Cristo Rey Cottage Assisted Living

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Sister Cecilia Marie, Resident Care Assistant and explained the purpose of the visit. Shortly after, Gabrielle McDonald, administrator arrived and assisted LPA. The facility is licensed to care for age range 60 and over, approved for (28) non ambulatory, of which (8) may be bedridden and approved hospice waiver for (12). There are currently (22) residents, of which (1) is under hospice care and (3) bedridden residents. LPA did not utilize the Compliance and Regulatory Enforcement (CARE) tools for the visit today as the tool was not available for this visit/facility type visit combination. LPA observed the following: Infection control practices and Personal Protective Equipment (PPEs) were observed. Infection Control Plan was last reviewed/updated on 07/29/2025. Staff are trained on the emergency infection control plan and following hand hygiene techniques. The facility does not have a dementia waiver and does not accept or retain residents with dementia. Liability Insurance is valid and expires on 06/15/2027. The most recent fire drill was last conducted on 05/22/2026. The facility is a 2 story craftsman style home located in the Santa Teresita Campus. The facility consists of: First floor: lobby, dining room, living room with covered fireplace, kitchen, office, den, activity room, medication room, laundry room, storage rooms, electrical room, boiler room and (10) resident rooms. Second floor: activity room, living room, office, medication room, laundry room, storage rooms, electrical room, staff break room and (11) resident rooms. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there is an outdoor fountain located in the open courtyard. Cleaning supplies and toxic substances are inaccessible to residents. LPA tested hot water temperature in (4) random resident rooms (Rooms #D5, #D10, #D27 and #D28) in the first & second floors. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The facility has fully charged fire extinguishers which were serviced on 05/21/2026. *****CONTINUED ON LIC809-C***** A total of (36) staff members provide care and supervision to the residents. LPA reviewed (5) staff files. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Proof of staff training, health clearance and 1st Aid/CPR training are current. Administrator's certificate is valid and expires on 01/25/2028. Resident personal rights, complaint hot line information and visitors policy posters are posted. Facility provides internet services to all residents and have access to the facility phone. There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly activity calendar is posted. The facility has a Resident Council and meet on a monthly basis. The kitchen was inspected, and there is sufficient food supply consisting of 2-day perishables and 7-day non-perishables. Sanitation practices and kitchen cleanliness was observed. Medications were reviewed containing 30-day supply of medications. The facility uses eMAR system, Point Click Care (PCC) medication management to administer medications. Medications are kept in medication carts that are centrally stored in locked medication rooms. A complete first aid kit is maintained. Medical and dental transportation is provided. A total of (4) resident files were reviewed including Admission Agreements, Physician's Reports, Pre Placement Appraisal, TB clearance, Appraisal/Needs Services Plan, Physician's Orders, Medical Consent, and Medication Records. Emergency and Disaster Plan was reviewed/updated on 08/01/2026 and evacuation chair at each stairway is in place. (1) resident uses oxygen and a "no smoking oxygen in use" sign was posted in the appropriate area. Exit interview conducted and a copy of this report was provided to Gabrielle McDonald, administrator.the state’s words, verbatim · CDSS document, Sep 14, 2026

Allegation investigated: Staff are not assessing residents for a higher level of care Staff are not checking on residents in a timely manner Untrained staff providing care to residents

The purpose of this report today 5/21/2026 is to gather additional information pertaining to the above allegations. The initial visit was conducted on 4/10/2026 and included the following: LPA obtained Staff and Resident Rosters. Copies of staff and med-tech training's were submitted. Interviews were conducted with Staff S1-Staff S4 and with Sister Cecilia Marie, Care Assistant. Interviews were conducted with Resident's R1-R9. At today's visit 5/21/2026 Resident's R1-R6 were interviewed. Resident's R7 and R8 refused to be interviewed. Resident's R9-R11 were interviewed. Sister Magdalene Grace and Staff S1 were interviewed. In regards to the allegation Staff are not assessing residents for a higher level of care, based on interviews conducted and information gathered it was revealed by 9 out of 9 residents that they were able to communicate what their name and date of birth were. While being interviewed all 9 were able to Unsubstantiated communicate their feelings about the staff, residents and the facility. All stated that there are not any residents with Dementia. Review of 9 out of 9 residents Physician's Report in which there was not dementia diagnosis listed. Staff interviewed stated that there are no Dementia residents at this facility. Said that all residents communicate their wants and needs. Stated that they are all alert. Nothing on the scale of Dementia. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff are not checking on residents in a timely manner, based on interviews conducted and information gathered it was revealed by 9 out of 9 residents that staff are wonderful and that they are always there to help them. They are very caring. All 9 residents also stated that staff do not administer medication for them and they independently can leave the facility and walk around and it's their choice to stay in their room. Also stated they have pendants that they can use and staff respond immediately. All stated that staff respond in a timely manner. Staff stated that they do respond in a timely manner. Said they have a call lite system that is located by the residents bed and bathroom. Said it is a very efficient system that alert staff on their phones when a resident is asking for assistance. Response is very quick being that most of the residents are independent in their Activity's of Daily Living (ADL's.) Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Untrained staff providing care to residents, based on interviews conducted and information gathered it was revealed by 9 out of 9 residents that staff are well trained and that the food staff, caregivers and med-techs carry out their job duties very efficiently. Staff interviewed stated that they have gone through hours of training which included shadowing other staff. Stated that only nurses assess residents and other staff don't make a decision on residents care. Also stated that there is an agency that comes into the facility and provides nursing care such as labs and x-rays so the resident does not have to leave. It is the family's decision. Caregiver training reviewed which included 8 hours facility practices and procedures and 6 hours Caring for Residents with Dementia. Training document was signed by the employee, trainer and Supervisor. Med-Tech Training was reviewed which included Special Needs of the Elderly 1 hour, Delivering Personal Care 8 hours, Psychosocial Care 2 hours, Responding to Resident Emergencies 3 hours, Caring for Residents with Dementia 6 hours, Successful Completion of all Hands on Checklists 16 hours (hands on training).Document was signed by the employee, trainer and supervisor. Medication Administration Skills Checklist Document was implemented and signed by the employee and supervisor. Also Rellias Training Program a software training program was completed by Staff and included Infection Control and Medication procedures. At today's visit 5/21/2026 Sister Magdalene Grace stated that the Dementia training is covered because even if non-dementia waiver the topic should be covered. Staff S1 stated it is helpful to cover Dementia Training so staff will be knowledgeable on signs to look for if residents have Cognitive Impairment and can recognize signs that might lead to Dementia. Regarding Activities there is a calendar posted each month. Sister Magdalene Grace and Staff S1 both stated that at breakfast the daily activities are discussed. Resident's R1-R6 and R9-R11 stated they get an Activity's calendar each month and it is also posted. All stated staff discuss the activities daily at breakfast. Stated that there is exercise class, bingo, dominoes, arts and crafts and knitting. LPA observed May 2026 Activity calendar which included exercise, painting, arts and crafts, spoon races, trivia, movie matinee, puzzle club, horseshoe toss, crosswords, roulette and coloring. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and copies provided.the state’s words, verbatim · CDSS document, May 21, 2026 · control 28-AS-20260407140427

Allegation investigated: Staff are not assessing residents for a higher level of care Staff are not checking on residents in a timely manner Untrained staff providing care to residents

Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced complaint visit to investigate the above-mentioned allegations. LPA was greeted by Staff S1 and shortly thereafter met with Sister Cecilia Marie, Care Assistant and explained the purpose of the visit. The investigation consisted of the following: LPA obtained Staff and Resident Rosters. Copies of staff and med-tech training's were submitted. Interviews were conducted with Staff S1-Staff S4 and with Sister Cecilia Marie, Care Assistant. Interviews were conducted with Resident's R1-R9. In regards to the allegation Staff are not assessing residents for a higher level of care, based on interviews conducted and information gathered it was revealed by 9 out of 9 residents that they were able to communicate what their name and date of birth were. While being interviewed all 9 were able to communicate their feelings about the staff, residents and the facility. All stated that there are not any residents with Dementia. Review of 9 out of 9 residents Physician's Report in which there was not dementia diagnosis listed. Unsubstantiated Staff interviewed stated that there are no Dementia residents at this facility. Said that all residents communicate their wants and needs. Stated that they are all alert. Nothing on the scale of Dementia. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Staff are not checking on residents in a timely manner, based on interviews conducted and information gathered it was revealed by 9 out of 9 residents that staff are wonderful and that they are always there to help them. They are very caring. All 9 residents also stated that staff do not administer medication for them and they independently can leave the facility and walk around and it's their choice to stay in their room. Also stated they have pendants that they can use and staff respond immediately. All stated that staff respond in a timely manner. Staff stated that they do respond in a timely manner. Said they have a call lite system that is located by the residents bed and bathroom. Said it is a very efficient system that alert staff on their phones when a resident is asking for assistance. Response is very quick being that most of the residents are independent in their Activity's of Daily Living (ADL's.) Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. In regards to the allegation Untrained staff providing care to residents, based on interviews conducted and information gathered it was revealed by 9 out of 9 residents that staff are well trained and that the food staff, caregivers and med-techs carry out their job duties very efficiently. Staff interviewed stated that they have gone through hours of training which included shadowing other staff. Stated that only nurses assess residents and other staff don't make a decision on residents care. Also stated that there is an agency that comes into the facility and provides nursing care such as labs and x-rays so the resident does not have to leave. It is the family's decision. Caregiver training reviewed which included 8 hours facility practices and procedures and 6 hours Caring for Residents with Dementia. Training document was signed by the employee, trainer and Supervisor. Med-Tech Training was reviewed which included Special Needs of the Elderly 1 hour, Delivering Personal Care 8 hours, Psychosocial Care 2 hours, Responding to Resident Emergencies 3 hours, Caring for Residents with Dementia 6 hours, Successful Completion of all Hands on Checklists 16 hours (hands on training).Document was signed by the employee, trainer and supervisor. Medication Administration Skills Checklist Document was implemented and signed by the employee and supervisor. Also Rellias Training Program a software training program was completed by Staff and included Infection Control and Medication procedures. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted and copies provided.the state’s words, verbatim · CDSS document, Apr 10, 2026 · control 28-AS-20260407140427

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required-1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Care Assistant, Sister Cecelia Cuesta and Sister Magdelene Grace, Administrator and LPA explained the purpose of the visit. The facility is licensed to care for 28 non-ambulatory, of which eight (8) may be bedridden. Approved hospice waiver for 12. The initial annual visit was conducted on 09/25/2025. During the initial visit the following seven (7) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Infection Control, Operational Requirements, Physical Plant/Environmental Safety, Resident Rights-Information, Planned Activities, Food Services, and Disaster Preparedness. During today’s annual visit, the following five (5) Compliance and Regulatory Enforcement (CARE) tool domains were observed and reviewed: Staffing, Personnel Records-Training, Resident Records-Personnel Reports, Incidental Medical & Dental, and Residents with Special Health Needs. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Staffing: A total of (43) staff members provide care and supervision to the residents, including the Administrator. LPA reviewed five (5) staff files. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated to the facility. Personnel Records-Training: LPA reviewed five (5) staff files which includes personnel record, criminal background clearance, health screening, TB clearance, Staff Training, Medication Administration Training, Employee Rights, and valid 1st Aid/CPR/AED training. Administrator on file is current; certificate is valid and will expire on 10/23/2026, Incident Medical and Dental: Residents are assisted with self-administration of prescription and non-prescription medications. LPA reviewed five (5) centrally stored resident medication records. Centrally stored medications are kept in a safe and locked place not accessible to residents in care. Medications are given according to Physician directions. The first Aid kit had all the required items. Medical and dental transportation is provided. Resident Records/Incident Reports: LPA reviewed five (5) resident files containing Face Sheet, Admission Agreements, Physician's Report, Ambulatory Status, TB clearance, Pre-Placement Appraisal, Appraisal/Needs and Services Plan, and Personal Rights. Residents with Special Health Needs: Per Administrator, (0) resident is under hospice care, (1) bedridden resident, (0) resident receiving home health services and (2) residents using oxygen have "No smoking in use" signs posted. