California Mission Inn - Rose Manor

Allegation investigated: Staff are not addressing cockroach infestation at facility Staff are not addressing mold at facility Staff not addressing leak in resident rooms.

On 07/01/2026, Licensing Program Analyst (LPA) Jewel Baptiste conducted an initial visit to investigate the above allegations. LPA Baptiste met with Administrator Jared Green and Maintenance Supervisor Andy Caro-Mendoza and discussed the purpose of today's visit. During today’s visit, LPA Baptiste toured the facility with the Maintenance Supervisor and inspected rooms 104, 107(vacant), 109 (vacant), 211 (vacant), 220, 303, 304, 405, 407, and 418. LPA also interviewed the Administrator and Staff #1- #4 (S1-S4). LPA interviewed a total of 7 residents, who shall be referred to as resident #1 through resident #7 (R1-R7). LPA obtained the staff roster, resident roster, and pest control invoices from Bellas Exterminator for April, May, and June; a statement from Enco Engineering Inc.; and Work orders for June. Report Continued on 9099c Unsubstantiated The investigation reveals the following: "Staff is not addressing cockroach infestation at facility.” It is alleged that cockroaches are present in various areas of the facility. According to the facility Administrator, the facility does not have cockroaches. A pest control company visits the facility weekly for preventive treatment. The administrator further stated that if a resident reports any cases, it is handled right away. Four (4) out of four (4) staff denied the allegation, stating that the facility currently does not have cockroaches. They also confirmed that the pest control company is present on the premises weekly. Seven (7) out of seven (7) residents denied the allegation and stated they believe the facility will take care of it when needed. LPA reviewed the pest control invoices and confirmed the preventative treatments. The investigation reveals the following: " Staff is not addressing mold at the facility”. It is alleged that there is mold in the bathrooms of bedrooms 104, 107, 109, and 211. It was also alleged that mold is growing on the kitchen ceiling. The Administrator stated they have never had issues with mold in the facility. Four (4) out of four (4) staff denied the allegation, stating they have never seen mold. Seven (7) out of seven (7) residents denied the allegation, stating they have never seen mold in the facility. LPA toured the facility and did not observe mold in the building. The investigation reveals the following: " Staff not addressing leak in resident rooms”. It is alleged that the ceiling is leaking in the kitchen areas of the bedrooms. The Administrator and all staff stated there is a leak in two (2) bedrooms; one (1) is currently vacant, and maintenance staff is working on it. The other room is being addressed by a plumber because the facility staff cannot locate the source of the leak. Seven (7) out of seven (7) residents denied the allegation, stating they have never had a leak in their rooms. LPA toured the facility and observed a small leak under the kitchen sink. The staff stated it was observed on Tuesday, and a work order is in process. LPA toured the facility and observed that most of the rooms reported were vacant, and that staff are actively gutting and addressing the leaks. Based on LPA's interviews and observation, the investigation revealed that although the allegation may have occurred or is valid, there is not a preponderance of evidence to prove whether the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted with Jared Green, and a copy of this record was emailed.the state’s words, verbatim · CDSS document, Jul 2, 2026 · control 28-AS-20260626143821

Allegation investigated: Staff are making inappropriate comments in the presence of resident(s) in care. Staff interrupted the sleep of a resident in care.

Licensing Program Analyst (LPA) Alberto Lopez made initial visit to investigate the above allegations. LPA met with Maria Roleda – Wellness Director and discussed the purpose of the visit. The investigation consisted of LPA reviewing and obtaining copies of resident and staff rosters, R1 physicians report, interviewing four (4) staff and six (6) residents adjacent to R1 room, and taking a tour of common areas and resident rooms. The investigation revealed: Regarding Allegation: Staff are making inappropriate comments in the presence of resident(s) in care. It is alleged that staff and/or other residents are making loud, intrusive and inappropriate comments and harassing resident on May 13, 2026, at around 2:22 am. LPA interviewed four (4) staff and all four (4) staff denied the allegations. LPA interviewed six (6) residents and all six (6) could not corroborate the allegations. (continued on 9099C) Unsubstantiated (continued on 9099C) Residents in adjacent rooms stated they do not hear sounds in the middle of the night. R1 stated that the sounds are coming from the adjacent room to the north side of resident's room. However, that room has been vacant since the beginning of the day on May 12, 2026 by 11:00am . Asked if R1 heard any sounds yesterday or this week coming from the unoccupied room, resident stated resident thinks resident heard sounds. R1 stated R1 will try to record the sounds next time. R1 could not identify the person(s) who are making the sounds or noise. There is no evidence to support this allegation. Allegation: Staff interrupted the sleep of a resident in care. It is alleged that resident was intentionally awaken when resident arrived at facility after being out on lengthy journey. LPA interviewed four (4) staff and all four (4) staff denied the allegations. LPA interviewed six (6) clients and all six (6) could not corroborate the allegation. R1 could not identify the person(s) who woke R1 up. Other residents interviewed stated they are not awakened in the middle of the night or anytime they are sleeping. There is no evidence to substantiate this allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies were cited during this investigation. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, May 19, 2026 · control 28-AS-20260519110404

