Colonial Acres Residential Care Home

Type of visit: Required - 1 Year

On this day, November 13, 2025, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA was granted entry by staff, Maria Dolores Floriza, and informed the reason for visit. John Ronald Olivarez, licensee, arrived at around 10:56 am. Licensee left at around 4:30 pm. LPA started inspection with Maria Dolores Floriza and continued with licensee. LPA inspected the kitchen, dining area, living/tv room, common areas, bathrooms and staff room. LPA randomly selected 5 residents rooms for inspection. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked. Hot water temperature in lavatory in one of the resident's rooms was tested. Fire extinguishers were observed fully charge with tags showed serviced September 23, 2025. Disaster drill records reviewed. LPA reviewed 5 staff and 5 residents files, and interviewed 1 resident. Medications checked, and compared with LIC622 Centrally Stored Medication and Destruction Records and doctor's orders. Facility does not handle residents' cash resources. Copies of the following updated/current documents were obtained on this same day: 1. LIC610E Emergency Disaster Plan (9 pages) 2. $3M Liability insurance certificate ....continued on 809C Licensee to submit copies of the following updated documents by November 27, 2025: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report The following deficiencies were observed, cited from Title 22 California Code of Regulations, and listed on 809Ds: -at 10:45 am and 11:26 am, front and back entrance/exit doors with locks operable with code. -at 11:00 am, resident's medication in the refrigerator. -at 11:02 am to 11:04 am, knives, kitchen shears, razor, lighter in kitchen drawers without locks. -at 11:05 am, knives and cleaning agents in unlocked kitchen cabinets and Vit D3 on kitchen counter. -at 11:23 am, loose light switch cover in one the residents' rooms. -at 11:25 am, hot water temperature at 121.3 degrees Fahrenheit. -at 11:27 am, dowels in another entrance/exit door. -at 11:30 am, unlocked utility room where cleaning supplies are kept. -at 11:40 am, 2 in one smoke/carbon monoxide detector not working due to no battery. -at 12:30 pm, facility does not conduct disaster drill every quarter; records showed last conducted 01/2025 and 04/2025. -at 1:25 pm and 1:50 pm, staff (S2 and S5) CPR/First Aid/AED certificates expired 11/11/25. -at 1:35, to 1:55 pm, staff, S3 & S4, do not have the required total 40 hours required training for 2024 and 2025 respectively. No TB test and LIC503 Health Screening on file. -at 2:30 pm, residents, R1 and R2, half bed rails have no doctor's order on file. -at 2:40, residents, R2 and R3, Physician's Reports/medical assessments are over a year old. -at 2:50 pm, resident, R4, LIC625 Appraisal/Needs and Services Plan is more than 2 years old. -at 3:25 pm, resident, R5, has doctor's order for a medication to be administered daily but facility does not have this medication. Facility does not have LIC622 Centrally Stored Medication and Destruction for all the medications received by the facility nor have complete record for medications administered. A $500.00 immediate civil penalty is assessed for deficiency section 87203 and $250.00 each for repeat violations of the following sections: 87309(a); 87303(a); 87303(e)(2); 1569.695(c); 87565(a)(4); 87608(a)(3). Failure to submit proof of corrections by plan of correction due dates may result in addtional civil penalties. ....continued on 809C Deficiencies and plan and proof of corrections were discussed with licensee over the phone, and authorized Maria Dolores Floriza. Exit interview conducted. Appeal Rights, LIC421IM, LIC421FC Civil Penalty Assessments, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Nov 13, 2025

Allegation investigated: -Resident (R1) developed stage 4 pressure injury while in care. -Staff allowed resident (R1) to become severely dehydrated while in care. -Staff did not seek timely medical attention for resident (R1). -Staff left resident (R1) soiled in urine for an unreasonable period of time.

