Chloie's Cottage

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual inspection. LPA was greeted by staff and the purpose of the visit was explained. Administrator Shorok Kharwish arrived shortly after. The facility is licensed to serve six (6) elderly residents age 60 and above. All residents may be non-ambulatory. The facility is approved for a maximum of three (3) residents on hospice. The facility is a single-story home located in a residential area of San Dimas. The home consists of a kitchen, dining area, living room, (3) resident bedrooms, (2) bathrooms, an office space, staff room, laundry/storage space, and a backyard. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Doors, exits, hallways, and passageways were clear and free of obstruction. The front yard and back yards were observed to be clean and free of debris. There is an outdoor shaded seating area in a covered patio with sufficient seating for clients. No pools or bodies of water were observed in or around the home. Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. Carbon monoxide detector was observed by the front entry, tested and operational. Smoke detectors are located throughout the facility. continued on LIC809C LPA inspected three (3) resident rooms. All residents’ bedrooms contained required furniture and linens all in good repair. Water temperatures in all grooming and bathing areas were measured to be 113.7 °F and 109°F, which is within the 105° – 120° F requirement. LPA observed grab bars near toilets and inside showers. A fire extinguisher was observed. Auditory devices on doors were observed to be in working order. Dining area was clean with sufficient seating. Living room was observed clean and free of obstructions with sufficient seating. LPA observed a variety of food supplies, facility has at least 2 days of perishables and 7 days of non- perishable food supplies. An additional refrigerator was observed in the storage area Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Kitchen was kept clean and free of litter, rodents, vermin and insects. LPA reviewed three (3) staff files. Files contained background clearance, personnel record, and training for each staff. 1 of 3 staff records reviewed did not contain a health screening with TB clearance. Deficiency cited. Centrally stored medications were observed locked in a kitchen cabinet. LPAs reviewed four (4) residents files and each contained admission agreement, medical assessment, TB clearance, pre-appraisal, and appraisal. The facility has a current emergency disaster plan LIC 610E(3/19) last reviewed on 07/05/26. Emergency drills are conducted quarterly, last emergency drill was conducted on 07/01/26. Fire extinguisher located in the kitchen, last serviced 06/2026. Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during today’s visit are documented on the LIC 809D. Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided to Administrator Shorok Kharwish.the state’s words, verbatim · CDSS document, Jul 14, 2026

Allegation investigated: Staff are locking and isolating a resident inside of the facility. Staff are not allowing a resident to file complaints.

