Care and Care Residence I

Type of visit: Required - 1 Year

On 06/30/2025, Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced annual inspection. LPA met with staff Michelle Perez, LPA explained the purpose of the visit. Administrator, Arlene Gomez, was contact over the phone. The Administrator gave permission to staff Michelle Perez to sign required report. LPA conducted a tour of the facility. Backyard was fenced, secured, and in good condition. All outdoor and indoor passageway were free and clear of obstruction. No accessible bodies of water or fire safety hazards observed. Kitchen was inspected, sufficient supply of food observed. Infection control practices reviewed. Medications, toxins and sharps stored appropriately and inaccessible to clients, a comfortable temperature was maintained, hot water temperature inspected to be compliant, furnishing and lighting was sufficient for comfort and safety. Carbon monoxide detector and smoke detector system inspected and met the requirements. fire extinguisher checked and fully charged. Facility has at least one completed first aid kit. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. No deficiencies were cited. Four technical violations were noted for incomplete documentation for the quarterly emergency drill, incomplete documentation for Records of resident's cash resources, incomplete documentation for reappraisal, and insufficient provision for emergency drinking water. The report was reviewed and discussed with staff. A copy of the report was left at the facility.the state’s words, verbatim · CDSS document, Jun 30, 2026

The state marks this report as 6 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

On 6/23/2025, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Care Staff Marlon Sicat. LPA explained the purpose of the visit. LPA toured the facility including all of resident rooms and kitchen area. Facility is a single story house with 7 bedrooms with two residents residing in each room. LPA observed Room 7 ceiling to be temporarily repaired. LPA observed residents hanging out in the living room area watching tv. The facility is observed to be clean, and well maintained. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps and toxic materials were observed locked. Food supply in was observed with an adequate two day perishable and seven day non-perishable. Carbon monoxide/ smoke detectors, and fire extinguisher were present throughout the facility. Facility has an updated log for emergency drill is done every quarter. Five resident records and four staff records were reviewed. Centrally stored medication was locked and inaccessible by residents. All medication was labeled and sorted by resident name. All medication logs are complete and updated. Administrator will send the Liability Insurance to LPA. No deficiencies cited today. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Jun 23, 2025

Allegation investigated: Facility has bed bugs Staff inappropriately sprayed chemicals on a resident's bed

On 10/31/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of initiating complaint investigation and was greeted by Lead Caregiver Staff, Michelle Perez (S1). LPA toured the facility, interviewed staff and outside parties, photographed and made observations during the investigation. Complaint alleges the facility has bed bugs. Upon interview with staff (S1 & S2), LPA was informed that staff had first been aware of bed bugs in resident's (R1) bedroom between 2-3 weeks prior to visit date. Based upon interview with Stepping Stone Day Program, Case Manager (I1), it was found that on 10/10/2024, I1 had conducted a facility visit and observed live bed bugs and bed bug carcasses on R1's bed and bedding. Additionally, on 10/17/2024, I1 observed bed bug carcasses under R1's bed and on 10/23/2024, R1 was observed to have a live bed bug on their clothing while attending day program. During interview with staff, S1 indicated that they did not not notify facility manager when first observed, delaying the contact for exterminator services. The extermination services were first contacted with a copy of the signed agreement for services dated 10/22/2024. Additional documentation indicated that the first visit conducted by the exterminator was on 10/25/2024, multiple days after bed bugs were first observed in the facility. Continued onto LIC9099-C Substantiated Upon facility inspection LPA and S1 observed multiple bed bug carcasses in R1's bedroom #5. S1 stated that the bed bugs had not spread throughout the facility. However, LPA observed additional bed bug carcasses near R1's roommate's bed, as well as in the adjacent bedroom #6 and in bedroom #1 located at the furthest end of the hallway from R1's quarters. LPA found that the bed bugs had spread throughout the facility effecting multiple bedrooms (photos taken). Complaint alleges staff inappropriately sprayed chemicals on a resident's bed. Upon interview with staff (S1), LPA was informed that bed bug chemical spray was applied around R1's bed and wall area. LPA was shown the chemical spray confirming that R1's living quarters had been exposed to chemicals (photos taken). In addition, upon interview with Stepping Stone Day Program Case Manager (I1), I1 indicated that during their visit to the facility, I1 had witnessed staff applying the chemical spray directly on R1's bed and bedding, effecting R1's furnishing, equipment and living accommodations. Allegations, facility has bed bugs & staff inappropriately sprayed chemicals on a resident's bed are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.the state’s words, verbatim · CDSS document, Oct 31, 2024 · control 14-AS-20241022112243