Allegation investigated: Staff does not ensure residents are provided a safe environment resulting in harrassment. Staff does not ensure resident's room is clean and sanitized. Staff do not ensure the facility is properly maintained

Licensing Program Analyst (LPA) Alberto Lopez made a subsequent unannounced visit to deliver findings for the above allegations. LPA met with Food service Director Juan Santiago, and discussed the purpose of the visit. On 03/03/2026 The investigation consisted of LPA reviewing and obtaining staff and resident rosters, interviewed five (5) staff S#1 -S#5 and seven (7) residents R#1 – R#7. Reviewed and obtained R1 physicians report, R1 care plan and taking a tour of common areas, R1 room and random rooms. Reviewed and obtained chain of emails between R1 and facility 03/21/2026 The investigation revealed regarding allegation: Staff does not ensure residents are provided with a safe environment resulting in harassment. It is alleged that residents in adjacent rooms are talking loudly and disturbing the peace of resident in early morninig hours and staff are not addressing the issue. (continued on 9099) Unsubstantiated (continued from 9099) LPA interviewed five staff (5) and all five (5) staff denied the allegation. LPA interviewed seven (7) residents in adjacent rooms to R1 and four (4) of seven (7) residents could not corroborate the allegation. Two (2) residents stated that they had a loud verbal disagreement recently, that is was only one day. They stated it had nothing to do with R1, and that it has not occurred again. Both residents stated their issue has been resolved between them. LPA explained this to R1 and R1 stated she understands. There is not enough evidence to substantiate this allegation. Staff does not ensure resident's room is clean and sanitized. It is alleged that R1 room is not being clean and sanitized. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. Several staff stated that resident has canceled room cleaning when scheduled and have refused to allow entry to housekeeping staff at times. LPA interviewed seven (7) residents and six (6) of seven residents could not corroborate the allegation. R1 admitted that R1 has cancelled scheduled room cleanings several times and stated that R1 does not want staff in R1 room when R1 is not present because things have gone missing before. LPA tour R1 room and it appeared clean. R1 stated outside service cleans room. There is insufficient evidence to support this allegation. Staff do not ensure the facility is properly maintained. It is alleged that R1 stove is uncleaned, toilet is leaking and cover for drawer is loose and needs repair and facility has not addressed the issues. LPA interviewed five (5) staff, and all five (5) staff denied the allegation. One staff member stated that as soon as they get a work order, they are on it right away. Records reviewed show that R1 requested to have her toilet repaired on 2/25/2026 and staff asked which dates would work for R1. Records show toilet was repaired on 02/27/2026 and R1 confirmed this. R1 alleged that there was a natural gas leak in room and called the Gas company. Gas company arrived and discovered that R1 does not have any appliance that uses natural gas and they did not detect any gas leak. One staff member stated that staff used a little spray of W40 to loosen bolt on toilet to repair it and that is what resident smelled. R1 agreed that was the smell after being told. On 03/04/2026, R1 alerted staff that there was a cover that came off a drawer and the facility had that repaired on 03/04/2026. There is insufficient evidence to substantiate this allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies were cited during this investigation. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 21, 2026 · control 28-AS-20260226083245

Allegation investigated: Staff did not provide meals to resident Staff neglect/lack of supervision caused resident to remain on floor for at least 12 hours.