On this day, 12/20/24, at 4:10 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Mary Eileen Legados, administrator (ADM), and informed the purpose of visit. John Ronald Olivarez, licensee, arrived after about an hour. During the course of investigation, the Department obtained the following resident’s documents: medical records; LIC601 Identification and Emergency Contact Information; Physician's Report; Admission Agreement; Pre-placement Appraisal; Appraisal; Functional Capability Assessment. The following were also obtained: LIC9020 Register of Facility Clients/Residents; staff schedule. Staff were interviewed on 12/27/22 and 1/12/23 and family members (FM1 and FM2) on 1/06/23 and 1/13/24. Licensee was also interviewed on 12/27/23. Witnesses (W1 and W2) were interviewed on 1/13/24. .....continued on 9099C (page 2) Substantiated Page 2 Allegation: Resident (R1) developed stage 4 pressure injury while in care. R1 was admitted to the facility on 1/08/22, and the Pre-placement Appraisal did not indicate that R1 had a pressure injury, however, the LIC602A Physician’s Report indicated that R1 had contractures to the upper and lower extremities, required continuous bed care, had fragile skin and needed to be repositioned every 2 to 3 hours. John Olivarez, licensee, stated that R1 has dementia, was bed bound and fully contractured when admitted to the facility and that R1 was always in fetal position. Licensee stated R1 was admitted to the facility as it was their hope that R1 could get to the point where R1 could sit up on her own. R1’s pressure injury was reported to him by staff which at the time he believes it was stage 1. The pressure injury worsened Staff (S3) stated she does not believe R1 should be admitted to the facility because S3 felt that R1 needed a higher level of care. R1 has dementia and needed assistance with all activities of daily living, with both feet and hands being contractured, and R1 was difficult to reposition. S3 also stated that the first person to notice the pressure injury was R1’s previous caregiver - when this private caregiver visited R1 and changed R1’s diaper and reported the pressure injury to her. S2 stated having noticed the wound which was approximately the size of a quarter. R1 had home health but S2 was not able to report anything because she never saw them, or she was busy assisting other residents. Between the time R1’s home health was terminated to the time R1 was hospitalized, S2 was cleaning R1’s wound. In September 2022, S2 noticed R1’s wound grown to about the size of a golf ball with soft center and had some pus. Two out of 3 residents interviewed did not know or remember R1 while the other 1 stated R1 can walk but R1’s documents and staff interviewed stated R1 is bedridden. Previous administrator (S1) stated R1’s daughter requested ambulance transportation on September 2022 to the hospital per advice nurse and R1’s doctor. Medical records showed R1 was admitted to the hospital on 9/16/22 and diagnosed with stage 4 sacral pressure injury and unstageable pressure injury at right lateral pelvis. .....continued on 9099C (page 3) Page 3 FM1 stated when R1 was admitted to the facility, R1’s pressure injury in the sacrum was superficial and eventually healed after home health services for 1 to 2 months. In May 2022, the pressure injury came back and R1 was placed on home health again and was discharged when the wound was not completely healed because the home health nurse felt it was okay to discharge R1 so long as the staff continue to change the dressing and reposition R1. FM1 and FM2 stated that they visited R1 several times a week for 30 minutes to 3 hours and staff did not check R1 unless they asked. FM1 stated she visited R1 on September 2022 on R1’s birthday and R1 was lethargic, unresponsive and barely able to eat. FM1 discussed the pressure injury with R1’s physician and requested for home health service. After 2 days, R1 was visited by a home health nurse and said that the injury was too advanced to treat with home health. FM1 called 9-1-1. Medical records showed R1 was admitted to the hospital on September 16, 2022 and was diagnosed with stage 4 pressure injury in the sacrum and unstageable pressure at right lateral pelvis. Based on interviews and records review, the allegation is substantiated. Allegation: Staff allowed resident to become severely dehydrated while in care. Staff (S2, S3 and S4) interviewed provided differing information in regard to R1 eating and drinking. S3 stated R1’s eating habits were inconsistent and that at the time of admission, R1 ate well and able to drink Ensure and water. S3 stated R1 ate a little, didn’t drink much, and noticed that R1 was dehydrated. S4 stated R1’s appetite and liquid intake were good, and that R1 was able to drink half a glass of water without issue. W1 and W2 stated that when they visited R1 and requested the staff to assist in transferring to wheelchair so that W1 can feed R1, the staff responded with an assumption that R1 will not eat. W1 stated that on their last visit prior to R1’s hospitalization, R1 appeared dehydrated. R1’s family members FM1 and FM2 stated that during heat wave, the facility has electric fans spread out in the facility blowing hot air around. R1 was sweaty, hot and lethargic. FM2 stated she brought misting fan that blows water to keep R1 cool; however, when FM2 visited R1 the fan was off and R1 was sweaty. The staff blamed each other for turning off the fan. R1 was sent out to the hospital and was diagnosed with hypernatremia and septic shock due to UTI among others. Based on information obtained, the allegation is substantiated. ........continued on 9099C (page 4) Page 4 Allegation: Staff did not seek timely medical attention for resident. Medical records showed R1 developed stage 4 pressure injury in the sacrum and unstageable pressure injury at right lateral pelvis and staff did not seek medical attention. It was R1’s family member who called 9-1-1. Allegation: Staff left resident soiled in urine for an unreasonable period of time. FM1, FM2, W1 and W2 stated they observed R1 soaked in urine. W1 stated that on 2 out of the 3 visits to R1, W1 observed R1 wet with urine and on one of these 2 visits, R1 was soaking wet up to the waist and W1 asked S3 for assistance when W1 changed R1. Based on interviews, the allegation is closed as substantiated. Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099Ds. A $500.00 civil is assessed for deficiency section # 1569.269(a)(6) and will continue for $100.00/day until corrected. Deficiencies, plan and proof of corrections and civil penalty were discussed with ADM and licensee. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form, and copy of this report provided.the state’s words, verbatim · CDSS document, Dec 20, 2024 · control 15-AS-20220927100258