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Nov 1, 2024

87468.1: Personal Rights of Residents in All Facilities - To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was not met as evidence by: Based upon LPA observation and photos taken, the facility was observed to have bed bug carcasses in resident (R1) bedroom as well as multiple bedrooms throughout the facility. In addition, upon interviews with staff (S1 & S2) and outside parties (I1), bed bugs were observed as early as 10/10/2024 without acquiring extermination services until 10/22/2024. Lastly, interviews with I1 indicate that I1 observed both live and dead bed bugs in R1's bedroom and on R1's person on mulitple occasions from 10/10/2024 to 10/23/2024. This serves as an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 31, 2024

Plan of correction: The facility has contacted appropriate extermination services as of 10/22/2024 and conducted their first service visit on 10/25/2024. The facility failed to initially respond to the bed bug infestation, however has not taken corrective measures. Deficiency cleared at time of visit. In addition, Licensee is to provide documentaiton of each exterminator visit and status of bed bug infestation to CCLD until services habe been completed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(d)(2) · Plan of correction due date: Nov 1, 2024

87307: Personal Accommodations and Services - The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This was not met as evidence by: Based upon interviews with staff (S1) it was found that bed bug chemical spray was applied around resident R1's bed. In addition, interview with outside party (I1) indicated that I1 witnessed staff spray the chemicals directly on R1's bed and bedding. This serves as an immediate health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 31, 2024

Plan of correction: The facility has replaced the mattresses for R1 and all residents in care. LPA observed new mattresses and clean bedding during visit. Although bed bug carcasses were still observed during visit, the facility has taken appropriate measures to treat bed bug infestation. Deficiency cleared at time of visit.

Type of visit: Case Management - Annual Continuation

On June 13, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:10 AM, to complete the Annual 1-year required inspection. LPA Calandra was greeted by Michelle Perez, Caregiver and explained the purpose of the visit. LPA Calandra tested the facility's hot water temperature. It was measured at 110.4 degrees Fahrenheit well within the required 105-120 degrees Fahrenheit range. No deficiencies were cited during today's visit. An exit interview was conducted. This report was reviewed with Michelle Perez, Caregiver and a copy of the report left at the facility.the state’s words, verbatim · CDSS document, Jun 13, 2024

