Bungalow

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Blanca Gonzalez and Mayra Cota conducted an unannounced Case Management-other (CM). LPAs met with Maritza Cruz, Caregiver, and the reason for the visit was explained. Administrator Linda Morales was notified telephonically and arrived at a later time. Manager Stacy Santana Lopez arrived to facilitate today’s visit. During today’s visit LPAs obtained staff and resident rosters, toured the facility, conducted interviews with staff #1-3 (S1-S3) and reviewed resident records #1-6 (R1-R6). Today’s CM visit stems from an annual inspection visit conducted on 10/06/25. During the annual visit, LPA Gonzalez observed facility to have five (5) resident bedrooms, however the facility sketch indicates that bedroom #4 is one (1) shared bedroom. During today’s visit LPAs observed bedroom #4 has two (2) twin beds, beds appear to be in different rooms as they are separated by a hallway. Per interview with S1 and S2, bedroom #4 is one (1) shared bedroom. Licensee agreed to move forward with Fire Inspection request. Licensee will submit to the department LIC200 and updated facility sketch within the next week. Once licensee submits relevant documents, Fire Inspection request STD850 will be submitted by the department. continued on LIC809C continued from LIC 809 Licensee was reminded of overdue licensing annual fees. As of 11/04/25, licensee has an outstanding balance of $1,237. Licensee agreed to pay fees by 11/06/25. Licensee was provided with PIN to complete payment online. LPAs discussed change of administrator application process. Licensee will submit relevant documents for review within the week. During today’s visit, no immediate health and safety risks were observed. No deficiencies cited. Exit interview held and a copy of this report was provided to Stacy Santana Lopezthe state’s words, verbatim · CDSS document, Nov 6, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual inspection visit. LPA was greeted by caregiver Lourdes Cruz and the purpose of the visit was explained. Administrator Linda Morales arrived shortly after to assist with the tour. The facility is licensed to serve six (6) residents age range 60 and over of which four (4) may be non-ambulatory and of which one (1) may be bedridden. The home is located in a residential neighborhood in Pasadena and consists of a living room, dining area, kitchen, five (5) resident bedrooms, one (1) full bathroom and two (2) half bathrooms, front yard and patio. The front yard is well maintained and there are no pools or large bodies of water. There is a covered patio providing a shaded seating area located in the patio with sufficient seating for residents in care. Passageways and exits are free of obstructions. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: The water temperature was tested in bathroom #1 and measured 105.8 degrees F, which is within the required 105 degrees F - 120 degrees F. Bathroom #2 water temperature measured 114.4 degrees F and bathroom #3 measured 106.8 degrees F. LPA observed grab bars and non-skid mats the bathrooms. Continued on LIC 809C continued from LIC 809 Resident bedrooms have the required furniture and have sufficient closet and storage space. Resident beds have the required linen and the linen is in good repair. Hallway cabinet contained PPE supplies, surplus clean linens. Combination smoke and carbon monoxide detector located throughout the home, were tested and are operable. LPA observed a fire extinguisher located in the kitchen last serviced March 31, 2025. Emergency drills conducted monthly, last drill was 09/11/25. Kitchen was observed to be clean and free of pests. Kitchen appliances are clean and were operating at the time of the visit. Sharps secured under the kitchen sink and are inaccessible to residents. Cleaning supplies and disinfectants are locked under the sink and are inaccessible to the residents. Sufficient supply of 2 days perishable and 7 days non-perishable foods were observed. Dining area observed clean with sufficient seating for residents in care. Centrally stored medication is located in a locked cabinet in the dining area. Medications are documented properly and given as prescribed. Six (6) resident and four (4) staff files were reviewed. R6 file did not contain physician’s report/medical assessment with TB clearance. Licensee was able to produce at time of visit. Technical violation noted. R6 receiving hospice care services, facility does not have a hospice waiver. Deficiency cited. Licensee provided with information to submit for change of administrator. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809D. Exit interview held and a copy of the report along with appeal rights were provided to the Administrator Linda Morales.the state’s words, verbatim · CDSS document, Oct 6, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Lourdes Cruz, Caregiver and explained the purpose of the visit. At 10:25am, Stacy Santam, Manager arrived and assisted LPA. Shortly after, Linda Morales, Administrator arrived and assisted LPA. The facility is licensed to care for six (6) elderly residents ages 60 and above, approved for (6) ambulatory of which (4) may be non ambulatory, of which (1) may be bedridden. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were maintained. The facility has submitted a COVID-19 Mitigation Plan and the Infection Control Plan. Bathrooms are maintained in operating condition. Operational Requirements: The Infection Control Plan was reviewed. However, the licensee cannot provide a copy of the Plan of Operation and stated that the plan is not kept and maintained in the facility. Last Fire Drill was conducted on 09/10/2024 and training is conducted with staff on a monthly basis. Liability Insurance policy is valid and expires on 10/07/2024. Facility does not handle cash resources for the residents. Facility has working signal systems in exit points, which were tested and operational. Physical Plant/Environment Safety: The facility is a single story home located in a residential neighborhood. It consists of (5) resident bedrooms, (3) bathrooms, living room with screened fireplace, kitchen, dining area, laundry area, detached garage, and backyard. Currently, there are six (6) non ambulatory residents living in the facility. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector and 5 beds with 1/2 bedrail and (1) with full bed rail, linen, dresser, light, chair and sufficient closet space. Exit doors have auditory device. Backyard was inspected and has a shaded area and sitting area. Laundry area is located outside. There are no cameras in the home. LPA observed (2) fire extinguishers that were last serviced on 03/06/2024. Smoke alarms and carbon monoxide were tested and operable. There are no firearms or weapons stored at the facility. Water temperature readings in (2) bathrooms measured within the required 105 - 120 degrees Fahrenheit. However the hot water reading in bathroom #3 did not go higher than 84.9 deg F. *****REPORT CONTINUED ON LIC809-C***** Staffing: A total of nine (9) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, fingerprint clearance, vaccinations and 1st Aid/CPR training are current. Administrator certificate is valid and will expire on 01/03/2025. Resident Rights-Information: Resident personal rights are posted. Facility provides internet services to all residents and have access to the facility phone. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly. Resident Records-Incident Reports: LPA reviewed (6) resident files. Resident files are maintained at the facility. Admission Agreement, Physician's Report (including TB and Ambulatory Status), Appraisal and Needs Services plan and Resident Personal Rights observed. Some residents do not have I.D. and Emergency Information (Face sheet), Consent for Medical Treatment, Resident Personal Property and Physician's order for 1/2 bed rails on their files. Health Related Services: Medications were reviewed for (4) residents to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log and medication list to document medications given. Medications are administered as prescribed by the Physician. Incidental Medical Services: There is zero (0) resident with a restricted health condition. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan. Emergency Intervention: Not-Applicable. Deficiencies cited. Exit interview and a copy of this report along with the appeal rights were provided to the Administrator/Licensee Linda Morales.the state’s words, verbatim · CDSS document, Sep 27, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 10/20/2023 at 08:22 am. LPA was met by Caregiver, Lourdes Cruz and explained the purpose of the visit. The facility is licensed to serve six (6) residents over the age of 60, of which four (4) may be non-ambulatory and one (1) bedridden. LPA OBSERVATIONS: The facility is a single-story building located in a residential neighborhood with five (5) resident bedrooms, three (3) bathrooms, kitchen, dining room, living room, front yard, backyard, and detached garage. Front Yard: Was clean and well maintained. No hazards were observed. Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to six (6) out of six (6) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in kitchen cabinet, to be inaccessible to six (6) out of six (6) residents in care. Kitchen sink water temperature was measured at 115.0 degrees F. Kitchen appliances were observed to be clean and in working order. Dining Room/Living room/: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed to have plenty of seating and lighting. LPA Ramirez observed private caregiver#1 feeding resident#2 (R2) breakfast at dining room table. LPA Ramirez observed Staff#3 (S3) providing care and supervision to residents at the dining room table. Linen Closet: Contained plenty linens, towels, hygiene products, and extra PPE supplies. Resident Rooms 1 - 5: LPA Ramirez observed all five (5) resident bedrooms to contain required furnishings, lighting, and linens. Bathrooms: Signs promoting hand washing were observed in all bathrooms. Water temperature in all three (3) resident bathrooms were within 105- 120 degrees F. Bathrooms were observed to be clean and well stocked. See 809-C Emergency Drills: Last documented drill was conducted on 9/30/23. Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable. Staff Personnel Files: Staff files are maintained at facility. LPA Ramirez reviewed staff files for six (6) staff. LPA Ramirez observed Administrator’s certificate for Linda Morales with an expiration date of 01/03/2025. Staff#1 (S1) personnel record could not be located. Staff #3(S3) and private caregiver #1 did not have proof of fingerprint clearance nor personnel record to review. LPA Ramirez will issue civil penalties of $200 for violation of criminal clearance. Resident Files: Six (6) resident files were reviewed. Liability Insurance & Infection Control Plan: Facility has current liability insurance on file. LPA Ramirez observed updated infection control plan. Deficiencies are being cited and civil penalties. Exit interview was conducted with Administrator Morales and a copy of this report, LIC 809-D, and appeals rights was provided.the state’s words, verbatim · CDSS document, Oct 20, 2023