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Dec 21, 2024

§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs and are delivered. -This requirement is not met as evidenced by: -Based on records review and interviews, the licensee did not comply with the section above for R1 who developed stage 4 and unstageable pressure injuries which posed immediate health risk to person in care. Civil penalty is assessed.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: R1 is no longer at the facility. Licensee and administrator to read the Regulations and ensure residents are provided the proper care and supervision needed by residents. Self-certification to be submitted by 12/21/24. Licensee stated will in-service the staff. A $500.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 21, 2024

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). -This requirement is not met as evidenced by: -Based on records review and interviews, the licensee did not comply with the section above in not meeting R1's needs for allowing R1 get dehydrated which posed immediate health risk to person in care.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: Administrator to in-service the staff and submit copy of training topic with attendees signatures by 12/21/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Dec 21, 2024

87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. ...... by compliance with the following(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. -This requirement is not met as evidenced by -Based on records review and interviews, the licensee did not comply with section above for not seeking medical attention for R1 when R1’s pressure injuries progressed which posed an immediate health risk to person in care.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: Administrator to in-service the staff and submit copy of training topic with attendees signatures by 12/21/24.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(5) · Plan of correction due date: Jan 3, 2025

§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights: (5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. -This requirement is not met as evidenced by: -Based on interviews, the licensee did not comply with the section above for having R1 left soiled in urine which posed potential health and/or personal rights risks to person in care.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: Administrator to in-service the staff and submit copy of in-service training with attendees signatures by 1/03/25.