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint visit to investigate the above allegations. LPA met with Administrator Iren Creighton and explained the purpose of today's visit. The investigation consisted of the following: On 8/21/2025 LPA reviewed Medications and Medication Administration Record for 5 residents, Reviewed 5 Resident Files, interviewed 3 staff and 4 residents, LPA attempted to interview 2 additional residents, however, due to cognitive disabilities the interviews were not successful. LPA interviewed responsible party for Resident #1 prior to leaving facility. During todays visit 8/23/2025 LPA delivered findings on the above allegations. (continued on the LIC9099-C page) Unsubstantiated The investigation revealed the following: Allegation: Staff are denying a resident from making phone calls. It is alleged that staff do not allow R1 to use the facility phone. LPA interviewed 4 residents and 3 out of 4 residents denied the above allegation and stated although they have not needed to make any phone calls they do not believe staff will restrict them of making any calls. LPA observed location of phone to be within the locked staff office that also holds all secured resident and staff files. During interviews with Staff, S2 stated that recently the phone has been relocated from the kitchen to the staff office as R1 has made unnecessary 911 calls. Interviews with 5 staff, each denied the above allegation and stated that residents are allowed to use the facility phone, however, when R1 asks to use the phone, they ask who R1 will be calling and often times staff will dial the number for R1 and give privacy for the phone call, staff added that this is done due to R1 making unnecessary 911 calls. S1 and S3 also confirmed S2’s statements. LPA reviewed R1s file and did not observe any notes of R1 making false/non-emergency 911 calls, there was no change of condition due to this being a continuous issue, there has been no reappraisal done for resident on how staff will assist resident with these new alleged behaviors and LPA reviewed Special Incident Reports (SIR’s) that have been sent to the department and there were no SIR’s received for these alleged 911 calls. LPA asked administrator for any notes on these alleged 911 calls and Administrator could not provide that information. Allegation is Substantiated. Allegation: Staff are mishandling a resident's medications. It is alleged that staff are not providing R1 with their prescribed medicine. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation and stated that residents are provided with medications that are prescribed by their physician and given per the doctors orders. LPA interviewed 4 residents and 3 out of 4 residents denied the above allegation and stated they are provided with their prescribed medications. LPA conducted a medication review and LPA observed R1’s medications to have dates that were not with complete medications (medications are prepackaged by day/time), when LPA asked staff why the dates were not matching, S2 and S3 stated that they recently took over medication administration and the medications were like that when they started and they have been pulling the correct medication but from future dates to ensure resident is still being administered the correct medication. During medication review LPA also noticed R1 to have a medication that is not listed within the doctors medication list nor the residents physician report, LPA also noticed that R5 was missing 1 routine medication and 1 PRN from their prescribed medications these medications were listed on R5’s current physician report dated 5/6/2025. Allegation is Substantiated. (Continued on LIC9099-C page) Additionally, during medication review LPA noticed that the Medication Administration Record (MAR) was not being signed for after administering medication to residents when LPA questioned staff, S3 stated that the medications have been administered they just sometimes forget to sign the MAR. Signatures were missing for 4 out of 14 medications for R1. This will be cited on a separate case management visit. Based on LPAs observations, interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview held, and a copy of this report and appeal rights were provided. The investigation revealed the following: Allegation: Staff are locking and isolating a resident inside of the facility. It is alleged that staff put R1 in a different room, isolated them and locked the door. Interview with R1 revealed that they are ambulatory, however, there have been times a chair has been left at the entrance of their room making it difficult to exit their room but the door has never been locked and they have never been confined in their room. LPA interviewed a total of 4 residents and 3 out of 4 residents denied the allegation and stated they have never been locked or isolated by staff at the facility. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation and stated they do not lock or isolate residents in their room and that R1 is ambulatory which allows them to ambulate freely throughout the facility. LPA interviewed 4 residents and 4 out of 4 residents denied the above allegation and stated that they are not locked or isolated in their rooms, when LPA questioned staff about placing a chair in front of R1’s room each staff denied doing that or witnessing other staff do that. Allegation is unsubstantiated. Allegation: Staff are not allowing a resident to file complaints. It is alleged that the facility staff does not allow residents to file complaints to the Department. LPA observed the complaint poster at entrance hallway along with ombudsman poster and residents rights signage, that is displayed clearly and in an area all residents access. LPA interviewed 5 staff and 5 out of 5 staff denied the above allegation and stated that the residents are free to file complaints and make phone calls to do so. LPA interviewed 4 residents and 3 out of 4 residents denied the above allegation and stated they have never needed to file a complaint and don’t think they would be prevented of doing so. Allegation is unsubstantiated Based on statements and interviews conducted with staff/residents, and LPA observations, there was not enough supportive evidence to concur with the reported allegations. 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. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 23, 2025 · control 28-AS-20250820121118

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Aug 24, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by: During medication review LPA observed 1 medication within R1's prescribed medications to not have a doctors order documented for it, additionally R5 was missing 1 routine medication and 1 PRN from their prescribed medications these medications were listed on R5’s current physician report dated 5/6/2025.the state’s words, verbatim · CDSS document, Aug 23, 2025

Plan of correction: Licensee/Administrator to obtain current medication lists for each resident and must have all medications that are listed in their prescribed medication boxes and submit photos of proof to LPA via email by POC due date. tena.herrera@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(14) · Plan of correction due date: Sep 1, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (14) To have reasonable access to telephones, to both make and receive confidential calls. The licensee may require reimbursement for long distance calls. This requirement was not met as evidence by: LPA observed facility phone to not be reasonably accessible to residents as it has been moved from the kitchen to the locked staff office. R1s calls are being monitored, per staff R1 allegedly calls 911 for non emergency matters but there was no documentaion or poof porvided to LPA of these alleged calls and continuous behaviors.the state’s words, verbatim · CDSS document, Aug 23, 2025