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview and a copy of this report were provided to Administrator, Sister Magdelene Grace.the state’s words, verbatim · CDSS document, Oct 9, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Daniel Konishi conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Sister Magdelene Grace and Administrator and Miguel Angel Gonzalez, Maintenance Technician/Supervisor and explained the purpose of the visit. Sister Magdelene Grace and Administrator and Miguel Angel Gonzalez, Maintenance Technician/Supervisor helped assist with the visit. The facility is licensed to care for 28 non-ambulatory, of which eight (8) may be bedridden. Approved hospice waiver for 12. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has an Infection Control Plan in places. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Emergency and disaster plan was completed and up to date. Operational Requirements: The Infection Control Plan has been added to the Plan. The facility does not have a Dementia Waiver in place. A Hospice Waiver for (12) is approved. A fire clearance is in place. The facility has valid Liability Insurance in place. Last fire drill was last conducted on 07/29/2025. Physical Plant/Environment Safety [Cont.]: The facility is a 2-story building located in a residential community. The facility consists of: First floor: lobby, dining room, living room, kitchen, office, den, activity room, medication room, laundry room, storage rooms, electrical room, boiler room and (10) resident rooms. Second floor: activity room, living room, office, medication room, laundry room, storage rooms, electrical room, staff break room and (11) resident rooms. LPA toured the facility with S1 and observed six (6) resident bedrooms, containing required furniture, lamps, dresser, chair, and closet space. Physical Plant/Environment Safety [Cont.]: The three bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, shower chair, and non-slip floor. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. LPA tested hot water temperature in (6) random resident rooms (Rooms #D3, #D7, #D10, #D20, #D27 and #D29) in the first & second floors. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The facility has ten (10) fully charged fire extinguishers, last serviced on 05/23/2025. Carbon Monoxide detectors were tested and operable. Resident Rights-Information: Resident personal rights, complaint hotline information and visitors’ policy posters are posted. Facility provides internet services and access to the facility telephone for all residents. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly activity calendar is posted. The facility has a Resident Council and meet on a monthly basis. Food Service: Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. Sufficient food supply is stored in the kitchen consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Kitchen has utensils for residents to use and to store their meals. Pesticides and cleaning supplies are kept away from the food preparation areas. Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least two (2) relocation sites. LPA observed the evacuation chair mounted by the stairway. ***Due to time constraints, LPA was not able to complete the annual inspection for this facility. LPA will do a continuation of this inspection at a later date.*** Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit. Exit interview and a copy of this report were provided to Administrator, Sister Magdelene Grace.the state’s words, verbatim · CDSS document, Sep 25, 2025

Allegation investigated: Staff is refusing to accept resident back after hospital stay.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced complaint visit to investigate the above-mentioned allegation. LPA met with Sister Cecilia Marie, OCD, Care Assistant and explained the purpose of the visit. Shortly after, Sister Magdalene Grace, OCD, BSN Care Coordinator arrived and assisted LPA with the investigation. The investigation consisted of the following: LPA toured the facility's common areas and obtained/reviewed a copy of the current Staff/Resident rosters and interviewed Staff #1 (S1). In regards to the allegation: "Staff is refusing to accept resident back after hospital stay." LPA reviewed the Resident roster (dated 03/25/2025) and found Resident #1 (R1) who was allegedly referred to in the complaint is not included in the list of residents on the facility's roster. LPA interviewed Staff #1 (S1) who confirmed that R1 does not live at this facility and stated that R1 resides at the sister facility that is adjacent to this licensed facility. Therefore, the complaint was filed against the incorrect facility. This agency has investigated the complaint alleging " Staff is refusing to accept resident back after hospital stay." Based on the information gathered during this visit, and the staff interviews, the allegation is deemed UNFOUNDED. A finding of UNFOUNDED means that the allegation is either false, could not have happened, and/or is without a reasonable basis. We have therefore dismissed the complaint. No deficiency cited. An exit interview was conducted, and a copy of this report was provided to Sister Magdalene Grace, OCD, BSN Care Coordinator. Unfoundedthe state’s words, verbatim · CDSS document, Mar 27, 2025 · control 28-AS-20250321153543

