Bonnevie Residence and Care

Type of visit: POC

Licensing Program Analyst Manuel Monter conducted a POC case management visit to clear deficiencies cited on August 13, 2025, during an annual inspection visit. LPA also amended the previous report to add additional information and to cite an additional deficiency that was erroneously not cited during the previous visit. The facility was cited the following Type A deficiency on August 13, 2025 87468.1 Personal Rights of Residents in All Facilities (a)(1), POC due date August 14, 2025. LPA received plan of corrections by POC date. Deficiencies cleared during todays visit. POC cleared letter provided to ADM. No deficiency was cited during todays visit. This report was reviewed with ADM Merclo Garcia. A copy of this report and Appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 19, 2025

Type of visit: POC

Licensing Program Analyst Manuel Monter conducted a POC case management visit to clear deficiencies cited on August 8, 2025, during an annual inspection visit. LPA also amended the previous report to add additional information and to cite an additional deficiency that was erroneously not cited during the previous visit. The facility was cited the following deficiencies on August 8, 2025 with the following POC dates 1569.695(c) - Emergency Drills- Type B- POC due date August 15, 2025. 87307 Personal Accommodations and Services (d)(6)- Type A- POC due date August 9, 2025. 87465 Incidental Medical and Dental Care (h)(6)- Type B- POC due date August 15, 2025. LPA received plan of corrections by POC date. Deficiencies cleared during todays visit. On August 8, 2025, during the tour of the home, LPA noted there was "hook & eye", metal latch outside the living room door, leading towards the outside. Note, this facility is licensed to have 3 non-ambulatory on the first floor and 1 bedridden in bedroom #3. The exit located in the living room, and adjacent to bedroom #3 is the only exit that has a ramp. LPA asked ADM why this latch was on the outside of the door. ADM asked staff S1, who stated the latch was put there because there used to be a resident who wanted to go outside a lot. ADM stated this resident no longer lives in the facility. ADM removed the metal latch during visit. A deficiency was cited during todays visit. This report was reviewed with ADM Merclo Garcia. A copy of this report and Appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 13, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Aug 14, 2025

87468.1 Personal Rights of Residents in All Facilities (a)(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by: Based on interviews conducted and observation, a metal latch was observed in the door exiting the living room. Staff interviewed stated they did this because a resident would try to exit. This poses an immediate health, safety, personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Aug 13, 2025

Plan of correction: ADM stated he will conduct a personal rights training, and the importance of keeping passageways cleared. ADM stated he will submit documentation showing the training occurred, who attended, who gave the training, and how long the training was. ADM stated he will submit by POC date, August 14, 2025.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Mercelo Garcia. During the visit, LPA observed 4 residents and 2 staff. LPA explained the purpose of the visit. (This report is being amended to add additional information.) LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 2 restrooms and residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. While touring the home, LPA noted there was "hook & eye", metal latch outside the living room door, leading towards the outside. Note, this facility is licensed to have 3 non-ambulatory on the first floor and 1 bedridden in bedroom #3. The exit located in the living room, and adjacent to bedroom #3 is the only exit that has a ramp. LPA asked ADM why this latch was on the outside of the door. ADM asked staff S1, who stated the latch was put there because there used to be a resident who wanted to go outside a lot. ADM stated this resident no longer lives in the facility. ADM removed the metal latch during visit. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 70 degrees F, and hot water temperature was measured at 118 degrees F in resident bathrooms. Page 1 Out of 2. LPA reviewed facility records for 3 staff and 3 residents. LPA reviewed 3 resident medications and centrally stored medication records. Residents R1, R2 and R3 did not have multiple medications listed on the centrally stored medication record. Note Resident R1, R2 and R3's centrally stored medication record did not have any medications listed with a fill date of 2025. Fire extinguisher was serviced in November 4, 2024. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. The facility's emergency and disaster plan was last reviewed by ADM on September 21, 2024. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility conducted drills on the following dates: June 15, 2024, September 21, 2024, April 13, 2025, and July 10, 2025. LPA discussed with ADM that drills conducted must occur at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, And Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. LPA Provided ADM with a copy of PIN 25-05-ASC, PIN 25-08-ASC Deficiencies and a technical Assistance is being cited during today's visit. This report was reviewed with Administrator Mercelo Garcia and a copy of the signed report was provided. Appeal rights were provided. Page 2 Out of 2. END OF REPORT.the state’s words, verbatim · CDSS document, Aug 8, 2025