Plan of correction: Licensee/Administrator to make phone accessible to all residnets and a training on all residnet personal rights must be conducted with all staff that include the right to make and receive confidential phone calls. The training must be completed by POC due date and a copy of the training materials and participant sigatures must be emailed to LPA by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced Case Management visit regarding deficiencies noted during a complaint investigation for complaint # 28-AS-20250820121118 conducted on 08/21/2025. LPA met with Administrator Iren Creighton and the purpose of the visit was discussed. Case Management findings: On 08/21/2025, LPA reviewed resident medications and Medication Administration Records (MAR) and these records revealed that staff are not properly documenting the MAR as signatures were missing for 4 out of 14 medications for R1 and when LPA questioned staff, S3 stated that the medications have been administered they just sometimes forget to sign the MAR. This did not meet the requirement per Title 22 regulations- 87506(a)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. Based upon this observation and record review, LPA will issue one (1) Type B Deficiency. Exit interview was conducted. A copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 23, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Sep 1, 2025

87506 Resident Records (a) 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 was not met as evidence by: During review of resident medications and MAR records it was revealed that staff are not properly documenting the MAR as signatures were missing for 4 out of 14 medications for R1.the state’s words, verbatim · CDSS document, Aug 23, 2025

Plan of correction: Licensee/Administrator to provide a training for all staff that assist with medication, training should include proper safe keeping of medication, procedures on how to administer medication and proper record keeping of medications. Training must be completed by POC due date and a copy of the training materials and participant signatures shall be emailed to LPA by POC due date. tena.herrera@dss.ca.gov