Type of visit: Case Management - Deficiencies

On this day, 12/20/24, at 4:10 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct a case management resulting from the investigation of a complaint (15-AS-20220927100258) by the Department. LPA met with Mary Eileen Legados, administrator (ADM), and informed the purpose of visit. John Ronald Olivarez, licensee, arrived after about an hour. During investigation, the Department observed the following: 1. Resident's (R1) LIC602A Physician's Report dated 1/25/22 indicated the following: non-ambulatory and bedridden; contractures on lower & upper extremities; advanced frontotemporal dementia; fractured pelvis (unable to rehabilitate). The staff interviewed indicated R1 needs to be repositioned. LIC9020 Register of Facility Clients/Resident was bedridden. 2. LIC602A showed R1 was dependent on others with all activities of daily living (ADLs). 3. R1's LIC9172 Functional Capability Assessment was incompletely filled-up. Deficiencies are cited from Title 22 California Code of Regulations and listed on 809Ds. A $500.00 civil is assessed for deficiency section # 87202(a)(2) and will continue for $100.00/day until corrected. Deficiencies, plan and proof of corrections and civil penalty were discussed with licensee and ADM. Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, LIC9098 Proof of Correction form, and copy of this report provided.the state’s words, verbatim · CDSS document, Dec 20, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: Dec 21, 2024

87202 Fire Clearance: (a) All facilities shall maintain a fire clearance approved by...... Prior to accepting or retaining any of the following types of persons.... licensee shall .... obtain an appropriate fire clearance approved by city, county, tor district..... ....(2) Bedridden persons. -This requirement is not met as evidenced by: -Based on record review and interviews, the licensee did not comply with the section above when R1 who is bedridden was admitted and facility does not have bedridden fire clearance.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: R1 is no longer at the facility. Administrator to review all residents files and check their ambulatory status. Proof to be submitted by 12/21/24. A $500.00 civil penalty is assessed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87615(a)(5) · Plan of correction due date: Jan 3, 2025

87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:(5) Residents who depend on others to perform all.... ... activities of daily living for them.... -This requirement is not met as evidenced by: -Based on record review and interviews, the licensee did not comply with the section above when R1 who is dependent on others will all ADLs was admitted which posed a potential health risks to person in care.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: Licensee and administrator to read the Regulations and ensure no resident with prohibited health conditions is admitted to the facility. Self-certification to be submitted by 1/03/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Jan 3, 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 is not met as evidenced by: -Based on records review, the licensee did not comply with the section in R1's incomplete LIC9172 which posed a potential health, safety and/or personal rights risks to person in care.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: Administrator to review all residents files and complete the records. Self-certification to be submitted by 1/03/24.