Allegation investigated: Resident is being financially abused

Licensing Program Analyst (LPA) conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Licensee/Administrator (ADM) Merclo Garcia and stated the purpose of today’s visit. On 9/10/2024, the Department received a complaint with the above allegation. On 9/13/2024, the Department conducted an initial investigation at the facility. It was alleged resident (R1) was financially abused on 9/1/2024 when R1 gave S1 cash ($500) to play at the casino. S1 drove R1 to the casino and R1 contributed to paying for gas to and from the casino. Continuation on LIC 9099-C, Page 1 of 3. Substantiated Page 2 of 3. On 09/13/2024, the Department interviewed ADM. ADM stated he was not aware of staff driving residents(s) to casino. ADM stated R1 is accompanied by facility staff when R1 needs to go for personal errands which includes but not limited to getting a haircut, going to the mall, going to the bank and visiting family. ADM stated staff S2 is the main staff who drives and accompany R1 during these runs. On 9/13/2024, the Department interviewed R1. R1 stated that on 9/1/2024, he/she offered S1 $500 to use at the casino which S1 accepted. R1 stated the money offered was a loan that S1 will pay back. R1 stated that he/she feels bad because staff at the facility always complain about financial issues and R1 felt pressured to give money to S1. R1 stated the staff tells him/her to buy food for everyone at the facility through Door Dash. On 12/19/2024, R1 further stated ADM was aware of the trip to the casino prior to 9/1/2024 and did not allow S1 to accompany R1. R1 stated S1 still took R1 to the casino. On 9/26/2024, the Department conducted an interview with R1 to clarify the statements made earlier to the Department. R1 stated that he/she wanted to go to the casino to celebrate and offered $500 to S1 so S1 can play at the casino with R1. R1 also stated that S1 gave back the money the next day. On 9/26/2024 the Department interviewed S1, S1 stated that he/she instructed R1 to ask permission from his/her family prior to going to the casino and if R1 family consents to the trip then they will go to the casino. S1 admitted to accepting the money offered by R1 on 9/1/2024 to gamble at the casino, however, S1 stated the money was offered by R1 as a loan and to be paid back the next day to R1. S1 stated he/she returned the money to R1 the next day. S1 stated he/she informed ADM a week later. On 10/16/2024 the Department interviewed R1s family member (F1) who stated that R1 told him/her of his/her trip to the casino with S1 and stated that R1 loaned money to S1 and was paid back the next day. On 2/28/2025 the department reviewed R1s ATM transaction statement and based on review of R1’s statement, R1 orders food online by using third-party vendors such as Door Dash from his/her mobile device. Based on review of the transaction the amount spent on food cannot be determined if R1 bought food for the whole facility or if food that was ordered was based on R1s preference. Page 3 of 3. On 4/9/2025, the Department interviewed ADM. ADM stated that R1 will sometimes refuse to eat what they serve and would rather buy his/her own food using his/her cell phone and would order online. ADM stated after the incident, there were no issues raised between staff and residents and R1 found a new place and moved out of the facility early this year. Based on review of R1’s bank statements, R1 is transferring money to a third-party vendor which is being used to make purchases of food. On 12/19/2024 LPA Rai obtained documents of the transactions occurring on the third-party vendor wherein resident made purchases of food from Door Dash from August 2024 to September 2024. Based on inspection and investigation, the department determines that although a resident extended a financial loan to a staff, facility employees or staff are not permitted to engage in borrowing from or allowing residents to make purchases such as food for residents or staff within the facility. In addition, the resident and licensee does not have an written agreement regarding handling resident's finances and loaning money from residents. Therefore, the preponderance of evidence standard has been met, the above allegation is found to be SUBSTANTIATED. Deficiencies were cited from California Code of Regulations, Title 22, please see LIC 9099-D. This report was reviewed with Administrator and a copy of the report was provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Aug 4, 2025 · control 26-AS-20240910164317

