California Sunshine RCFE

Type of visit: Required - 1 Year

On 06/10/2026 at 8:30AM, Licensing Program Analyst (LPA) Andrew Christy arrived unannounced to conduct the 1-Year Annual Required inspection. LPA met with Administrator, Crystal Vaka, and explained the purpose of the visit. The facility currently houses five (5) residents with a max capacity of six (6) residents. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area, and backyard. All outdoor and indoor passageways are kept free of obstruction. A pool was observed with an appropriate fence and a locked gate. A comfortable indoor temperature is maintained at 69.0 degrees Fahrenheit. The hot water temperature in the residents’ shared bathroom was measured at 108.3 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 06/10/2026. At 10:00AM, LPA reviewed five (5) resident files and four (4) staff files, all found to be complete. The emergency disaster plan was last reviewed 06/10/2026. Quarterly emergency drills were last conducted 04/01/2026. A review of resident medications and the Centrally Stored Medications List found no outstanding errors. No deficiencies cited during visit. Exit interview conducted and a copy of this report was provided to the administrator.the state’s words, verbatim · CDSS document, Jun 10, 2026

Allegation investigated: Staff failed to address resident’s urinary catheter needs while in care Staff failed to provide appropriate care resulting in resident skin tears

On 5/20/2025 at 4:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Manager, Mateaki Ofahengaue and explained the purpose of the visit. During the course of investigation, LPA interviewed 3 residents and staff. LPA also obtained and reviewed physician's report, emergency information, and pre-placement appraisal. Staff failed to address resident’s urinary catheter needs while in care Interview with resident (R3) revealed that staff assist in emptying urinary bag. R3 stated staff will assist resident when asked. Facility did not have pre-placement appraisal or a current appraisal needs and service plan for R3 indicating care provided. (Continue on LIC9099C...) Unsubstantiated Staff failed to provide appropriate care resulting in resident skin tears Facility did not have a current appraisal needs and service plan for R3 to indicate specific care needs. Interview with resident (R3) revealed that R3 can reposition and turn independently, but staff have assisted R3 in transfers. R3 stated staff will provide assistance when asked. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted with Mateaki. A copy of this report provided.the state’s words, verbatim · CDSS document, May 20, 2025 · control 15-AS-20241211144727

Type of visit: Required - 1 Year

On 5/20/2025 at 11:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Manager, Mateaki Ofahengaue and explained the purpose of the visit. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, kitchen, and outdoor area. Smoke and carbon monoxide detectors were observed. One week of nonperishable and 2-day of perishable food supplies were available. Hot water temperature was measured at 112.1 degrees F in the hallway bathroom. LPA observed grab bars and non-skid mats/materials in the bathrooms. Resident rooms were observed to be cleaned and fully furnished. Fire extinguisher was observed to be full. First Aid kit is complete. Last fire drill was conducted on 3/15/2025. LPA reviewed 2 residents and 3 staff files starting at 12:30PM. LPA reviewed a sample of resident's medications during inspection. At 11:30AM, LPA observed unlocked knives drawer, unlocked cleaning supplies in bathrooms, and unlocked gardening tools in the backyard. Manager locked up the items during inspection. At 12:40PM, LPA observed R1 does not have admission agreement on file. At 12:45PM, LPA observed R2 does not have medical assessment and TB test on file. At 12:50PM, LPA observed R1 and R2 does not have current reappraisal needs and service plan on file. (Continue on LIC809C...) At 1:15PM, LPA observed S2 and S3 does not have health screening and S2 does not have TB test on file. At 1:20PM, LPA observed no staff on duty have current CPR and First Aid training. At 2:00PM, LPA observed R1's medical assessment states that R1 is bedridden and on hospice care. LPA was informed by manager that R1 is no longer on hospice care. The facility does not have a bedridden fire clearance. Interview with R1 revealed that R1 can move side and side independently. The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and Health & Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted with Mateaki. A copy of this report, civil penalty, and appeal rights were provided.the state’s words, verbatim · CDSS document, May 20, 2025

The state marks this report as 15 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 06/12/2024 at 11:10AM, Licensing Program Analyst (LPA) T. Syess-Gibson arrived unannounced to conduct an Annual 1-Year required inspection. LPA met with Maupuku Ofahengaue, Caregiver and explained the purpose of the visit. Maupuku, caregiver contacted the administrator via telephone and explained my purpose of visit. Crystal Vaka, Administrator, arrived at 11:54AM. Administrator currently holds a certificate #6051305740 Expires 04/03/2025. The facility’s fire clearance was approved for six (6) Non ambulatory residents. LPA toured the facility including but not limited to bedrooms, bathrooms, kitchen, common area and back yard. The facility consists of six (6) bedrooms and four (4) bathrooms. LPA did observe an enclosed swimming pool in the backyard. A comfortable temperature is maintained at 78 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 103.9 degrees Fahrenheit. Residents' bathrooms are equipped with grab bars and nonskid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 10/24/2023. Emergency Disaster Plan was last posted on 09/01/2023. First aid kit was observed to be complete. Fire drill last conducted on 09/01/2023. Continued LIC809C. Continue from LIC809 LPA reviewed all three (3) residents records and three (3) staff records were reviewed. LPA also reviewed a sample of medication LPA requested the following documents to be submitted to CCLD by 06/19/2024. · LIC 200 Application for a Community Care Facility ..... · LIC 308 Designation of Administrative Responsibility · LIC 309 Administrative Organization · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan (last page) · Liability Insurance · Updated Facility Sketch LPA observed the following deficiencies: At 11:46AM LPA observed unlocked medicine in cabinet located in the kitchen area At 12:00PM LPA observed a swimming pool in the back yard with unsecured lock around the gate At 12:10PM LPA observed an unlocked cabinet the common bathroom with windex and pine sol and fabuloso antibacterial multi purpose cleaner on counter near sink At 12:28PM LPA observed resident in room #2 in a medical bed with a Half (1/2) bed rail Deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. A copy the appeal rights, and the report provided.the state’s words, verbatim · CDSS document, Jun 12, 2024

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.