Type of visit: Required - 1 Year

At 12:30 pm on this day, November 14, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with John Ronald Olivarez, licensee, and informed the reason for visit. LPA also met with staff, Maria Dolores Floriza, Macario Balingit, Jackylen Mendoza and Celeste Olivarez. LPA toured the facility inside out with licensee. LPA inspected the kitchen, dining area, living/tv room, common areas, staff and laundry room, bathrooms, side and backyard. LPA randomly selected 6 residents rooms for inspection. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked. Facility has 2 in 1 carbon monoxide detector that was tested and observed in operating condition. Hot water temperature in the common bathroom was tested. Disaster drill records reviewed. Fire extinguishers were observed fully charge with tags showed serviced September 17, 2024. LPA reviewed 5 staff and 5 residents files, and interviewed 2 residents. Medications checked, and compared with LIC622 Centrally Stored Medication and Destruction Records and doctor's orders. Facility does not handle residents' cash resources. The following updated/current documents were obtained on this same day: 1. LIC308 Designation of Facility Responsibility 2. LIC500 Personnel Report 3. LIC610E Emergency Disaster Plan (9 pages) Licensee or administrator to submit by November 28, 2024 a copy of $3M Liability insurance certificate. ....continued on 809C (page 2) Page 2 The following deficiencies were observed, cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections by plan of correction due dates may result in civil penalties. -at 12:35 pm, the 3 entrance/exit doors with no auditory signals. -at 12:39 pm, residents medications in 2 refrigerators unlocked. -at 12:44 pm, cleaning supplies/agents in unlocked cabinet in the kitchen. -at 12:47 pm, peritoneal cleanser and broken drawer in residents' room. -at 12:50 pm, wound cleanser in the cabinet under the sink in another resident's room. -at 12:55 pm, wound dressing, saline solution, grooming kit in the night stand drawer in another resident's room. -at 1:01 to 1:03 pm, insect killer, wound cleanser, staff medications, liquid laundry soap, Clorox spray in unlocked staff's room. -at 1:12 pm, water temperature at 127.4 degrees Fahrenheit. -facility has new administrator who took over the position when Adeliza Magallones resigned in September 13, 2024 and licensee failed to notify the Department. -at 2:30 pm, records showed disaster drills last conducted July 6 and 9, 2024. -at 4:00 pm. resident (R2) was discharged back to the facility on 7/2024 with LIC602A Physician's Report indicated stage 3 pressure injury and dependent on others with all activities of daily living (ADLs); however, R2 is able to feed self. LIC625 not updated. -at 5:00 pm, all 5 resident's half bed rails do not have doctor's order on file. -at 5:45 pm, resident (R1) doctor's order for Acetaminophen is 650 mg tablet, 2 tablets PRN but the medication in facility's hand is 325 mg tablet, 2 tablet PRN. Has doctor's order for Vascepa but facility does not have this medication. Order for ducosate sodium is 50 mg 1 capsule daily but medication on hand is 100 mg twice daily. Order for Atorvastatin is 20 mg 1 tablet at bedtime but medication on hand is 10 mg 1 tablet at bedtime and facility administers 10 mg. Order for Amlodipine is 5 mg once daily and the medication on hand is 10 mg once daily. ...continued on 809C (page 3) Page 3 -at 7:00 pm, resident (R5) doctor's order for prenisolone is 1 mg, 3 tablets daily but medication on hand is 1 mg, 1 tablet daily and facility administers only 1 mg 1 tablet daily. Has PRN order for Senna and Lorazepam and facility does not have these medications. Deficiencies and plan and proof of corrections were discussed with licensee. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Nov 14, 2024

Allegation investigated: Licensee did not keep resident's (PR) personal information confidential.

At 12:05 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Adeliza Magallones, administrator, and informed the reason for visit. LPA spoke over the phone with John Ronald Olivarez, licensee. During investigation, LPA obtained copy of LIC9020 Register of Facility Clients/Residents. LPA interviewed licensee who stated he did not disclose the name of prospective resident (PR) but disclosed the health information to prospective room mate (R1) and R1''s family member, but PR was never admitted to the facility. LPA also interviewed the administrator who stated that PR was not admitted to the facility. Review of LIC9020 showed PR is not listed. Based on information obtained and FR is not admitted to the facility, the allegation is unsubstantiated. No deficiency cited. Exit interview conducted and copy of this report provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 20, 2024 · control 15-AS-20240617080839

Type of visit: Case Management - Other

On this day, June 20, 2024, an LIC9102 Technical Advisory is being issued resulting from investigation of complaint (15-AS-20240617080839) conducted by Licensing Program Analyst (LPA) Delmundo. The license admitted to disclosing health information of prospective resident to prospective roommate (facility resident). LPA discussed the above with the licensee and administrator. No deficiency cited. Exit interview conducted, and copy of this report provided.the state’s words, verbatim · CDSS document, Jun 20, 2024