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(29)(E) · Plan of correction due date: Aug 6, 2025

HSC1569.269(29)... a licensee, or a spouse, domestic partner, relative, or employee of a licensee, shall not do any of the following:(E) Enter into a loan or promissory agreement or otherwise borrow money from a resident without outlining the terms of the repayment being given to the resident. This requirement is not met as evidenced by: Based on interview review, R1 and licensee does not have an written agreement regarding handling R1's finances and loaning money from residents which pose/poses an immediate health, safety, and personal right risks to persons in care.the state’s words, verbatim · CDSS document, Aug 4, 2025

Plan of correction: Licensee/Administrator stated to submit a written plan of action understanding regulation and staff training will be completed by POC due date. Licensee/Administrator agreed and understood.

Type of visit: Case Management - Other

On 4/11/2025 - Licensing Program Analyst (LPA) Maria (Mita) Partoza - conducted an unannounced visit for case management - other. The purpose of the visit is to amend one report that was inadvertently created in error on 4/9/2025 - The LIC 9099 was created in error, instead of amending the original LIC 9099 issued on 1/8/2025, LPA created a new LIC 9099 with unsubstantiated findings instead of stating "needs further investigation" for new information received. This was explained to the Licensee / Administrator, Merclo Garcia during today's visit. All amended and original reports were provided. During today's visit LPA conducted additional interviews with staff and residents. No deficiencies were cited during today's visit based on California Code of Regulation (CCR) Title 22.the state’s words, verbatim · CDSS document, Apr 11, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced case management visit for Type A and Type B deficiencies cited on 10/31/2024 and compliance with the fire clearance. LPA met with Administrator Merclo Garcia and stated the purpose visit. The facility is licensed to serve adults 60 years and over, 4 may be non-ambulatory and 2 ambulatory and 1 may be bedridden. LPA observed 4 out 4 residents (R,R2,R3 & R4). LPA toured the facility inside and outside including the kitchen, dining, living room, 5 resident bedrooms and 2 staff bedrooms, restrooms, food pantry, medication cabinet, supply cabinet, exterior walkways and ramp. LPA observed knives/sharps, medications, chemicals are not accessible to the residents, the food pantry has 7 days of non-perishable food that have a variety of vegetable and protein, organized and labeled. 2 Days of perishable food labeled and organized. The water temperature measured with a digital thermometer at 119 to 121 degree F. ADM stated that the water heater tank was recently replaced and will be monitored for a week to ensure that the water temperature stays within the regulatory standard of 105 degree F to 120 degree F. Walkways and hallways inside the facility were free from obstruction. LPA observed audible alarms on exit doors by the living room. The exterior are maintained, with no broken screen windows, free from cobwebs, exterior ramp is maintained and free from obstructions. Page 1 of 2 See LIC809-C The Fire Clearance was approved by the Fire Marshall on 3/27/2025 and a copy was provided to ADM. ADM submitted an updated LIC 500 reflecting the hours and days that ADM will be at the facility and ensure coverage during day and night time. LPA inspected 2 resident records and 2 staff record and observed that the files were complete and updated. The facility conducted a disaster training on 9/21/2024 and will be administered again on 4/13/2025 as stated by ADM. No deficiencies were cited during today's visit based on California Code of Regulations, Title 22. This report was reviewed with Administrator Merclo Garcia and a copy of the report was provided.the state’s words, verbatim · CDSS document, Apr 9, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPAs) Marcela Yanez and Simi Rai conducted an unannounced case management visit to follow up on the Type A and Type B deficiencies cited on 10/31/2024. LPAs met with Administrator Merclo Garcia and stated the purpose of today's visit. LPA Yanez observed 4 staff and 4 residents in the facility. During visit, LPA Yanez inspected the kitchen area. LPA Yanez observed sharps, such as knives, and toxic chemicals locked in cabinet and inaccessible to residents. LPA Yanez observed medications were in the locked cabinet and inaccessible to residents. During visit LPA tested the hot water temperature with thermometer at 110.8 degrees F. During visit LPA reviewed Admission agreement for Residents R1-R5 to