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced annual inspection visit using the CARE tool. LPA met with Fe Abejo Caregiver and explained the reason for the visit. The facility is licensed to serve (6) elderly residents age 60 and above of which all may be non-ambulatory, and a hospice waiver for (3). The facility is located in a residential area and consist of a single home with a kitchen, dining room, living room, (3) resident bedrooms, (2) bathrooms, an office space, staff room,laundry/storage space, and a backyard. The following domains were reviewed during this visit: Infection Control: Facility maintains a copy of infection control and was last reviewed on 7/1/25. All staff have a TB clearance. Operational Requirements: Facility maintains a plan of operation, infection control plan, fire clearance. Facility is operating within the limitations of their license. They currently don't have residents under hospice care. A current liability insurance was observed and a copy was obtained. Physical Plant/Environmental Safety: LPA toured the facility with Fe Abejo caregiver and observed the following. Facility was observed in good repair. Living room has a fireplace with a metal cover and it is furnished. Dining room was observed with furniture and in good repair. Kitchen was observed clean, a large pair of scissors was observed in a small drawer without a lock which was moved by staff to a drawer with a lock which was unlock at the time of the visit were knives and sharps are stored. Refrigerator/freezer and pantry were observed. Medication cabinet is located in the kitchen area. Passage ways were observed clear of obstructions. Back porch and side porch were observed with old furniture clutter around, A ripped chair cushion chair was also observed. Garage space has been converted into an office space, a staff room, and laundry/storage area. (CONT. 809C) Three (3) resident rooms were observed with sufficient lighting, required furniture and bedding supplies. Room #1 and #2 were each observed with one bed with two half bed rails combine making it a full bed rail, and a bed with a full bed rail and Room #3 was observed with 3/4 bed rails in each bed. Door in bedroom #2 leading to a passage way which exits the facility did not have a sound device. Sound device was not working at the time of the tour on door exiting to back porch which leads to outside passageway. Two (2) bathrooms were observed in good repair, however shower floors were observed with soap buildup and mold in the corners. Water temperature was tested in each bathroom sink and tested between 112.8-114.2 degrees F., which is within the required 105-120 degrees F. There are no large bodies of water at the facility. Carbon Monoxide/Smoke detectors were tested and are in working condition. A fire extinguisher was observed. Staffing: Administrator certificate was reviewed for Linda Renard #7008248740 exp. date: 5/3/25. CPR/First aid training was observed for staff. A living staff is on duty during the night shift. Personnel Records/Staff Training: LPA reviewed 5 staff files. Files were available for review. Files include; TB clearance, health screening, background clearance, personnel record, and training for each staff. Two staff were interviewed. Resident Rights/Information: License, Let us Know (PUB 475), Ombudsman, personal rights posters were posted in the entrance of the home. Planned Activities: Facility provides activities such as board games, puzzles, books and music and crafts provider. Food Services: Although LPA did not observed a variety of food supplies, facility has at least 2 days of perishables and 7 days of non- perishable food supplies. An additional refrigerator was observed in the storage area. Kitchen was observed clean and free of pest. Cleaning supplies were observed stored in storage space. Staff were observed practicing hygiene and infection prevention. Four out of five residents have a modified diet per medical assessments. Incidental Medical and Dental: Facility provides assistance with medical/dental arrangements and with medication assistance. Medications were observed stored in locked medication cabinet. LPA reviewed medication for 5 residents. Resident Records/Incident Reports: LPAs reviewed 5 residents files, each contained admission agreement, medical assessment, TB clearance, pre-appraisal, and appraisal, 3 out of 5 residents did not have a medical assessment within the last 12 months. Three residents were interviewed. Disaster Preparedness: LPAs reviewed emergency disaster plan LIC 610E(3/19) last reviewed on 7/1/25. Emergency drills are conducted quarterly, last emergency drill was conducted on 7/2/25. (CONT. 809C) Residents with Special Health Needs: Facility is only serving 1 resident on Home Health Care, no bedridden, no hospice residents. Assistant Administrator Iren Creighton notified LPA that the facility is going under a change of ownership. Deficiencies are noted on LIC 809D per Title 22 Regulations. Exit interview was conducted with Iren Creighton Assistant Administrator and a copy of this report, LIC 809D, and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 18, 2025

The state marks this report as 9 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: Staff do not have fingerprint clearance

