Canyon Lake Terrace

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced annual required visit. Upon entry, LPA was greeted by Julita Mendoza, Administrator, and informed them of the purpose of the visit. At the time of the visit, there were three (3) staff members and one (1) resident present. Facility Overview: The facility is a one-story home with six (6) bedrooms and four (4) bathrooms, including an attached garage. There are no pools or known firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility has infection control plan in file. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents. Both the smoke detector and carbon monoxide detector were operational, and the hot water temperature was 113.5°F. Fire extinguisher located at kitchen has current inspection tag. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Continued on LIC809-C..... Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate. Record Review and Resident/Staff Files: LPA reviewed files for two (2) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. One (1) resident file was reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for one (1) resident, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 07-02-2025, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided.the state’s words, verbatim · CDSS document, Sep 9, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that five (5) residents live at this facility. There was three (3) staff members present. The Administrator, Julita Mendoz was advised of the annual over the phone, however the Caregiver, SarahJane Nate conducted and completed the facility tour. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Five (5) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration: LPA reviewed employee records. Two (2) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. California Department of Social Service has received Julita Mendoz, Administrator’s certificate renewal application. Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a location for sharps in the kitchen. Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 75 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 108.0 degrees F. Laundry is done in the garage. There is a locked location for storing laundry soap, cleaning supplies and chemicals in the garage. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA dialed the facility’s landline number, which rang and was operable. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There are zero (0) fireplaces at this facility. There are zero (0) pools at the facility. There is one (1) secured gate that has a self-latching lock located on the northwest side of the house, with 3 resident’s exit doors that lead out to the front entrance. LPA observed emergency supplies and three (3) first aid kits. The last emergency fire drill was conducted on 07/04/2024. Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that staff had infection control training. Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked cabinet allocated for medication storage. Centrally stored medication and destruction logs are maintained separately. LPA reviewed medication logs and observed that they were dispensed accurately. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed eight (8) dual smoke detectors and carbon monoxide and one single carbon monoxide detector throughout the facility. There were one (1) fire extinguishers on site, date charged was 03/01/2024. Pursuant to Title 22 of The California Code of Regulations Division 6, there are zero (0) deficiencies observed. An exit interview was conducted, this LIC 809 was reviewed with, and a copy of this report was provided to Caregiver, SarahJane Nate.the state’s words, verbatim · CDSS document, Sep 19, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cheryl Goodrich arrived at 3:46 PM to conduct an unannounced annual visit. LPA met with Caregiver Sarah Nate and was granted entry. The Administrator Julita Mendoza was unavailable for the inspection. The purpose of today’s visit is to inspect the facility to ensure that the facility is following California Code of Regulations, Title 22, Division 6. Facility is approved for six (6) non-ambulatory residents of which 1 may be bedridden. The facility has an approved dementia plan of operation and a hospice waiver for 2 residents. Infection Control: The facility has an approved infection control plan and a surplus of supplies for infection control including but not limited to mask, gloves, gowns, first aid kit, and cleaning supplies. Physical Plant and Environmental Safety: The facility temperature read at 73 degrees. The facility consists of 5 resident bedrooms, and 3 bathrooms, living room, and kitchen. The bedrooms are furnished with tv, lighting, closet space, and dresser. The beds are clean and have clean linens and the pathways are clean and clear of obstruction. The bathroom temperature read at 111 degrees within regulation requirements. The living room and kitchen clean and clear of obstruction. The medications are stored in a locked cabinet in the kitchen and inaccessible to the resident. The facility and has a current fire clearance, smoke and carbon monoxide detectors and fire extinguishers and are in working order. Personnel Records-Training: The staff records are completed with fingerprint clearance, Health screening for TB, CPR/First Aid training, and in-service trainings. Client Records-Incident Reports: The facility has identification and emergency information, physician’s report, resident appraisal, hospice documentation, client rights, and admissions agreements. (Continued on LIC809-C) (Continued from LIC809) Client Rights-Information: The facility has client rights information posted in the facility. Food Service: 7-day non-perishable and 2 day of perishable food supply was observed, and all food was properly stored and available. Health- Related Services: The facility has a medication logbook, and the facility documents the resident’s medication and in compliance with physician’s orders and regulations. Disaster Preparedness: The facility has a disaster plan and has posted the evacuation plan, visible for staff and residents in care. The last fire drill was completed 07/05/23. The facility has emergency supply of food and water. Summary: Based on today's visit, no deficiencies were observed at this time. An exit interview was conducted with Caregiver Sarah Nate, a copy of this report was printed Signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Sep 28, 2023