be signed by the Administrator and the resident. During visit LPA observed windows clean and clear of debris and cob webs and Screens were in good repair in Resident bedrooms. LPAs observed 2 day perishable and 7 day non perishable food supply. LPAs observed 7 day non perishable food to be a variety of vegetables and protein. During visit, LPA Yanez provided letter of the Deficiency Citations cleared. Administrator stated that the Fire Clearance is still pending further review. ADM stated the Fire Marshall will call back with further details. In order to exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves, LPA Rai discussed with ADM Merclo Garcia for Administrator to be available and present at the facility 20 hours a week, Monday through Friday 8:00am - 5:00pm. ADM updated LIC 500 which reflect the hours of ADM present at the facility during Monday - Friday and was submitted to LPA Rai. No deficiencies were cited at this time as per California Code of Regulations, Title 22.This report was reviewed with Administrator Merclo Garcia and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 19, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPAs) Marcela Yanez and Mita Partoza. Licensing Program Manager (LPM) Romeo Manzano conducted an unannounced Required 1 Year visit and met with Merclo Garcia Administrator, 3 staff-Bienvenido (Ben) and Ramiro Custodio (brothers), and Mary Wacheke and met with 5 residents (R1 to R5). During inspection LPAs observed a total of 7 bedrooms (1 of which is the upstairs office converted into a room which is not being utilized as a staff bedroom). Based on physical floor plan submitted to the department and during initial application, there are only 2 bedrooms on the first floor (#1 & #2) and 2 bedrooms on second floor (bedroom#3 and caregiver bedroom (no designated number) adjacent to the second floor stairway next to the bathroom. A review of the approved 3 STD 850 dated on 11/7/13 and 11/18/2013 are approved for 2 ambulatory and 4 non-ambulatory and on 12/4/2013, fire clearance change from 2 ambulatory, 3 non-ambulatory and 1 bedridden clearance in bedroom #2 on 1st floor. An overall analysis of the facility fire clearance, the facility is currently approved for 2 Ambulatory and 3 Non-Ambulatory and 1 bedridden clearance (as it states #1 and #2 on first floors are either ambulatory and/or non-ambulatory) and Bedroom #3 is ambulatory only and an office on the second floor. On 7/1/2024, Mr. Merclo Garcia was elected by the officers of the corporation the corporation as the new president/Administrator and Ramiro Custodio, a corporate member. Mr. Merclo stated that the former board members (Edralyn Lanzi and Rochelle Basco) stated that when they took over of the facility in 2013 from the previous licensee, the facility bedrooms already existed which is contrary to the submitted floor plan and fire clearances on file by Ms. Lanzi and Ms. Basco. Mr. Garcia will contact the former board members for additional information about the facility physical floor plan including the landlord and to contact the San Jose Fire Marshal to obtain history and building permits of the facility property building. The Department did not issue a citation on the discrepance of the fire clearance but advised to immediately contact SJFD and to submit a new fire clearance and updated new/updated floor plan request to CCLD before COB 11/1/2024. Page 1 of 3 Mr. Garcia will contact the former board members for additional information about the facility physical floor plan including the landlord and to contact the San Jose Fire Marshal to obtain history and building permits of the facility property building. The Department did not issue a citation on the discrepance of the fire clearance but advised to immediately contact SJFD and to submit a new fire clearance and updated new/updated floor plan request to CCLD before COB 11/1/2024. LPA observed 2 fire extinguishers 1 on the first and 1 second floor which were last inspected on 6/2023. LPA informed ADM to ensure that their fire extinguishers are inspected and current. The facility Fire and Earthquake log was last conducted on 07/15/2024. ADM stated that Fire and Earthquake or Disaster Drills are conducted every quarter. Smoke detector were tested and in good operating condition including carbon monoxide. There were also at least 22 tubes of triple antibiotics cream found in hallway closet across the living area unlocked. ADM stated the these antibiotics belonged to a former resident who was under hospice (name of resident unknown). LPA discussed with ADM regarding proper destruction of unused medications. During visit, LPAs toured the facility inside and out. LPAs observed food storage areas and locked cabinets for