Derry Way Home

Type of visit: POC

LPA Jeung reviewed correction of Type A violation cited on 7/31/26 during annual inspection, and for which proof of correction was submitted on 8/3/26. Hot water temperature tested within range of 105 - 120 degrees F. Acknowledgement of correction is given to staff--one page.the state’s words, verbatim · CDSS document, Aug 13, 2026

Type of visit: Case Management - Annual Continuation

To complete annual inspection of 7/31/26, LPA Jeung met with staff in the absence of licensee/administrator and reviewed staff files and clients' medications. Centrally Stored Medication Records are not available for review. There are 3 residents under age 60 and one resident who is over 60. Deficiencies of the California Code of Regulations, Title 22 are cited on following pages. RCFE license is issued to correct licensed capacity, which was initially issued erroneously.the state’s words, verbatim · CDSS document, Aug 13, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(h)(1) · Plan of correction due date: Aug 27, 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...visit, such as a visit summary, shall be added to the record. This requirement is not met, as date of MD report for client #1 is not clearly indicated. Licensee failed to ensure clear records that 1 out of 4 clients has an annual medical evaluation, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: Updated, signed, dated MD assessment for client #1 will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(6) · Plan of correction due date: Aug 27, 2026

INCIDENTAL MEDICAL CARE A record of centrally stored prescription medications for each resident shall be maintained and include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength and quantity, dates filled, started & expiration, prescription number and instructions. This requirement is not met, as Centrally Stored Medication Records are not available for review, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: Centrally Stored Medications Records shall at all times be maintained and accessible for licensing staff review. Proof of correction will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: Aug 27, 2026

PERSONNEL REQUIREMENTS Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met, as first-aid training for 3 out of 5 staff is not current. Licensee failed to ensure that staff who provide care have valid first-aid training, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: First aid training for staff #2, #4, #5 will be completed, and proof of correction will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.69(b) · Plan of correction due date: Aug 27, 2026

HEALTH AND SAFETY CODE Each employee who received training and passed the exam required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete 8 hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement is not met, as it cannot be verified that all staff have received annual medications training. Licensee failed to ensure that all staff who handle clients' medications has received 8 hours of annual medications training.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: Proof of required 8 hours of annual medications training for staff who handle or administer clients' medications will be sent to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Aug 27, 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, as defined in Section 87101, Definitions, 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 all clients are dated more than 12 months ago. Licensee failed to ensure annual appraisals are documented.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: Updated, signed and dated reappraisals for all clients will be sent to CCLD BY DUE DATE

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Audrey Jeung toured facility and grounds of this 2 story home, consisting of three client bedrooms on the 2nd floor--2 private and one shared--and five staff rooms on the 2nd floor--4 with a bed in each. There are two full bathrooms for staff and a full bathroom for clients on the 2nd floor, and a full bathroom on the ground floor, which consists of common areas--living room, sitting room, dining/family room, and kitchen. There is a large deck that is accessed from ground floor family room. There is a 2-car garage, where washer and dryer are located. A comfortable temperature is maintained and lighting is sufficient for comfort and safety. Water temperature is tested in main bathroom on 2nd floor. Medications, sharps, and chemicals are observed locked and inaccessible to residents. Food supplies of perishables for 2 days and non-perishables for 7 days are maintained. First aid kit is observed to be complete. Carbon monoxide detector is tested and operable. There are 4 regional center residents present, and 2 staff. Client records are reviewed. Centrally Stored Medication Records and staff records will be reviewed at a later date, due to time constraints. Yu Heung Kwok is a certified RCFE administrator (x 10/26) that oversees facility operations. The following information/forms are requested to be submitted to CCLD BY 8/14/26: - Administrative Organization (LIC309) - Designation of Administrative Responsibility (LIC308) - Personnel Report (LIC500) - Emergency Disaster Plan (LIC610E, including signed and dated page 9) - updated Facility Sketch, showing room designations Deficiencies of the California Code of Regulations, Title 22, are observed. See Technical Advisory Notes --4 pages. Report is reviewed with administrator and a copy is provided.the state’s words, verbatim · CDSS document, Jul 31, 2026

Type of visit: Required - 1 Year

On 8/6/2025 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Yvonne Kwok . LPA explained the purpose of the visit. LPA toured the facility inside and outside. Facility is a two-story house with resident rooms on the second floor. All residents are ambulatory. 2 residents arrived from day program. While touring the facility it was observed that the room temperature was at 70 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 was observed with an adequate with two day perishable and seven day non-perishable food supply. Carbon monoxide/smoke detectors, and fire extinguisher were present throughout the facility. Two resident records and two staff records were reviewed. Staff have criminal record and fingerprint clearances on file. Resident records were reviewed and were observed to be complete with documents such as Admission Agreements, Medical Assessments, and Needs and Service Plans. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. LPA received a copy of the liability insurance. No deficiencies are cited at this time. Report is reviewed with and a copy is provided.the state’s words, verbatim · CDSS document, Aug 6, 2025

Type of visit: Required - 1 Year

On 8/8/2024 LPA Grace Donato made an unannounced annual visit to the facility. LPA met with Administrator Yvonne Kwok . LPA explained the purpose of the visit. LPA toured the facility inside and outside including all of resident rooms, garage, and kitchen area. Facility is a two-story house with resident rooms on the second floor. Residents are currently in the day program. While touring the facility it was observed that the room temperature was at 68 deg F. Hot water was also tested in the bathrooms and the temperature was 110 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 was observed with an adequate with two day perishable and seven day non-perishable food supply. Carbon monoxide/smoke detectors, and fire extinguisher were present throughout the facility. Four resident records and four staff records were reviewed. Staff have criminal record and fingerprint clearances on file. Resident records were reviewed and were observed to be complete with documents such as Admission Agreements, Medical Assessments, and Needs and Service Plans. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. LPA requested LIC 500 to be emailed. LPA received copy of Liability Insurance. No deficiencies are cited at this time. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Aug 8, 2024