Allegation investigated: Staff physically abused resident in care.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit to investigate the above allegation and deliver finding. LPA met with Sister Magdalene Grace, OCD, BSN Care Coordinator and discussed the purpose of today's visit. During the initial visit on 09/17/2024, LPA conducted a tour of the facility's common areas and obtained/reviewed copies of Resident & Staff Rosters, Resident #1 (R1) files, Care notes, Podiatrist appointment/notes/instructions, Unusual Incident/Injury Report (Nov. 2022-Mar. 2024), Hospital contusion notes/instructions, Medication Review Report and photo of R1's bruised right foot. LPA also obtained copies of Staff #6 (S6) files. LPA interviewed Staff #1 (S1) - Staff #3 (S3) and telephonically interviewed Staff #4 (S4). On 09/18/2024, LPA telephonically interviewed Staff #5 (S5) - Staff #6 (S6). During today's visit, LPA conducted a tour of the facility and obtained copies of Resident & Staff Rosters, and R1's Podiatry Progress Notes (09/11/2024). LPA interviewed Resident #1 (R1) - Resident #5 (R5). *****CONTINUED ON LIC9099-C***** Unsubstantiated The investigation reveals the following: In regards to the allegation: “Staff physically abused resident in care.” It is alleged that R1 may have been physically abused by a staff due to bruising, discoloration and swelling observed on R1's right foot. (6) of (6) staff interviewed denied the allegation and stated that they care for the residents and would never harm them. S6 stated that if R1 was stomped on her foot, she would have screamed and other staff could have heard her due to the proximity of her bedroom to the kitchen where staff are present at all times. Based on file reviews and interviews, on 9/07/2024, while R1 was being assisted by S4, R1 was slowly slipping down and was lowered to the floor to sit, no noted injury. The following day, S2 and S6 were assisting R1, when S2 noticed that R1's right foot toes were bruised. Staff reported it to S3 and provided first aid on R1 but no hospitalization required. On 9/09/2024, S1 promptly made a podiatry appointment for R1. And on 9/11/2024, R1 was seen by the podiatrist and had her ingrown toenail removed. Doctor's notes indicated that R1 fell and hurt her foot, with the right big toe being the site of the ingrown toenail. Documentation reviewed revealed that R1 has history of falls and contusion. (4) out of (5) interviewed residents denied the allegation and stated that the staff/caregivers are caring and have never caused harm to them. (5) out of (5) residents stated that they feel safe and comfortable in the facility. During the visit, LPA observed that R1's room is located next to the kitchen where (2) staff members are working. Based on documentation reviewed and interviews conducted with residents and staff, there was not enough supportive evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Exit interview and a copy of this report was provided to Sister Magdalene Grace, OCD, BSN Care Coordinator.the state’s words, verbatim · CDSS document, Sep 20, 2024 · control 28-AS-20240916115742

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was met by Sister Cecilia Marie, Resident Care Assistant and Miguel Angel Gonzalez, Maintenance Technician/Supervisor and explained the purpose of the visit. Shortly after, Sister Marie Estelle OCD, Chief Executive Officer assisted LPA with the inspection. There are currently (20) residents, 60 years and older residing in the facility, of which (1) is under hospice care and (0) bedridden resident. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. Staff are trained on the emergency infection control plan and following hand hygiene techniques. Emergency and disaster plan was completed and up to date. Operational Requirements: The Infection Control Plan has been added to the Plan. The facility does not have a Dementia Waiver in place. A Hospice Waiver for (12) is approved. A fire clearance is in place. Liability Insurance is valid and expires on 06/15/2025. Last fire drill was last conducted on 04/29/2024. Physical Plant/Environment Safety: The facility is a 2-story building located in a residential community. The facility consists of: First floor: lobby, dining room, living room, kitchen, office, den, activity room, medication room, laundry room, storage rooms, electrical room, boiler room and (10) resident rooms. Second floor:activity room, living room, office, medication room, laundry room, storage rooms, electrical room, staff break room and (11) resident rooms. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. Cleaning supplies and toxic substances are inaccessible to residents. LPA tested hot water temperature in (6) random resident rooms (Rooms #D3, #D5, #D10, #D23, #D28 and #D31) in the first & second floors. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. The facility has eight (8) fully charged fire extinguishers, last serviced on 05/10/2024. *****CONTINUED ON LIC809-C***** Staffing: A total of (43) staff members provide care and supervision to the residents, including the Administrator. LPA reviewed (5) staff files. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Personnel Records-Training: (5) staff files reviewed. Proof of staff training, health clearance, vaccinations, food handling certificates, and 1st Aid/CPR training are current. Administrator on file is current, certificate is valid and will expire on 12/23/2024. Resident Rights-Information: Resident personal rights, complaint hotline information and visitors policy posters are posted. Facility provides internet services to all residents and have access to the facility phone. Planned Activities: There is sufficient space to accommodate both indoor and outdoor activities. LPA observed sufficient equipment and supplies to accommodate residents with special needs to meet the requirements of the activity program. Monthly activity calendar is posted. The facility has a Resident Council and meet on a monthly basis. Food Service: Sufficient food supply is stored in the kitchen consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness was observed. Kitchen has utensils for residents to use and to store their meals. Pesticides and cleaning supplies are kept away from the food preparation areas. Incident Medical and Dental: Medications were reviewed containing 30-day supply of medications. Medications are centrally stored. A complete first aid kit is maintained. Medical and dental transportation is provided. Resident Records/Incident Reports: A total of (5) resident files were reviewed. They contained Admission Agreements, Physician's Reports, Pre Placement Appraisal, TB clearance, Functional Capability Assessment, Physician's Orders, Medical Consent, and Medication Records. Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and evacuation chair at each stairway is in place. Residents with Special Health Needs: Currently, (1) resident is under hospice care, (0) bedridden, (0) resident receiving home health services and (2) residents using oxygen have "No smoking in use" signs posted. Inspection Tool was completed and no Title 22 deficiencies are being cited on todays' visit. Exit interview conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 9, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrative Assistant Nathan Nemeth. The following (CARE) tool domains were utilized during the inspection: Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. An Infection Control Plan was observed Physical Plant/Environment Safety: The facility is a two story building. The first floor consists of a dining room, living room, kitchen, activity room, medication room, laundry room, storage rooms, electrical room, boiler room and 10 resident rooms. The second floor consist of an activity room, living room, office, medication room, laundry room, storage rooms, electrical room, staff break room and 11 resident rooms. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction. Cleaning supplies and toxic substances are inaccessible. There are no open bodies of water Water temperature readings measured within title 22 regulations. Operational Requirements: A current Plan of Operation observed. The facility has an approved fire clearance for a capacity up to twenty-eight (28) Non-ambulatory residents of which ip to eight (8) may be bedridden. The Licensee has a Hospice Waiver for 12 residents. Facility is operating within the scope of its fire clearance Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Continued on LIC 809-C Personnel Records - Staff Training: Administrator on file is current . Certificate is active Staff have criminal background clearances. Five(5) staff files were reviewed. Required documents and training's observed Staffing: Sufficient staff observed during visit. At least one on each shift has CPR training Administrator on schedule sufficient amount of time Signal system in resident rooms were observed and operational. Resident Records - Incident Reports: A total of six (6) resident files were reviewed. Required documents observed on file Resident Rights - Information Required postings observed Food Service: Sanitation practices and kitchen cleanliness was observed. Kitchen has utensils for residents to use and to store their meals No cleaning supplies stored near food Sufficient supply of perishables and non perishables was observed Incident Medical and Dental: First Aid Kid observed (6) of (6) Resident medications reviewed. Medications are centrally stored. Disaster Preparedness: Emergency and Disaster Plan observed Evacuation Chairs observed at each stairwell Residents with Special Health Needs: Currently (0) residents receiving hospice services. Inspection Tool was completed and no Title 22 deficiencies are being cited on todays visit. Exit interview conducted and a copy of this report was providedthe state’s words, verbatim · CDSS document, Feb 15, 2024