cleaning supplies including sharp objects. Cleaning solutions and other toxins were found accessible in the following areas bedroom, bathrooms, basement and outside underneath the ramp (all these are noted on LIC809-D). Food supplies for 7 day non-perishable and 2 days perishables were observed. During inspection of the facility food supplies for 7 days, there were only 20 can foods comprised of fruits and tomato soup. LPAs did not observed can foods variety in protein and vegetables. Also, LPAs reminded Administrator to have an Emergency food supplies in the facility such as can foods, water, emergency disaster kits. The facility was equipped with kitchen appliances such as but not limited to refrigerator, stove/oven and microwave. Inspections of these appliances noted to have stains, grease, crumbs and food residue wherein the Administrator was present during the inspections and photos were taken. Page 2 of 3 Surveillance cameras were observed during inspection visit in the following areas: carport, front/main door, living room, office (in the kitchen). ADM stated that cameras were installed or grandfather from the previous corporate members. ADM and S1 stated that cameras are recorded but no audio. LPAs advised ADM to submit a program plan for the use of surveillance cameras. Use of cameras does not specifically address on statutes, however, a waiver is needed when being used in private areas, and is allowed only in areas which does not infringe the personal rights of the residents. Audio is not allowed and is prohibited, and storing recording/records only those with legal authority to review it. ADM agreed and understood who will be submitting a program plan of the use of surveillance cameras. All bedrooms and common areas including staff bedroom were inspected. During inspection, the facility carpet had stains, and other unknown particles; the residents furniture were not dusted, and cobwebs were observed in the windows of the resident bedrooms and window screen had holes (only in bedroom #3 window). Moreover, there was a loose floor board in the dining area (LPM almost tripped during visit). Residents' prescribed and non-prescribed medication and the Centrally Stored Medication log residents were reviewed including their facility file record. All 5 residents did not have Appraisal, Needs and Services Plan including Consent forms wherein ADM was advised to obtain consent forms from residents' responsible parties. Staff record were also randomly reviewed, 3 staff (S1,S2,S3) files were reviewed wherein staff have a complete files including required training including first aid and/or CPR. During random audit of 3 residents' medications records, LPAs noted that medications for 3 residents were not documented on the centrally stored log. In addition, a nasal spray belongs to R1 was observed in the kitchen shelves, and also his/her PRN medications and 1 prescribed medication found in his/her unlocked closet and door which is accessible to any residents. Facility bathrooms were inspected equipped with non-skid mats, grab bars and handicap chairs and operational. Hygiene products and toiletries were observed and adequate. The facility hot water temperatures was also measured in the following areas: in the bathroom #1 sink measured with thermometer at 145.7 degrees F in b athroom #1, 130.1 degrees F in bathroom #2 and 140.1 in bathroom #3 and 141.1 in kitchen sink. During visit LPA suggested to remove stove knobs to prevent resident with neuro-cognitive disorder and mental illness to prevent resident from harm of fire and also discusses about facility hospice waiver stipulations such as notifying CCLD when accepting or discharging residents under hospice. and to review PIN 22-24 home health and hospice agency. LPA also suggested that door knobs should have single access mechanism for resident with neuro-cognitive disorder to access door in case of emergency or disaster. LPA informed ADM to post a Oxygen in use sign when a resident in hospice has one. LPAs also discussed about care and supervision for the residents who are on the first floor that there should be an on-call awake staff between (10pm and 6pm) per title 22 87415. all staff reside on second floor. there are 3 resident on the first floor 1 under hospice and 1 with mental illness. Deficiencies were cited as per California Code of Regulations Title 22, SEE LIC809-D. This report was reviewed with Merclo Garcia and Ben Custodio and a copy of this report and appeal rights discussed and provided. This document was signed by Bienvenido Custodio on behalf of Merclo Garcia who had to leave for work and deficiencies were discussed with Merclo Garcia. Page 3 of 3the state’s words, verbatim · CDSS document, Oct 31, 2024