The state marks this report as 7 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On June 12, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:30 AM to conduct the unnanounced Annual 1-year required inspection. LPA Calandra was greeted by Michelle Perez, Caregiver and explained the purpose of the visit. Arlene Gomez, Administrator was contacted by phone but could not join the visit. LPA Calandra toured the physical plant. This is a 1-story building which consists of 7 bedrooms, two bathrooms, a backyard, a staff bedroom, and storage room. All bedrooms had the required furniture and sufficient lighting. All bathrooms had the required grab bars and non-skid floor mats. No accessible bodies of water or hazards were observed. The facility temperature was set to 70 degrees Fahrenheit. The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. The fire extinguishers were observed to be fully charged and last inspected by the fire department on January 11, 2023. At 1:00 PM, Michelle Perez, Caretaker showed LPA Calandra the 2024 fire extinguishers which were observed to also be fully charged. The facility's first aid kit was observed to have the required sterile first aid dressings, bandages, scissors, tweezers, and thermometers. The facility's smoke and carbon monoxide detectors were observed to be in working order.Per a conversation with Jay Navarez on the phone at 10:24 AM, the smoke and carbon monoxide detectors are connected directly to the San Francisco Fire Department. All sharp objects, poisons, soaps, and detergents were observed to be locked and in-accessible to persons in care. LPA Calandra reviewed 5 resident files and 5 staff files. Resident files were observed to have incomplete documents such as the LIC 602: Physician's report and Annual Needs and Services Plan. Staff files were observed to have incomplete LIC 503: Health Screening Reports and TB results. LPA Calandra interviewed 4 residents and 3 staff. A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility. A Type A violation was provided for not having TB results for S1, S2, and S3. A Type A violation was provided for not conducting emergency drills quarterly per shift and documenting those drills. A Type B violation was provided for not fixing the ceiling in Bedroom 7 which per an interview had retained water damage from the latest storms. A Type B violation was provided for not having a medical assessment for R1. A Type B violation was provided for not having Annual Needs and Services Plans for R1, R2, R3, R4, and R5. LPA Calandra requested the following documents be sent to the Regional Office: -Updated LIC 500 -Current Lease Agreement -Administrator Certificate The Annual inspection will be completed at a later date. Deficiencies are cited under California Code of Regulations, Title 22, cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. This report was reviewed with Michelle Perez, Caregiver and an exit interview conducted. A copy of the report along with appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Jun 12, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 12/23/23 at 3:30pm to conduct a Case Management - Deficiencies visit. LPA met with Caregiver(s) Michelle Perez and Elvis Perez and stated the purpose of the visit. Michelle Perez, Caregiver was unable to contact Arlene Gomez, Administrator regarding todays visit. Michelle stated that Arlene Gomez submitted a plan of correction to the Community Care Licensing Office. Observations during this visit regarding Deficiencies that were cited on 12/10/23: -Administrator certificate expired 5/18/23 for Arlene Gomez. LPA did not observe an Administrator certificate for Jose Nevarez nor supporting documents with proof of payment for renewal for neither. Michelle Perez, Caregiver stated that the file has not been updated with pertinent documentation or proof of payment to renew. She also stated Arlene Gomez has not received the renewal yet. NOT CLEARED TO BE RE-CITED -LPA did not observed an updated LIC308 Designation of Responsibility NOT CLEARED TO BE RE-CITED -LPA did not observe a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, tweezers, and antiseptic solution. Michelle stated it was ordered and it has not been delivered yet. NOT CLEARED TO BE RE-CITED -LPA did not observe TB results for staff. Michelle stated regarding the TB for staff Arlene Gomez is working on it. NOT CLEARED TO BE RE-CITED -LPA inquired with both staff regarding the Infection Control Plan. Michelle has not received a copy of the Infection Control Plan. NOT CLEARED TO BE RE-CITED -LPA observed medications belonging to staff accessible and on top of refrigerator not locked. - LPA observed the same medications on top of the refrigerator which was removed during this visit. A photo was taken. NOT CLEARED TO BE RE-CITED - During file review LPA observed expired first aid/CPR certificates for staff. Michelle stated regarding the First Aid/CPR for staff Arlene Gomez is working on it. NOT CLEARED TO BE RE-CITED See 809C for continuation... 809 Continued... -LPA observed screen at front of facility window to be not in good repair. LPA observed the window screen has not been repaired. A photo taken. NOT CLEARED TO BE RE-CITED -LPA observed records of residents (R) incomplete, without signatures and dates. A review of R1 and R2 files during this visit revealed the files have not been corrected. NOT CLEARED TO BE RE-CITED The Department is not in receipt of the Plan of Correction that was submitted by the Administrator Arlene Gomez and proof was not provided during this visit. LPA shall issue an Advisory note. In addition, the Licensee/Administrator shall submit the documents requested below. Upon a file review the following items were discussed to be submitted with any changes annually: Infection Control Plan (LIC9282), updated Designation of Facility Responsibility (LIC308), Liability Insurance, Control of Property such as rental agreement or lease agreement, Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, Emergency Disaster Plan (LIC610D). Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being re-cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The facility representative was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.the state’s words, verbatim · CDSS document, Dec 23, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Dec 24, 2023

Administrator - Qualifications and Duties All facilities shall have a qualified and currently certified administrator...When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section... This requirement is not met as evidenced by: Based on: LPA did not observed an LIC308 Designation of Responsibility as designee on file was sleeping during this visit. This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2023

Plan of correction: Administrator/Licensee shall submit an updated LIC308 by fax on POC due date. 12/24/23

From the deficiency page — Deficiency type: Type A · Section cited: CCR87406(g) · Plan of correction due date: Dec 24, 2023

