Damenik's Home

Type of visit: Case Management - Annual Continuation

To complete annual inspection of 6/30/26, LPA Jeung reviewed resident records, including clients' centrally stored medications. The following updated information/forms are requested to be submitted to CCLD BY 8/5/26: - Proof of current liability insurance - Administrative Organization (LIC309-2 pages) - Designation of Administrative Responsibility (LIC308) - Emergency Disaster Plan (LIC610E, including page 9, signed and dated) Deficiencies of the California Code of Regulations, Title 22, are cited on following page. See also Technical Advisory Note--one page--for additional information.the state’s words, verbatim · CDSS document, Jul 22, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(h)(1) · Plan of correction due date: Aug 5, 2026

REAPPRAISALS The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every 12 months, either in person or by video appointment. Documentation of the annual routine visit... shall be added to the resident's record. Documentation of a resident's refusal to receive an annual routine visit...shall be added to the resident's record. This requirement is not met, as MD reports for 6 out of 7 clients are dated over 12 months ago, altho MD signed medication lists are dated in 2026. No MD identified for client #3 MD report.the state’s words, verbatim · CDSS document, Jul 22, 2026

Plan of correction: MD assessments for Clients #2, #3, #4, #6, #7, #8 will be updated and documented annually. Proof of correction will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Aug 5, 2026

REAPPRAISALS The pre-admission appraisal... shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition... and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met, as appraisals for 4 out of 8 clients are dated over 12 months ago.the state’s words, verbatim · CDSS document, Jul 22, 2026

Plan of correction: Appraisals or Needs and Services Plans for clients #2, #4, #6, #8 will be updated and documented annually. Proof of correction will be sent to CCLD BY DUE DATE

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds of this 2 story RCFE. No accessible bodies of water or fire safety hazards are observed. There are 4 client bedrooms, full bathroom, dining/TV room, staff room, and 1-car garage on the ground floor and 4 client bedrooms, full and half bathroom, kitchen, living/dining room on the second floor. The backyard is level, fenced and can be accessed from exterior stairs from second floor. Carbon monoxide detector is tested as operational. Washer and dryer are located in one car garage. Each resident is issued a pendant alarm, which transmits an audible alert to staff in kitchen, that identifies the resident. Food supplies are adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Hot water temperature tested at 109 degrees F in ground floor bathroom. Soap and paper towels are present in bathrooms and kitchen sink. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There is one resident receiving hospice services. Criminal record clearances or exemptions for facility staff or other individuals who have client contact are reviewed, as well as other staff and training records. Client records, including Centrally Stored Medications Records, will be reviewed at a later date, due to time constraints. Danilo Montillo and Nicole Montilla are certified RCFE administrators (x 11/26 & x 2/27) that oversee facility operations. The following information/forms are requested to be updated and submitted to CCLD BY 7/14/26: - Proof of current liability insurance - Administrative Organization (LIC309) - Designation of Administrative Responsibility (LIC308) - Emergency Disaster Plan (LIC610E) Updated Personnel Report (LIC500) is provided to LPA today. No deficiencies of the California Code of Regulations, Title 22, Division 6, are cited. See Technical Advisory Notes--3 pages--for additional information.the state’s words, verbatim · CDSS document, Jun 30, 2026

Type of visit: Required - 1 Year

On 7/16/2025, LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Care Staff Maria Alday then Co-Administrator Nicole Montilla followed after. LPA explained the purpose of the visit. LPA toured the facility inside and outside including all of resident rooms, garage, and kitchen area and backyard. Facility is a 2-story home. LPA observed residents having morning exercises and have just finished breakfast. While touring the facility it was observed that the room temperature was at 70 deg F. Hot water was also tested in the bathrooms and the temperature was 106 deg F. The facility is observed to be clean, odorless, and well maintained. Residents bedrooms were observed to be well organized and fully furnished with adequate lighting. Sharps and toxic materials were observed locked. Food supply in kitchen and pantry was observed with an adequate two day perishable and seven day non-perishable food supply. Carbon monoxide/ smoke detectors, and fire extinguisher were present throughout the facility. Facility has an updated log for emergency drill is done every quarter. Seven resident records and five staff records were reviewed. Centrally stored medication was locked and inaccessible by residents. All medication was labeled and sorted by resident name. All medication logs are complete and updated. Administrator will send the Liability Insurance to LPA. LPA received copy of LIC500. No deficiencies cited today. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Jul 16, 2025

Type of visit: Required - 1 Year

On 8/13/2024, Licensing Program Analysts (LPA's) Tobola & Jian conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Caregiver Staff, Maria "Tess" Alday. Assistant Administrator, Matt Montilla was contacted and arrived later in the visit. The facility currently provides care for 11 residents, 1 of which are receiving hospice services and some of which with a diagnosis of dementia. LPA's continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 10/6/2023. Carbon monoxide detectors found in both upstairs and downstairs hallways, were tested and found to be functioning. Smoke detectors are inspected by local fire inspection agency with last inspection dated 1/26/2024. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings, enough for residents in care. LPA's however, observed multiple items including milk, fruits and eggs expired or with mold. Medications were observed unsecured in kitchen refrigerator, accessible to residents. Cleaning supplies and other toxins are safely stored in locked cabinets in the, bathroom, garage and under kitchen sinks, all of which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. Water measured at faucets accessible to residents measured between 106.7 and 109.4 degrees F and within regulation. Residents that were awake during the inspection were observed interacting with staff in the common area, or in their bedroom resting. The facility encourages regular family visits and utilizes common and outdoor space for resident exercise and mobility. The outdoor patio is equipped with shade with sufficient space for resident use. Continued onto LIC809-C During inspection LPA's observed 2 auditory alarms in resident bedrooms inoperable, and is required for residents with dementia. LPA conducted a sample file review for 4 residents and found all items to be in order. LPA's provided technical support on facility to provide additional information on resident Needs & Service Plans. Technical Violation. Upon a sample review of staff files, LPA's found all staff to have 1st aid and CPR and annual training up to date. Lastly, during a spot medication check, LPA's found that 1 out of 1 resident was missing a single dose of prescribed medication. In addition, facility was found to have pre-poured medication 2 days prior and not stored in original container. During inspection, LPA's observed resident (R1) with a bedridden status but had recently graduated from hospice services. A physician's assessment for R1 was conducted today 8/13/2024 with pending physician's report. LPA to follow up on R1's ambulatory status and determine findings at a later date. Danilo Montanilla's Administrator Certificate 7035451740 is currently active through 11/26/2024. LPA requested the following documents be sent to CCL by COB 8/27/2024: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Client’s/Resident’s Liability Insurance Pest Control Receipt Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.the state’s words, verbatim · CDSS document, Aug 13, 2024