Type of visit: Case Management - Incident

LPA Mita Partoza, conducted an unannounced case management for the incident that was received on 9/17/2024 regarding unknown death of a resident (R1). LPA met with licensee/administrator (LIC/ADM) and administrator/staff 1 (ADM/S1), Ramiro Custodio. At 2:28 p.m. LPA interviewed ADM/S1, who stated that he called the coroner's office on 9/20/2024 to follow up on the death report/certificate of R1. ADM/S1 stated that according he was informed it was a mistake it was not a coroner's report. LPA requested LIC 602, needs and appraisal needs and services plan of R1. Due to lack of information this case management will remain open for further investigation.the state’s words, verbatim · CDSS document, Sep 26, 2024

Type of visit: Case Management - Other

On 9/26/2024 - at 2:28 p.m. LPA Partoza conducted an unannounced visit to amend LIC 809C to add the PIN 19-01-CCLD Communication With Complainants and 809D to reflect the deficiency statement of *87355 (e)(1), obtain the signature which was both not captured during visit on 9/15/2024. On 9/15/2024 - at 2:45 p.m. LPA Partoza conducted an unannounced visit to amend the case management report to reflect the series of events and correct the citation that was issued at the time of the visit on 9/13/2024. At 3:45 p.m. LPA encountered a technical issue and have recreated this case management to correct the LIC 421BG. The previous LIC 421BG has the incorrect individual's name. In addition the LIC 809 D has the incorrect deficient statement and is missing a citation. On 9/13/2024, Licensing Program Analysts (LPAs) Maria (Mita) Partoza and Marcella Tarin, conducted an unannounced case management - deficiency visit and met with licensees (LICs) Ramiro Custodio and Merclo Garcia and stated the purpose of the visit. On 9/13/2024, at 11:30 a.m. LPAs Partoza and Tarin interviewed the licensee and inquired about staff who are currently working at the facility. LIC stated that the facility currently has 5 staff and 1 out of 5 lives in the facility since July 1, 2024 and did not have a fingerprint/criminal record clearance. LIC stated that staff 1 (S1) is a family and helps with care and supervision of the residents such as but not limited to activity of daily living. At the time of the visit S1 was not present and was asked by the LIC to obtain a livescan. LIC stated that S1 have not been trained for the care and supervision of the resident which is a requirement for Residential Care Facility for the Elderly (RCFE) staff. page 1 of 2 see LIC 809C LPA discussed with LIC that S1 is required to have a fingerprint/criminal background clearance and be associated to the facility, prior to working, residing or volunteering. LPA informed LIC that S2 cannot work or be present in any community care facility unless he/she receives a criminal record clearance from the Care Provider Management Branch (CPMB). LPA discussed with LIC the importance of training staff prior to working with RCFE residents. LIC stated that they understand and will provide training to S1. A deficiency was cited per California Code of Regulations, Title 22 87355 (e)(1) See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days x 1 individual = $500), for S1 that is residing at the facility without fingerprint and criminal background clearance. See LIC 421BG and for Title 22 87411 (c) Personnel requirement. LPAs provided Licensee PIN 19-01-CCLD - Providers are prohibited by law from retaliating against anyone who submits a complaint to the Department or the State Long-Term Care Ombudsman. See California Health and Safety Code Sections 1539, 1568.07(d), 1569.37, 1596.857(b). An exit interview was conducted during today's visit with licensee (LIC) Merclo Garcia. A copy of the report and appeals rights were provided page 2 of 2 end of reportthe state’s words, verbatim · CDSS document, Sep 15, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Sep 14, 2024