Licensing Program Analyst (LPA) Alberto Lopez made a subsequent unannounced visit to investigate the above allegations. LPA met with Hayden Petrovick, Marketing Director and the purpose of the visit was discussed. 12/16/2026 - The investigation consisted of LPA taking a tour of facility, interviewing five (5) staff (S#1-#5), Six (6) residents (R#1- R#6), reviewing and obtaining R1 admissions agreement, physician's report, staff and resident rosters, AR form, R1 care plan and other pertinent documentation related to the investigation. Due to time constraints, needs further investigation. LPA will return another day to complete investigation. 12/15/2026 - Licensing Program Analyst (LPA) Alberto Lopez made an unannounced visit to investigate the above allegations. LPA met with Wellness Coordinator Maria Cruz and the purpose of the visit was discussed. (Continued on 9099C) Unsubstantiated (continued from 9099) The investigation consisted of LPA taking a tour of facility, interviewing two (2) staff (S#1-#2), reviewing and obtaining R1 admissions agreement, physician's report, staff and resident rosters, and R1 care plan. The investigation consisted of LPA taking a tour of facility, interviewing five (5) staff (S#1-#5), Six (6) residents (R#1- R#6), reviewing and obtaining R1 admissions agreement, physician's report, staff and resident rosters, AR form, R1 care plan and other pertinent documentation related to the investigation. The investigation revealed: Regarding Allegation: Staff did not provide meals to resident. It is alleged that staff did not provide meals for resident one day. LPA interviewed five (5) staff and all five staff were aware that resident missed all three meals on 12/01/2025. Several staff stated that resident usually went to the dining hall on the fifth floor to eat meals. Culinary supervisor noticed she had not seen resident that day and asked another staff member if she knew about the resident.. The staff member answered with “resident is OK” and never checked on resident. Resident was receiving escorts to meals when she first arrived at the facility on care plan that was created on 06/19/2024. Effective 04/15/2025 an updated care plan was created and removed wellness checks and meal escorts to the dining room. The resident should have no expectation for staff to check on resident or to deliver a meal tray to resident’s room on this day according to the services agreed upon by the resident and facility on 04/15/2025. There is insufficient evidence to support this allegation. (continued) (continued) Allegation: Staff neglect/lack of supervision caused resident to remain on floor for at least 12 hours. It is alleged that staff neglected resident after a fall that resulted in resident being on the floor for twelve hours. Resident had wellness checks removed from care plan effective 04/15/2025. The resident was provided with a call pendant to press in case resident required assistance; however, resident did not press the pendant at any time during the time resident spent on the floor. According to the care plan effective 04/15/2025, the resident should have no expectation of a wellness check on 12/01/2026. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies were cited during this investigation. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 24, 2026 · control 28-AS-20251210091356

Allegation investigated: Staff did not assist resident in a timely manner.

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 10/23/2025 regarding the above allegation. During today’s visit, LPA Ramirez was greeted by Clinical Director Maria Roleda and explained the purpose of the visit. The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 5 interviews (S1 – S5), Resident#1 – 6 (R1 – R6), Pendant call logs from October 01, 2025, through 10 14, 2025, Staff Timesheets for October 1, 2025, & October 14, 2025, and physical plant tour. See 9099-C for continued Substantiated The investigation revealed the following: regarding the allegation “Staff did not assist resident in a timely manner.” It is alleged staff are not assisting residents in a timely manner when residents push their pendant for assistance. Six (6) out of the six (6) residents interviewed corroborated this allegation. Resident interviews revealed that staff take between 10 mins to 45 mins to answer pendant calls. Record review of Pendant call logs from October 01, 2025, revealed the following: at 11:44am, R3 pressed their pendant for assistance and staff arrived 1hr 8mins 2 seconds later, at 6:50am, R1 pressed their pendant for assistance, staff arrived 41 mins 2 seconds later, and at 7:42am R2 pressed their pendant for assistance, and staff arrived 29mins 23seconds later to assist. Review of Pendant call log for October 14, 2025, revealed the following: at 7:22am, R6 pressed their pendant for assistance and staff arrived 1hr 58mins 18 seconds later, and at 7:51am, R3 pressed their pendant for assistance and staff arrived 1hr 38mins 40 seconds later to assist. Staff interviews corroborated the allegation. Staff interviews revealed that due to staffing absences, some residents are waiting longer than 5 mins for assistance. Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. One (1) deficiency was cited during this complaint investigation. Exit interview was conducted. A copy of this report, 9099-D and appeals rights was provided.the state’s words, verbatim · CDSS document, Oct 23, 2025 · control 28-AS-20251017161449