Licensing Program Analyst (LPA) Jose Villalobos conducted an unnannounced subsequent complaint investigation visit for the allegation listed above. LPA met with Staff Maria Blanco and the purpose of the visit was discussed. As of today, LPA has completed the following: LPA has toured the physical plant, Interviewed staff #1-4 (S1-S4), interviewed residents #1-6 (R1-R6), interviewed witnesses #1-2 (W1-W2), collected copies of the residents roster, staff roster, and collected copies of resident and staff files pertaining to the allegations. Staff #5 (S5) is not an employee at this time as was unavailable for interview. The investigation revealed the following: Continued on LIC 9099-C Substantiated In regards to the allegation "Staff do not have fingerprint clearance" it was alleged that S5 worked at this facility without fingerprint clearance. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff interviews stated S5 did work one (1) day at the facility. It was an emergency and due to staff shortage S5 worked. S5 did not return to work at this facility any longer. The exact date was not provided to LPA. Staff was not able to provide LPA fingerprint clearance for S5. Interview stated it is possible S5 had an exempted clearance for working at another facility but was not able to provide that to LPA. This shows the facility failed to verify S5 fingerprint clearance prior to having S5 work at the facility. Based on LPA observations, interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 1), are being cited on the attached LIC 9099D. An exit interview was conducted. A copy of this report, Plan of Correction, and appeal rights were discussed and provided. In regards to the allegation "Residents are being sexually abused in the facility and staff do not intervene" it is alleged that dementia residents are sexually molested by other residents and staff do not intervene. LPA was provided a name but the person named is not a resident or staff of the facility. (4) of (4) Staff denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Residents interviewed denied any sexual abuse and were not aware of that occurring in this home. Staff denied ever hearing of any sexual abuse incidents in the home and were not aware of it ever happening. File review does not show any documents on file related to the allegation. In regards to the allegation "Staff consume liquor while on shift" it is alleged staff drink alcohol while on shift. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff interviewed denied drinking alcohol on shift and denied knowledge of anyone drinking alcohol in the facility. Residents interviewed were not aware of any staff drinking on shift. LPA did not observe any alcohol in the facility. LPA was not provided further information regarding which staff drink on shift. In regards to the allegation "Staff lock facility doors to prevent residents from leaving" it is alleged night staff place locks high on the doors so they can sleep and prevent the residents from leaving the facility. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Residents denied having issues with leaving the facility when they want to and denied knowledge of observing staff sleeping while on shift. LPA's did not observe locks placed high on the facility doors. There were no door locks observed to be used to prevent residents from leaving their rooms or the facility. In regards to the allegation "Staff insert suppositories to residents in care" it is alleged staff insert suppositories into residents and are not trained to. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff stated there are no residents who require suppositories and if they did, it would be a procedure done by a certified nurse. Residents interviewed denied needing a suppository at any point while being in the facility. LPA reviewed residents medication files and did not observe any prescribed suppository medication. In regards to the allegation "Staff did not complete required training" it is alleged facility staff do not have training. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff interviewed were able to describe the training they complete yearly as caregivers. LPA reviewed training documentation on file and observed staff training to be completed per title 22 regulations. Residents interviewed stated to not have issues with the staff regarding their duties. CONTINUED ON LIC 9099-C In regards to the allegation "Staff facility records are falsified" it is alleged staff have fake CPR training cards and health screenings. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff interviewed denied falsifying any documents. Residents were not able to provide any information regarding staff files. LPA reviewed staff CPR certificates on file to be in order. Health screening documents for staff on file were also completed as required by Title 22 Regulations. LPA was not provided with proof that any records were falsified. In regards to the allegation "Staff did not maintain resident records" it is alleged that residents do not have current physicians reports and resident rosters on file. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff interviewed stated resident physicians are kept up to date and any changes are documented. LPA reviewed all resident physicians report on file to be completed within the last year. Resident roster was also reviewed. File review showed resident records to be maintained. In regards to the allegation "Staff do not ensure residents are provided with adequate food and food service" it is alleged the facility staff does not purchase enough food for the residents. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff interviewed stated groceries are purchased weekly. There has been no shortage of food in the home. Residents were not aware of any shortage of food in the facility. LPA observed the facilities food supply to be adequate. In regards to the allegation "Staff are not providing residents with adequate care and supervision to meet the residents needs" it is alleged that staff are not meeting residents grooming and toileting needs.(4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Residents interviewed did not show there was an issue with their grooming or toileting needs not being met. Staff stated they provide assistance to residents daily and anytime they request it. LPA observed staff assisting residents in care throughout the visits. File review showed that the care residents received match the needs and services plan. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation(s). 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 allegation(s) are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided. In regards to the allegation "Staff did not inform resident’s physician of resident’s change of condition" it is alleged residents have health conditions not addressed with their physicians. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. LPA was not provided with information as to which resident had a change in condition not addressed. Residents interviewed did not state there were any issues or changes in their health conditions not being addressed. Resident files were reviewed and needs and service plans were up to date. In regards to the allegation "Staff did not provide adequate medication assistance to residents in care" it is alleged that staff do not provide the residents medications as prescribed. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Residents stated to be receiving their medications with no issue. Staff interviewed stated to be providing residents their medication as prescribed. LPA reviewed residents medications and did not observe any errors or missed medications. In regards to the allegation "Staff refuse to call an ambulance for residents in care" it is alleged that when residents ask for ambulance assistance the staff refuse to call. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Residents interviewed denied that they have ever been refused ambulance assistance by staff when needed. The staff interviewed stated they will always call an ambulance when needed and have not denied residents that right. In regards to the allegation "Staff threaten and yell at residents in care" it is alleged that staff yell and threaten residents when they ask for help. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Residents interviewed stated they have never been yelled at or threatened by staff. Staff interviewed denied ever yelling or threatening any of the residents in care. LPA did not observe staff speaking inappropriately to residents in care during the visits. In regards to the allegation "Centrally stored medications are accessible to residents in care" it is alleged that the key for the locked medication is out in the open where residents can grab it. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Residents interviewed were not aware of where the key to the locked medications was kept only that staff had access to them. Staff denied that the keys for the medication cabinet are out in the open. A staff on shift will carry the keys everyday. LPA observed the medication was locked in a cabinet and the staff had the key. The key was not accessible to residents in care. Continued on LIC 9099-C In regards to the allegation "Staff do not have a fire evacuation plan at the facility" it is alleged that the facility does not have an evacuation plan in place in case of emergency.(4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff interviewed stated there is an emergency disaster plan in place that includes an evacuation plan for any emergency. LPA reviewed the emergency disaster plan on file. In regards to the allegation "Staff do not have an infection control plan at the facility" it is alleged the facility does not have a completed infection control plan. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. Staff interviewed stated there is a completed infection control plan in place and procedures to follow if needed. LPA was provided an infection control plan and it was reviewed during the visit. The facility did have a completed infection control plan. In regards to the allegation "Staff are not following reporting requirements" it is alleged that Incident reports are falsely written and not all incidents are reported. (4) of (4) Staff interviewed denied the allegation. (6) of (6) Residents interviewed could not corroborate the allegation. LPA was not provided with specific dates or incidents not being reported correctly. Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation(s). 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 allegation(s) are UNSUBSTANTIATED. Exit interview held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 3, 2025 · control 28-AS-20241119143625