Type of visit: POC

On this day, April 19, 2024, Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct proof of correction (POC) visit. LPA met with Adeliza Magallones, administrator, and informed the reason for visit. On 4/11/24, LPA conducted the first POC visit for the citations issued on 3/21/24 with POCs to be submitted by 4/04/24. Licensee failed to submit the POCs by the due and civil penalties were assessed on 4/11/24. Most of the documents (POC) requested for one of the deficiencies, section # 1569.269(a)(3), were only submitted by the licensee on 4/16/24. Additional civil penalty is assessed for deficiency section # 1569.269(a)(3). Civil penalty = $100.00/day x 5 days (from 4/12/24 to 4/16/24)= $500.00 Civil penalty was discussed with the Adeliza Magallones. Exit interview conducted. Appeal Rights, LIC421FC Civil Penalty Assessment, and copy of this report provided.the state’s words, verbatim · CDSS document, Apr 19, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct proof of correction (POC) visit. LPA met with Celeste Olivarez, facility consultant, and Adeliza Magallones, administrator, and informed the reason for visit. On 3/21/24, LPA issued citations for the following deficiencies with POCs to be submitted by 4/04/24. Licensee failed to submit the POCs up to this day. Civil penalties are assessed on this day, 4/11/24, and will continue for $100.00/day until POCs are submitted:. 1. Complaint Investigation deficiency section # 1569.269(a)(3). Licensee has not submitted proof that documents were released. nor responded to the reporting party's request and follow-ups. Civil penalty = $100.00/day x 7 days (from 4/05/24 to 4/11/24)= $700.00 2. Case management deficiency section 87405(a). Magallones who stated she quit as administrator on 12/31/23 and came back 4/03/24; however, licensee failed to submit proof that a full time administrator is hired. Civil penalty = $100.00/day x 7 days (from 4/05/24 to 4/11/24)= $700.00. In order to satisfy the POC, licensee to submit the following: signed letter indicating Magallones has been re-hired with effective date she took the position; copy of current administrator certificate; LIC500 Personnel Report POCs and civil penalties were discussed with the Celeste Olivarez and Adeliza Magallones. Exit interview conducted. Appeal Rights, LIC421FCs Civil Penalty Assessments, LIC9098 Proof of Correction form, and copy of this report provided.the state’s words, verbatim · CDSS document, Apr 11, 2024

Allegation investigated: Licensee not providing prompt access to or photocopies of resident (R1) records.

At 3:45 p.m. on this day, March 21, 2024, Licensing Program Analyst (LPA) Delmundo ariived unannounced to investigate the above allegation. LPA met with Ethel David, staff, and Celeste Legazpi, facility consultant, and informed the reason for visit. LPA requested to call John Ronald Olovarez, licensee, who arrived after several minutes. During investigation, LPA intervieed the reporting party (RP), staff (S1 and S2), R1's responsible person (FM) and licensee. .....continued on 9099C Substantiated RP stated several attempts were made starting from February 2, 2024 to March 5, 2024 requesting for R1's documents. Requests via mail and e-mails were made with signed authorization from FM to release the documents to RP. Phone calls were also made by RP, and licensee has not responded to the request. LPA interviewed FM who confirmed she signed the document for the release of the documents to RP. LPA interviewed S1 and S2 who confirmed receiving calls and/or emails from RP and licensee was informed. Licensee stated he received the request but has not responded to the request and emails nor returned RP's calls. Based on information obtained, the preponderance standard has been met, therefore the allegation of "Licensee not providing prompt access to or photocopies of resident (R1) records" is substantiated. Deficiency is cited per Title 22 California Code of Regulations, and listed on LIC9099D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the licensee. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 21, 2024 · control 15-AS-20240314140353

From the deficiency page — Deficiency type: Type B · Section cited: CCR 1569.269(a)(3) · Plan of correction due date: Apr 4, 2024

§1569.269 Enumerated rights; severability (a) .....(3) To confidential treatment of their records and personal information and to approve their release, except as authorized by law. -This requirement is not met as evidenced by: -Based on interviews, the licensee did not comply with the section above for not releasing the requested documents.the state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: Licensee to release the documents, and submit proof by 4/04/24.