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2 · Plan of correction due date: Oct 24, 2025

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Residents calls for assistance were not met in a timely due to staffing shortages.the state’s words, verbatim · CDSS document, Oct 23, 2025

Plan of correction: Administrator will draft plan to address how the facility plans to deliver staff that are sufficient in numbers to provide care and supervision to residents in care. Plan must be received by 10/24/25.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced Required - 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to the Administrator Jared Green and Maria Roleda, Wellness Director, assisted LPA with the visit. On today's date, LPA inspected the following domains 1.Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility still practices the infection control with hand washing. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirements: The current plan of operation is completed. The facility has a Dementia Waiver in place. A Hospice Waiver for 20 residents is approved. A fire clearance for 85 non-ambulatory residents, of which 9 may be bedridden, is in place. Liability Insurance in the amount of at least ($1,000,000) per occurrence and total amount of aggregate ($3,000,000) is in place. 3. Physical Plant/Environmental Safety: The facility consists of a 5-floor building. The first through fourth floors consist of residents rooms and the fifth floor is the dining area. The common areas are located on the first and third floors. LPA inspected random rooms and are clean and have required furnishing. Bathrooms were clean, toilets and water faucets worked properly and were properly supplied, have functional fixtures, and have secure grab bars. Emergency pull cords were observed in every resident room. (See LIC 809C for continuation) (continued from 809) Showers were free of mold/ mildew and non-skid mats or strips were properly in place. The hot water temperature was tested between 109.4 and 115.8 F which is within the Title 22 regulation of 105.0 – 120.0 degrees F. LPA also inspected the carbon monoxide detectors in the facility, are working properly. The facility has a telephone service on the premises. 4. Staffing: The facility has sufficient staffing to provide care and supervision to residents. 5. Personnel Record-Training: All the staff are over 18 years old and they are fingerprint clear and associated with the facility. LPA inspected four (4) staff files, and they all have the required documents which include heath screening, TB test result, required training hours, updated first aid and CPR certificate. The facility administrator is Jared Green and his administrator certificate expiration date in 4/14/26. 6. Resident Record-Incident Reports: LPA inspected four (4) residents files and they all have the required documents in file which included: admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records. 7. Resident's Right: LPA observed the required posters posted on the board on the first floor in the TV/Living room which include Long Term Care Ombudsman, Community Care Licensing Complaint and Personal Right Poster. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physician. 8. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted, and LPA reviewed the calendar for the facility. 9. Food Service: The facility has sufficient 2 days perishable and 7 days non-perishable food supply and the emergency food supply are stored and locked in emergency food supply room. 10. Incidental Medical and Dental: LPA inspected four (4) residents medication, and the medication is centrally stored and locked in the Wellness Center room, and they are accurate and updated and also contain 30 days’ supply of medication. The facility will also provide transportation to residents' medical and dental appointments. 11. Disaster Preparedness: The facility has an Emergency Disaster Plan (LIC610E) posted but needs updated to show one evacuation site out of the area. The last fire drill was conducted on 09/16/2025 and the last disaster drill was conducted on 06/06/2025. Records of resident Appraisal and Needs services plans are part of Emergency training. 12. Residents with Special Health Needs: No residents in the facility with prohibited health condition. Currently there are three (3) residents on hospice and two residents in home health. Individual Service Plan and appraisals are on resident's files for home health and hospice. No deficiencies were observed during the visit. Technical advisories provided. Exit Interview Conducted and a copy of the report was provided to Wellness Director Maria Roledathe state’s words, verbatim · CDSS document, Oct 14, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff does not ensure facility elevator is in good repair.