Administrator Certification Requirements Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements. This requirement is not met as evidenced by: Based on: LPA did not observe an Administrator certificate for Jose Nevarez nor supporting documents with proof of payment for renewal. This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2023

Plan of correction: Administrator/Licensee shall submit an updated Administrator Certificate and/or proof of completion by fax on POC due date. 12/24/23

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(8)(A-F) · Plan of correction due date: Dec 24, 2023

Incidental Medical and Dental Care If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. Sterile first aid dressings. Bandages or roller bandages. Scissors. Tweezers. Thermometers. This requirement is not met as evidenced by: Based on: LPA did not observe a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, tweezers, and antiseptic solution. This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2023

Plan of correction: Administrator/Licensee shall submit proof a complete kit is on the premises by fax on POC due date. 12/24/23

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(f) · Plan of correction due date: Dec 24, 2023

Personnel Requirements - General All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Based on:LPA did not observe TB results for staff during this visit. This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2023

Plan of correction: Administrator/Licensee shall submit a plan on when this will be completed with results and/or provide previous results for staff by fax on POC due date. 12/24/23

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(c) · Plan of correction due date: Dec 24, 2023

Infection Control Requirements An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by: Based on: LPA inquired with both staff regarding the Infection Control Plan. LPA did not receive an answer from either.This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2023

Plan of correction: Administrator/Licensee shall submit a plan on when this will be completed by fax on POC due date. 12/24/23

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Dec 24, 2023

Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on: LPA observed medications belonging to staff accessible and on top of refrigerator not locked.This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2023

Plan of correction: Administrator/Licensee shall submit a plan to conduct an in-service on medication management with all staff. In addition, proof of completion shall be submitted with signatures and dates by fax on POC due date. Plan -12/24/23 Inservice due -12/29/23 additional time to be requested in writing to CCL.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.618(c)(3) · Plan of correction due date: Dec 24, 2023

Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Based on: LPA did not observe current first aid/CPR certificates for staff during this visit. This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2023

Plan of correction: Administrator/Licensee shall submit a plan when training for staff has been set which is to be faxed on POC due date. Plan -12/24/23 Additional time to be requested in writing to CCL.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87506(a) · Plan of correction due date: Dec 24, 2023

Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff This requirement is not met as evidenced by: Based on: LPA observed records of residents incomplete, without signatures and dates. This violation poses a potential health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2023

Plan of correction: Administrator/Licensee shall submit a plan on when this will be completed by fax on POC due date. 12/24/23

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(c) · Plan of correction due date: Dec 24, 2023

Maintenance and Operation All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Based on: LPA observed screen at front of facility window to be not in good repair. This violation poses a potential health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 23, 2023

Plan of correction: Administrator/Licensee shall submit a plan on when this will be completed by fax on POC due date. 12/24/23

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 12/10/23 at 11AM to conduct a Required -1 Year visit. LPA met with Caregiver Elvis Perez and stated the purpose of the visit. Caregiver contacted Michelle Perez, Caregiver regarding todays visit. Administrator certificate expired 5/18/23 for Arlene Gomez. LPA did not observe an Administrator certificate for Jose Nevarez nor supporting documents with proof of payment for renewal. LPA was allowed entry into the facility that is licensed to serve 14 residents of which 6 maybe non-ambulatory in rooms 1, 4, & 5. Facility staff roster provided during this visit. The physical plant was toured inside and outside to ensure the safety of the clients. LPA observed the staff and residents preparing for lunch. LPA observed a pull alarm fire system, fire extinguisher(s), smoke and carbon monoxide detectors in the facility. The temperature inside the facility was measured at 68*F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water temperature was measured at 118.4 *F which is within the required range of 105-120*F. LPA observed during this visit regarding the first aid kit: sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, however the following were not made available: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, tweezers, and antiseptic solution. LPA observed 2 staff and 2 resident records during this visit. During file review LPA observed expired first aid/CPR certificates for staff and no results for TB. -LPA did not observed an LIC308 Designation of Responsibility as designee on file was sleeping during this visit. -LPA did not observe an Administrator certificate for Jose Nevarez nor supporting documents with proof of payment for renewal. -LPA did not observe a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, tweezers, and antiseptic solution. -LPA did not observe TB results for staff. See 809C for continuation... 809 continued... -LPA inquired with both staff regarding the Infection Control Plan. LPA did not receive an answer from either. -LPA observed medications belonging to staff accessible and on top of refrigerator not locked. - During file review LPA observed expired first aid/CPR certificates for staff. -LPA observed screen at front of facility window to be not in good repair. -LPA observed records of residents incomplete, without signatures and dates Upon a file review the following items were discussed to be submitted with any changes annually: Infection Control Plan (LIC9282), updated Designation of Facility Responsibility (LIC308), Liability Insurance, Control of Property such as rental agreement or lease agreement, Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, Emergency Disaster Plan (LIC610D). Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.the state’s words, verbatim · CDSS document, Dec 10, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Dec 11, 2023