87355 Criminal Record(e)All individuals...pursuant to Health and Safety Code Section 1569.17(b)... prior to working, residing ...in a licensed facility: (1)Obtain a California clearance ...as required by the Department. This requirement is not met as evidenced by: *deficiency stmnt did not printthe state’s words, verbatim · CDSS document, Sep 15, 2024

Plan of correction: LIC directed S1 to obtain a clearance during LPAs visit on 9/13/2024. LIC provided LPAs a copy of the livescan receipt. LIC stated as soon as S1 received the clearance from CPMB, LIC will associate S1 to the facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 874111(c) · Plan of correction due date: Sep 27, 2024

87411 Personnel Requirement General (c) All RCFE staff who assist residents ... shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement is not met as evidenced by Based on interview, LIC stated that S1 does not have training since residing in the facility 7/1/2024, and is current assisting with resident's with personal activties of daily living, which pose/poses a potential health, safety & personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 15, 2024

Plan of correction: LIC stated that S1 will have an onboarding training and will not assist with resident's acitivities of daily living until fully trained. LIC stated that proof of training will be emailed to LPA by the end of the due date. *87355 Criminal Record: Based on interview licensee did not obtain California criminal background clearance for S1 prior to residing and providing care & supervision since 7/1/2024, which poses/poses an immediate health, safety & personal right risk to persons in care.

Type of visit: Case Management - Deficiencies

On 9/15/2024 - at 2:45 p.m. LPA Partoza conducted an unannounced visit to amend the case management report to reflect the series of events and correct the citation that was issued at the time of the visit on 9/13/2024. On 9/13/2024, Licensing Program Analysts (LPAs) Maria (Mita) Partoza and Marcella Tarin, conducted an unannounced case management - deficiency visit and met with licensees (LICs) Ramiro Custodio and Merclo Garcia and stated the purpose of the visit. At 11:30 a.m. LPAs Partoza and Tarin interviewed the licensee and inquired about staff who are currently working at the facility. LIC stated that the facility currently has 5 staff and 1 out of 5 lives in the facility since July 1, 2024 and did not have a fingerprint/criminal record clearance. LIC stated that staff 1 (S1) is a family and helps with care and supervision of the residents such as but not limited to activity of daily living. At the time of the visit S1 was not present and was asked by the LIC to obtain a livescan. LIC stated that S1 have not been trained for the care and supervision of the resident which is a requirement for Residential Care Facility for the Elderly (RCFE) staff. LPA discussed with LIC that S1 is required to have a fingerprint/criminal background clearance and be associated to the facility, prior to working, residing or volunteering. LPA informed LIC that S2 cannot work or be present in any community care facility unless he/she receives a criminal record clearance from the Care Provider Management Branch (CPMB). LPA discussed with LIC the importance of training staff prior to working with RCFE residents. LIC stated that they understand and will provide training to S1. A deficiency was cited per California Code of Regulations, Title 22 87355 (3)(b)(1) See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days x 1 individual = $500), for S1 that is residing at the facility without fingerprint and criminal background clearance. See LIC 421BG and for Title 22 87411 (c) Personnel requirement. An exit interview was conducted during today's visit with licensee (LIC) Merclo Garcia. A copy of the report and appeals rights were provided.the state’s words, verbatim · CDSS document, Sep 13, 2024

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.