Licensing Program Analyst (LPA) Alberto Lopez made a subsequent unannounced visit to the facility to deliver findings for allegation above. LPA met with Hayden Petrovick, Marketing Dirctor and discussed the purpose of the visit. 09/17/2025 LPA interviewed Administrator - S#5 via phone. 09/15/2025 - The investigation consisted of LPA taking a tour of facility and testing the two (2) elevators in the Rose Manor section of facility, interviewing four (4) staff (S#1-S#4) and four (4) residents (R#1– R#4), reviewed of elevator repair invoices dated 05/01/2025, 07/24/2025, 08/01/2025, 09/10/2025, and 09/11/2025 The investigation revealed: Allegation: Staff does not ensure facility elevator is in good repair. It is alleged that staff are not addressing the constant disrepair of elevators for at least four (4) weeks (continued on 9009C) Unsubstantiated (continued from 9099) LPA interviewed five (5) staff members, and all five (5) staff members corroborated the allegation. All five (5) staff members stated that the elevators being in disrepair has been an ongoing issue for several weeks now. Facility maintenance man stated that the elevator repair company has been called several times recently and repairs the elevator. One staff stated that some residents force the door to stay open so that residents can board the elevator and that causes the elevator to break down. LPA interviewed four (4) residents, and all four (4) residents corroborated the allegation and stated that it is an inconvenience. LPA reviewed and obtained several invoices from Next Level Elevator for maintenance on the elevators dated 05/01/2025, 07/24/2025, 08/01/2025, 09/10/2025, and 09/11/2025. The administrator stated they will discontinue using Next Level Elevator and seek another elevator repair company that can provide better results. During the visit on 09/15/2025, LPA observed the repair technician from Next Level Elevator and the technician was able to repair the elevator during the visit, as LPA was leaving the facility, LPA tested the elevator once again and the issue of the door not closing returned. The invoices from Next Level Elevator are evidence that the facility is addressing the issue of the elevators in disrepair. The elevators being in disrepair is not a fire hazard as the fire department recommends not using the elevators in case of fire. There is not enough supportive evidence to show that the facility is not addressing the elevators in disrepair. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies were cited during this investigation. Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 20, 2025 · control 28-AS-20250912113820

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted required annual inspection. LPA met with Jessica Estrada (Wellness Coordinator) and discussed the purpose of today’s visit. Maintenance Director Andy Mendoza arrived shortly after to assist with the inspection. The facility is licensed for 85 non-ambulatory residents, age 60 and over, of which nine (9) may be bedridden. The facility has an approved hospice waiver for twenty (20) residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected eight (8) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. Facility maintains a monthly waterlog to record water temperature throughout the facility. LPA Ramirez observe postings encouraging proper hand washing etiquette in restrooms. LPA Ramirez observed grab bars near toilets and inside showers. LPA Ramirez tested emergency pull cord in room#216. Staff responded 5 minutes later to assist. LPA Ramirez observed evacuation chairs in stairways. LPA Ramirez observed video surveillance in rooms# 211 & 216. Video surveillance was placed at the request of the residents and family. LPA Ramirez will issue Technical Violation based on this observation. Food Service: LPA Ramirez observed sufficient supply of nonperishables for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0 degree F (-17.7 degree C), and refrigerators with maximum temperature of 40 degree F. (4 degree C). LPA Ramirez observed facility weekly and daily menu, which is approved by the facility certified dietary manager. LPA Ramirez observed kitchen staff preparing for lunch while wearing hair nets and gloves. LPA Ramirez observed several dinning room servers disinfecting tables and counters while wearing gloves and hair nets. See 809-C for continuation. Planned Activities: LPA Ramirez observed an activities calendar for October of 2024 with various activities and outings for residents. LPA Ramirez observed sufficient outdoor space. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility computers with internet access and a facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. LPA Ramirez observed evacuation chair in stairway. Last documented emergency drill was conducted on 09/17/24. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. Residents with Special Needs: Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Operational Requirements: The facility is licensed for 85 non-ambulatory residents, age 60 and over, of which nine (9) may be bedridden. The facility has an approved hospice waiver for twenty (20) residents. LPA Ramirez reviewed facility liability insurance and auto registration for one (1) facility vehicle. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training only for four (4) out of the four (4) staff files requested. LPA Ramirez reviewed required annual training for staff working with dementia residents. LPA Ramirez was unable to review the following: CPR and First Aid, TB testing results, Health screening, fingerprint clearance, and job application. Staffing: Administrator Certificate for Jared Green and it expires 04/14/2026. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication rooms and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. No deficiencies were observed during this inspection. Exit interview was conducted with Jared Green and a copy of this report, LIC 9120 and appeals rights was provided via email.the state’s words, verbatim · CDSS document, Oct 3, 2024