Type of visit: Case Management - Deficiencies

While at the facility investigating a complaint (Control # 15-AS-20240314140353), Licensing Program Analyst (LPA) Delmundo obtained information that the facility does not have an administrator. LPA called and spoke with Adeliza Magallones who stated she quit as administrator December 31, 2023, John Ronald Olivarez, licensee, stated that they have a certified administrator, Angeline Bangi. LPA interviewed Bangi who stated she stsrted working at the facility on February 2024 and works only either Wednesday or Thursday from 1:00 p.m. or 2:00 p.m. to 5:00 p.m.. Bangi stated she does not intend to work 20 hours per week as administrator as she has other full time job. Staff (S1) was interviewed and confirmed Bangi only comes ether Wednesday or Thursday and works only 3 or 4 hours per week. Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D. Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty. Deficiency and plan and proof of correction were discussed with the licensee. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Mar 21, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Apr 4, 2024

87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator.... The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the .facility as specified in this section......... -This requirement is not met as evidenced by: -Based on interviews, the licensee did not comply with the section abuve for not having administrator in January 2024 and the new administrator working only at most 4 hours per week.the state’s words, verbatim · CDSS document, Mar 21, 2024

Plan of correction: Licensee to hire a full time administrator, and submit proof by 4/04/24.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Delmundo arrived unannounced to conduct an annual required inspection. LPA met with Adeliza Magallones, administrator, and informed the purpose of the visit. LPA also met with Celeste Olivarez, facility consultant, and staff, Mary Eileen Olivarez-Legados, Ethel David, Bonifacio Flores and Maria Dolores Floriza. Facility has Infection Control Plan that was submitted on June 30, 2022. LPA toured the facility inside out with Adeliza Magallones and Mary Eileen Olivarez-Legados. LPA inspected the kitchen, dining area, living/tv room, common areas, staff and laundry room. bathrooms, side and backyard. LPA randomly selected 5 residents rooms for inspection. Food supplies were observed good for 2 days of perishables and 7 days of non-perishables. Central storage for medications was observed locked. Facility has 2 in 1 carbon monoxide detector that was tested and observed in operating condition. Hot water temperature in one of the common bathrooms was tested and measured at 119.2 degrees Fahrenheit. LPA reviewed 5 staff and 5 residents files, and interviewed 3 staff and 3 residents. Medications checked, and compared with records and doctor's orders. Facility does not handle residents' cash resources. The following updated/current documents were obtained on this same day: 1. LIC308 Designation of Facility Responsibility 2. Proof of $3M liability insurance coverage Administrator to submit the following updated documents by November 23, 2023: 1. LIC500 Personnel Report 2. LIC601E Emergency Disaster Plan (9 pages) ......continued on 809C Page 2 The following deficiencies were observed and cited from Title 22 California Code of Regulations, and listed on 809Ds. Failure to submit proof of corrections (POCs) by plan of correction due dates, and any repeat violations within 12 month period may result in civil penalties. -at 11:04 am, medicines in the medicine box with broken lock in the refrigerator. -at 11:06 am, expired sour cream with mold. -at 11:19 am Albuterol inhaler solution in the drawer in one of residents rooms. -at 11:24 am, shave cream, shaver glucose lancets, ointment in another resident's room. -at 11:42 am unlocked utility room where bleach and cleaning supplies are kept. -at 11:52 am, unlocked storage in the backyard where bleach and other cleaning supplies are kept. -at 12:30 pm, LPA asked the administrator who stated they haven't conducted disaster drill since last year. -at 2:15 pm, S1's first aid certificate expired 6/05/23 -at 2:50 pm, S3 has no first aid training, no annual training record and no LIC503 Health Screening and TB test record on file -at 3:15 pm. S4 and S5's first aid certificate expired 11/26/21 -at 5:00 pm, R1's LIC602A Physician's Report indicated needs assistance with all ADLs. -at 5:20 pm, R3's LIC602A is over a year old -at 5:30 pm, 5 out of 5 residents' LIC625 AppraisalNeeds and Services Plan do have residents' representative signatures. -at 6:05 pm, R1 has order for 4 medications but facility does not have on hand. Medications filled on 2023 and dates started not recorded on LIC622 Centrally Stored Medication and Destruction Record. No doctor's order on file for half bed rails. Deficiencies and plan and proof of corrections were discussed with the administrator and Mary Eileen Olivarez-Legados. Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.the state’s words, verbatim · CDSS document, Nov 9, 2023