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Feb 4, 2025

87355. Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department This was not met as evidenced by: S5 working 1 day at the facility prior to fingerprint clearance being verified or obtained. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Feb 3, 2025

Plan of correction: S5 no longer works in the faciltiy. POC cleared at the time of this visit.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Assistant Administrator Maria Blanco at approximately 12:09 PM and explained the reason for the visit. Facility is licensed to serve elderly residents aged 60 and above. All residents may be non-ambulatory. Facility approved for Three residents on hospice. The facility a single-story home and consists of three (3) shared resident Bedrooms and two (2) Resident Bathrooms, dining room, living room, TV room, staff room, office, and patio/deck area. LPA toured the facility and observed the following: Each resident’s bedroom has the required furniture and bedding. There is extra clean linen and towels in hallway closet. Smoke detectors were observed in each room and throughout the facility and are properly operating. There is 1 carbon monoxide in the dining room and is properly operating. The facility has one (1) fully charged fire extinguishers which is kept in the kitchen. Cleaning supplies and toxic substances are inaccessible to clients in a locked storage in garage. Freezers are maintained at a temperature of 0-degree F and the refrigerators at a maximum of 45 degrees F. Sufficient supply of 7 days non-perishable foods was observed in the kitchen. There was not enough 2-day perishable food deficiency cited. There is an extra refrigerator and freezer in garage that did not have much food. There are no firearms or weapons stored at the facility. The hot water temperature in the bathrooms were measured between the range of 128.6-129.7 degrees F that does not meet title 22 regulations deficiency cited. Bathrooms have the required grab bars and nonskid mats in bathrooms. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating area for the residents located in the backyard. Passageways and exits are free of obstruction. Four (4) staff files were reviewed and included Criminal clearance record, CPR/training, and health screening with TB. Six (6) residents files were reviewed and included physicians report, TB clearance. Last fire/earthquake drill was conducted in April of 2024. Infectious control plan was reviewed. Four (4) out of six (6) residents’ medications were reviewed. Medications are centrally stored in kitchen in locked cabinet. Deficiencies have been noted on LIC 809D under Title 22 Regulations. Exit interview was conducted and a copy of this report, LIC 809D and appeal rights were provided to Maria Blanco.the state’s words, verbatim · CDSS document, Jul 11, 2024