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

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Wong conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to the Administrator Dwight Dunagan and assisted LPA with the visit. The facility is licensed to RCFE/Dementia for age range 60 and over. Approved for 85 non-ambulatory, of which 9 may be bedridden, approved hospice waiver for 20. Currently, there's two residents on home health, six residents on hospice but no bed ridden residents. On today's date, LPA inspected the following domains which include: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Record-Training, Resident Records/Incident Reports, Resident's Right, Planned Activities, Food Service, Incident Medical and Dental, Disaster Preparedness and Resident with Special Health Needs 1.Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility still practice the infection control with hand washing. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirements: The current plan of operation is completed. The facility has a Dementia Waiver in place. A Hospice Waiver for 20 residents is approved. A fire clearance for 85 non-ambulatory residents; of which 9 may be bedridden is in place. Liability Insurance in the amount of at least ($1,000,000) per occurrence and total amount of aggregate ($3,000,000) is in place. 3. Physical Plant/Environmental Safety: The facility is consisted of a 5 floor building. The first through fourth floors consist of residents rooms and the fifth floor is the dining area. The common areas are located on the first and third floor. LPA inspected Room#106, #116, #212, #205, #303, #301, #412, #414 and the rooms are clean and have required furnishing. Bathrooms were clean, toilets and water faucets worked properly and were properly supplied, have functional fixtures, and have secure grab bars. Emergency pull cords were observed in every resident room. (See LIC 809C for continuation) Showers were free of mold/ mildew and non-skid mats or strips were properly in place. The hot water temperature were tested between 105 and 112.6 degrees F which is within the Title 22 regulation. LPA also inspected the carbon monoxide detectors in the facility and they are working properly. The facility has a telephone service on the premises. 4. Staffing: The facility has sufficient staffing to provide care and supervision to residents 5. Personnel Record-Training : All the staff are over 18 years old and they are fingerprint cleared and associated with the facility. LPA inspected four staff files and they all have the required documents which include heath screening, TB test result, required training hours, updated first aid and CPR certificate. The facility administrator is Dwight Dunagan and his administrator certificate expiration date 7/11/2024. 6. Resident Record-Incident Reports: LPA inspected 4 residents files and they all have the required documents in file which included : admission agreements, Physician's Reports, Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, medical consent, and medication records. 7. Resident's Right: LPA observed the required posters posted on the board on the first floor in the TV/Living room which include Long Term Care Ombudsman, Community Care Licensing Complaint and Personal Right Poster. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physician. 8. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. An activity calendar is posted and LPA reviewed the calendar for the facility. The facility does not have a resident council but regular town hall meeting. 9. Food Service: Currently the facility has 3 resident is on a modified diet with physician order in file. The facility has sufficient 2 days perishable and 7 days non-perishable food supply and the emergency food supply are stored and locked in emergency food supply room. Sanitation practices and kitchen cleanliness was observed. 10. Incidental Medical and Dental: LPA inspected four (4) residents medication and the medication are centrally stored and locked in the Wellness Center room and they are seemed accurate and updated and also contained 30 days supply of medication. The facility would also provide transportation to residents' medical and dental appointments. 11. Disaster Preparedness: The facility has an updated Emergency Disaster Plan (LIC610E) and its updated on 10/20/22. The last fire drill was conducted on 9/22/23 and the last disaster drill was conducted on 6/28/23. The facility has two temporary alternative shelter location. Records of resident Appraisal and Needs services plans are part of Emergency training. 12. Residents with Special Health Needs: No residents in the facility with prohibited health condition. Currently there are six resident on hospice and two residents on home health. Individual Service Plan and appraisals are on resident's files for home health and hospice. No deficiencies were observed during the visit. Exit Interview Conducted and a copy of the report was provided to Administrator Dwight Dunagan.the state’s words, verbatim · CDSS document, Oct 31, 2023