Administrator - Qualifications and Duties All facilities shall have a qualified and currently certified administrator...When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section... This requirement is not met as evidenced by: Based on: LPA did not observed an LIC308 Designation of Responsibility as designee on file was sleeping during this visit. This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 10, 2023

Plan of correction: Administrator/Licensee shall submit an updated LIC308 by fax on POC due date. 12/11/23

From the deficiency page — Deficiency type: Type A · Section cited: CCR87406(g) · Plan of correction due date: Dec 11, 2023

Administrator Certification Requirements Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements. This requirement is not met as evidenced by: Based on: LPA did not observe an Administrator certificate for Jose Nevarez nor supporting documents with proof of payment for renewal. This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 10, 2023

Plan of correction: Administrator/Licensee shall submit an updated Administrator Certificate and/or proof of completion by fax on POC due date. 12/11/23

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(8)(A-F) · Plan of correction due date: Dec 11, 2023

Incidental Medical and Dental Care If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. Sterile first aid dressings. Bandages or roller bandages. Scissors. Tweezers. Thermometers. This requirement is not met as evidenced by: Based on: LPA did not observe a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, tweezers, and antiseptic solution. This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 10, 2023

Plan of correction: Administrator/Licensee shall submit proof a complete kit is on the premises by fax on POC due date. 12/11/23

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(f) · Plan of correction due date: Dec 11, 2023

Personnel Requirements - General All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Based on:LPA did not observe TB results for staff during this visit. This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 10, 2023

Plan of correction: Administrator/Licensee shall submit a plan on when this will be completed with results and/or provide previous results for staff by fax on POC due date. 12/11/23

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87470(c) · Plan of correction due date: Dec 11, 2023

Infection Control Requirements An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. This requirement is not met as evidenced by: Based on: LPA inquired with both staff regarding the Infection Control Plan. LPA did not receive an answer from either.This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 10, 2023

Plan of correction: Administrator/Licensee shall submit a plan on when this will be completed by fax on POC due date. 12/11/23

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Dec 11, 2023

Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on: LPA observed medications belonging to staff accessible and on top of refrigerator not locked.This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 10, 2023

Plan of correction: Administrator/Licensee shall submit a plan to conduct an in-service on medication management with all staff. In addition, proof of completion shall be submitted with signatures and dates by fax on POC due date. Plan -12/11/23 Inservice due -12/18/23 additional time to be requested in writing to CCL.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.618(c)(3) · Plan of correction due date: Dec 11, 2023

(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Based on: LPA did not observe current first aid/CPR certificates for staff during this visit. This violation poses an immediate health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 10, 2023

Plan of correction: Administrator/Licensee shall submit a plan when training for staff has been set which is to be faxed on POC due date. Plan -12/11/23 Additional time to be requested in writing to CCL.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Dec 11, 2023

Resident Records The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff This requirement is not met as evidenced by: Based on: LPA observed records of residents incomplete, without signatures and dates. This violation poses a potential health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 10, 2023

Plan of correction: Administrator/Licensee shall submit a plan on when this will be completed by fax on POC due date. 12/11/23

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(c) · Plan of correction due date: Dec 11, 2023

Maintenance and Operation All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Based on: LPA observed screen at front of facility window to be not in good repair. This violation poses a potential health, and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 10, 2023

Plan of correction: Administrator/Licensee shall submit a plan on when this will be completed by fax on POC due date. 12/11/23