalty of $100 per day until received.

Type of visit: Post Licensing

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a post-licensing inspection. LPA met with Staff and explained the purpose of the visit. Staff who then contacted Licensee, Baby Ofelia Quintero, who then arrived to the facility shortly. During today's visit, LPA observed only two names, Licensee's and former Administrator are listed in facility roster via Guardian. Day prior to visit, LPA received email from former Administrator informing LPA his date of employment ended day of email. LPA did not received the required documents from Licensee for a change of facility administrator. However, Licensee provided proof of notification to CCLD's sactransferrequest.ca.gov email. LPA observed S1 to be working at the facility with no background clearance association to facility roster, confirmed via Guardian. LPA was informed S2 has been appointed as Administrator, who has been an employee at the facility since operation but criminal clearance transfer was submitted to CCLD a day prior to visit. Licensee informed LPA that facility operation has been in effect for a month now. LPA provided facility CCR 22 87355 Criminal Record Clearance, section (c)(1) and (c)(2)(A-C) is needed to be submitted to CCLD. Licensee informed LPA of a bedridden resident inquiry, LPA informed Licensee a new fire inspection is needed for bedridden clearance as facility is licensed for six non-ambulatory residents only. Licensee agreed to submit LIC 200 and facility sketch to LPA for a new fire clearance request. LPA informed Licensee new admission of bedridden resident is restricted until new clearance approval. LPA and Licensee conducted a tour of the facility and observed fire door to be hooked opened. LPA informed Licensee fire doors are to be closed at all times, if desired for fire door to be open, a magnetic door opener will need to be installed which is connected to fire alarm which will automatically release door when activated. Deficiencies cited, please see LIC 809-D. Civil Penalties assessed. Exit interview and a copy of the report and appeal rights was provided.the state’s words, verbatim · CDSS document, Jul 18, 2024

Type of visit: Prelicensing

On 4/9/2024, Licensing Program Analyst (LPA) Cassie Yang arrived announced at the facility to conduct a pre-licensing inspection. LPA met with applicant, Baby Quintero and Administrator, Sashi Prasad, and explained the purpose of the visit. During today's inspection, LPA conducted a tour of the interior and exterior of the facility. Areas toured included but not limited to: four residents bedrooms, two bathroom, laundry room, garage, kitchen, backyard, outdoor shed and the common areas. Facility is currently fire approved for six non-ambulatory, but LPA observed four beds to be installed only. It was discussed Room#1 and Room#2 may be arranged for shared couple rooms. LPA observed Room 1, 2, 3, and 4 to have the required items for personal accommodation. Component III was waived as Administrator and applicant operated in previous facilities. LPA provided the following copies to Administrator and Applicant, LIC 311F RECORDS TO BE MAINTAINED AT THE FACILITY- RCFE, LIC 624 UNUSUAL INCIDENT/INJURY REPORT, 87307 PERSONAL ACCOMMODATIONS AND SERVICES, 87621 COLOSTOMY/ILEOSTOMY and §1569.625 Staff training; legislative findings; contents No deficiencies are being cited as a result of todays inspection. Facility is in significant compliance. License is pending. Exit interview conducted and copy of report left at the facility.the state’s words, verbatim · CDSS document, Apr 9, 2024

Type of visit: Office

Component II completion: Successful Facility Type: Residential Care Facility for Elderly (RCFE) Application Type: Initial Capacity: 6 Census (if any clients in care): none COMP II Participants: Baby Quintero, Applicant Sashi Prasad, Administrator Interview Method: Telephone interview On February 26, 2024 at 9:00AM, Applicant and Administrator participated in COMP II interview. Identification of the Applicant and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant and Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. During COMP II, CAB analyst confirmed Applicant and Administrator’s understanding of following areas: 1. Facility Operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing Requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General Provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing Readiness Exit interview conducted with Applicant and Administrator. Report sent via email and informed to return sign copy to CAB by end of business day.the state’s words, verbatim · CDSS document, Feb 26, 2024