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Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with staff and explained the reason for the visit. Licensee Arlene Martinez arrived shortly after. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. At approx 10:50 a.m. LPA inspected the kitchen/food service area. Kitchen appliances appeared clean and to be in operable condition at the time of the visit. At approx 11:02 a.m. , LPA observed a resident watching TV in the living room and staff cleaning. Facility has a sufficient supply of perishable and non-perishable food properly stored. Food labels were inspected and checked for dates and expiration dates. The knives and sharps were observed locked and inaccessible to residents in care. LPA observed (4) resident bedrooms , which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The resident bathrooms were clean, sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured between 105 - 120 degrees Fahrenheit. Laundry area was located near hallway restroom. Cleaning supplies were locked and inaccessible to residents in care. LPA observed hallway closet to medication cabinet, first aid kit, emergency response kit and facility files all locked and inaccessible to residents in care. A sufficient supply of clean linen and towels were observed stored in a hallway closet. At the time of the visit, the common area furniture's were observed to be in good condition. LPA observed board games, cross word puzzles, a karaoke machine and other activities for residents. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers to be fully charged and purchase on 06/2026. All exits have functioning auditory devices and were operational at the time of the visit. LPA observed required postings in the entry area and throughout the facility. There is an attached garage observed inaccessible to residents in care.LPA observed garage to store, emergency water, extra incontinent supplies, PPE , as well as additional furniture and medical equipment for facility use. LPA also observed an office area to store additional facility files and a break area for staff. The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use.There is a storage shed locked and inaccessible to residents in care. LPA observed it to store extra furniture and supplies for facility use. LPA observed two (2) self-latching gate with clear passageways clear of obstruction. LPA did not observe any bodies of water during the visit. Records review, five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Six (6) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time. Medication review, medications for all residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. Administrator Cleofe Barretto arrived during review. Infection control / Emergency Disaster plan: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 06/10/2026. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator. Smoke detectors and carbon monoxide detectors were tested, all alarms were functional at the time of the visit. During today’s visit LPA obtained a copy of the facility’s LIC 500, Limited Liability Insurance and resident roster. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, Aug 24, 2026

Type of visit: Required - 1 Year

At 09:45 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted a required annual visit to the above noted facility. The LPA met with staff and explained the reason for the visit. Administrator Cleofe Barretto arrived shortly thereafter and was explained the reason for the visit. At 10:00 a.m. the LPA conducted a tour of the physical plant with staff to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of two (2) private bedrooms and two (2) shared bedrooms. Bedroom #1 and #4 have direct access outside. The LPA observed one (1) fire extinguisher which was fully charged and last purchased on 05/16/2024, during today's visit a new fire extinguisher was purchased. All smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the hallway near the entrance area. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Snacks and beverages are always available for the residents. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding. Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. At 1:50 p.m. water temperature in resident’s common restroom was measured at 109.6 degrees Fahrenheit. Report will continue on LIC809-C, 2nd page. Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There were no obstructions and/or tripping hazards throughout the facility. The garage: The LPA observed the garage where additional supplies and the emergency water is stored. Cleaning supplies and disinfectants are kept in the garage. Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises. Record Review: At 10:45 a.m. a review of facility files was initiated. The LPA reviewed five (5) out of five (5) resident files. The following was observed: Resident 1 (R1)'s negative TB test was dated over a year prior to admission, Resident 2 (R2) did not have a signed Appraisal/ Needs and services Plan, and two out five residents (R2, R3) did not have consent for Emergency Medical Treatment forms (LIC627C) on file. Otherwise, all other documents were complete and current. The LPA reviewed five (5) out of eight (8) staff files, all records were complete and current. The LPA observed documentation of Infection Control Plan and Emergency and Disaster Plan and last disaster drill conducted on 07/18/25. The LPA obtained a resident and staff roster. Medication Audit: Medications: At 1:00 p.m. a medications review was initiated for two out of five residents and the following was observed. The medications were stored locked cabinets in the hallway closet and inaccessible to the residents. Medications were properly documented on the Centrally Stored Medication and Destruction Record (CSMDR). During R1's audit, the LPA observed one Sertaline HCL 25 mg pill missing based on the start date and quantity on the CSMDR and bubble pack. During R2's audit the LPA observed that there were still 7 Imodium pills left, however based on the start date, quantity and Medication Administration Record R2 should have finished their Imodium medication by 8/5/25. The LPA observed R2 without a PRN authorization form on file, upon observation the Administrator stated that all three resident that take PRN medications do not have a PRN authorization form. Interviews: The LPA conducted one (1) resident interview, attempted to conduct a second resident interview and conducted two staff interviews. No immediate concerns were voiced. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to the Administrator.the state’s words, verbatim · CDSS document, Aug 5, 2025

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Prelicensing

At 10:00 a.m. Licensing Program Analyst (LPA) Esther Cortez conducted a pre-licensing visit to the above noted facility. The LPA met with applicants, Cleofe S Barretto and Arlene Martinez. This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver for three (3) has been requested. Component III was completed during the inspection with the applicants. The facility is a single story home. At 12:05 PM, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing the home for five (5) non-ambulatory residents in rooms #2, 3, and 4 and one (1) bedridden resident in room #1. The facility has two (2) private bedrooms and two (2) shared bedrooms. Bedroom #1 and #4 have direct access outside. All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space. The beds are furnished with comfortable mattress and clean linen; which includes, top and bottom linens, pillowcases, blanket and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. The facility does not have a staff room, therefore will have 24 hour awake staff. All rooms were free of odors. All window screens were clean and maintained in good repair. There is one (1) common restroom in the hallway and one private restroom in bedroom #4.Both resident bathrooms have showers with grab bars and non-skid materials. The hot water temperature was measured as follows: resident’s private bathroom in room #4 = 111.7 *F, and resident's common bathroom 111.9*F and the kitchen – 110.7 *F, which fall within the allowable range of 105*F to 120*F. Report continued on LIC 809-C (2ND PAGE). Resident and staff records will be stored in a locked filing cabinet in the closet located in the hallway. Medications will also be centrally stored in a locked filing cabinet in the closet located in the hallway. Knives and cleaning supplies will be stored in locked cabinets in the Kitchen. The supply of dishes, utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. The supply of perishable and nonperishable food is adequate. There was a three day supply of emergency water. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet located in the garage. No flies or other vermin were observed. The common areas were appropriately furnished, and the lighting was adequate. The facility has televisions, puzzles, coloring books, books and games for activities. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to non-private bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. The facility has emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have ceiling fans, floor fans, and pedestal fans throughout the home and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit. The facility smoke alarm system is hard wired. At 12:32 PM the smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There is one (1) fire extinguisher in the hallway leading to the garage, fully charged and do not exceed the purchase date 05/16/2024. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate. There is a functioning telephone on the premises. The emergency exiting plans/sketch, emergency telephone numbers and other required postings are posted in the entry way of the home. Report continued on LIC 809-C (3RD PAGE). The exterior passageways were clean and clear of any obstructions. There is a covered patio area with outdoor seating. The back and sides of the house are separated from the front yard by gates on each side. The garage is accessible from the house; the doors were locked from the inside of the house. Infection control practices were discussed with the applicant.. Facility has a 30 day supply of Personal Protective Equipment (PPE) on site. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted and report issued.the state’s words, verbatim · CDSS document, Aug 21, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 0 COMP II Participants: BARRETTO, CLEOFE S - Licensee/Administrator Interview Method: Telephone interview On 08/13/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Aug 13, 2024