Devonshire Elderly Care

Allegation investigated: Staff bribed resident in exchange for not reporting complaints.

At 9:30 am, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent complaint visit to investigate the above stated allegation. LPA met with the Staff #1 (S1) Farrah Siddiqui and the House Manager was contacted via telephone. LPA explained the reason of the vist. The House Manager informed LPA that they are unable to come to the facility and designated the staff to sign and receive today's report. To investigate the allegation above LPA conducted an initial visit on 08/11/2026. LPA obtained copies of client and staff roster and other pertinent information including but not limited to Physician’s Report, Admission Agreement, Appraisal Needs and Services Plan, the pest-control product purchase receipt, and etc., relevant to the course of investigation. LPA conducted a physical plant tour.Interviews were conducted with the House Manager, two (2) staff members (S1 & S2), and six (6) out of six (6) residents. Continue on LIC 9099C Unsubstantiated Allegation: Staff bribed resident in exchange for not reporting complaints. It was alleged that facility staff offered or provided R1 with money in exchange for not reporting complaints against the facility. To investigate this allegation, LPA interviewed the House Manager, two (2) staff members, and six (6) residents. The House Manager denied offering or providing R1 with money and stated that, after R1 moved out, R1 requested $10,000 and threatened to take the facility to court regarding the reported insect issue. The House Manager denied providing any money or instructing R1 not to report complaints. S1 denied knowledge of any payment or agreement involving R1. S2 stated that S2 began working at the facility approximately four (4) months ago, after R1 had moved out, and therefore had no knowledge of interactions between R1 and facility staff. S2 also reported no knowledge of any current residents being offered money in exchange for not reporting complaints. The six (6) residents interviewed did not report hearing or observing any arrangement involving payment to R1 in exchange for not reporting complaints. Based on interviews and information obtained, there was insufficient evidence to establish that facility staff offered or provided money to R1 in exchange for not reporting complaints. Therefore, this allegation is deemed Unsubstantiated at this time. Exit interview conducted and appeal rights explained. Copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Aug 26, 2026 · control 31-AS-20260806082953

Allegation investigated: Staff does not ensure facility is kept free of pests for residents in care. Staff does not ensure food is kept free of foreign objects. Staff had inappropriate conversations with resident in care.

At 9:45 AM, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced initial complaint visit to investigate the above stated allegations. LPA met with Staff #1 (S1) who granted access to the facility. S1 contacted the House Manager via telephon and LPA explained the reason for the visit. During course of the investigation, interviews and record review were made. At 9:55 AM, LPA requested client and staff roster. At 10:05 AM, LPA requested copies of pertinent information which include, but not limited to Physician Report, Admission Agreement, Appraisal Needs and Services Plan,the pest-control product purchase receipt, and ect., relevant to the course of investigation. At 10:15 AM, LPA conducted a physical plant tour. Between 10:25 AM - 12:25 PM, LPA conducted an interview with the House Manager, two (2) staff members (S1 & S2), and six (6) out of (6) residents. Continue on LIC 9099C Unsubstantiated Allegation: Staff does not ensure facility is kept free of pests for residents in care. It was alleged that the facility had a cockroach infestation while R1 lived at the home. To investigate this allegation, LPA interviewed the House Manager, two (2) staff members, and six (6) residents, and conducted a tour of the facility, including the kitchen and bathrooms. The House Manager and S1 confirmed that cockroaches and ants were observed in September 2025, and that R1 reported seeing cockroaches. Staff stated that insect-control powder was purchased and applied in the areas of concern. Furthermore, S2 is responsible for cleaning and sanitation of the facility and reported to LPA that S2 had not observed any insect infestation during the four (4) months of employment. All six (6) residents interviewed denied seeing cockroaches or other pests at the facility. During the facility tour, LPA did not observe cockroaches, signs of an active infestation, or other evidence of pests. Based on interviews and LPA's observations, there was insufficient evidence to show that the facility failed to address the reported pest concern. Therefore, this allegation is Unsubstantiated at this time. Allegation: Staff does not ensure food is kept free of foreign objects. It was alleged that R1 found two (2) pieces of glass in his/her food. To investigate this allegation, LPA interviewed the House Manager, two (2) staff members, and six (6) residents. The House Manager stated R1 did not report finding glass in food but reported vomiting, an insect concern, and a toe injury on 09/24/2025. The House Manager stated R1 was offered medical assistance and the facility notified Home Health regarding the toe injury. During today’s visit, LPA was shown a photograph of R1's bandaged toe. S1 and S2 stated they were not aware of any incident involving glass in R1's food. All six (6) residents interviewed denied finding foreign objects in their food or hearing about an incident involving glass in a resident's food. Based on interviews and information obtained, there was insufficient evidence to confirm that glass was found in R1's food or that the facility failed to keep food free of foreign objects. Therefore, this allegation is Unsubstantiated at this time. Continue on LIC 9099C Allegation: Staff had inappropriate conversations with resident in care It was alleged that staff offered R1 $30,000 to marry a family member and elope to Las Vegas so the family member could remain in the country. To investigate this allegation, LPA interviewed the House Manager, two (2) staff members, and six (6) residents. The House Manager, S1, and S2 denied knowledge of the alleged $30,000 offer, marriage proposal, or conversations involving immigration. They also denied observing inappropriate conversations involving R1. Furthermore, interviewed with six (6) residents denied hearing or observing inappropriate conversations involving money, marriage, immigration, or complaints. Based on interviews and information obtained, there was insufficient evidence to confirm that the $30,000 offer or inappropriate conversations occurred. Therefore, this allegation is Unsubstantiated at this time. Exit interview conducted and appeal rights explained. Copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Aug 11, 2026 · control 31-AS-20260806082953

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit. LPA was met by Farrah Siddiqui, Caregiver and explained the purpose of the visit. The co-administrator, Maria Bangash was called to inform of the visit. The facility is approved to serve residents age range 60 and above, (6) non ambulatory residents of which (1) may be bedridden. Facility is approved hospice waiver for (3) residents. 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 maintained. Infection control plan was developed and reviewed/updated on 07/01/2026 by the administrator. Bathroom has hygiene items such as paper towel, hand soap and toilet paper. Operational Requirements: The facility has a dementia care plan to accept or retain residents with dementia. Staff does not have the complete (12) hours of required training to provide special care to dementia residents. Facility maintains liability insurance in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate and expires on 09/18/2026. Physical Plant/Environment Safety: The facility is a 2-story home located in a residential neighborhood, 1st floor consists of (5) resident bedrooms, (3) bathrooms, (2) living rooms (one has a covered fireplace), (2) dining areas, kitchen, and backyard with a separate storage shed. 2nd floor consists of (4) bedrooms, (1) of which is a staff bedroom with uncovered fireplace, (2) bathrooms, laundry area. There are currently (6) residents, 60 years and older residing in the facility, (2) are under hospice care and (1) bedridden. The interior and exterior physical plant was inspected. Resident bedrooms were toured. Each bedroom has a smoke detector, linen, light, chair and sufficient closet space. Backyard was inspected and there is a locked storage shed to house tools, garden supplies and other miscellaneous items. There is (1) unmounted fire extinguisher purchased on 02/19/2026. LPA observed a partially exposed ceiling in the downstairs hallway due to a water leak. Staff stated that a repairman has already been called and would be back to finish the work today or tomorrow. Knives, cleaning solutions, and disinfectants are locked. Smoke alarms and carbon monoxide were tested and operable. The facility has a video camera monitor system in the common areas. Hot water temperature reading measured within the required 105 - 120 degrees Fahrenheit (110.3 deg F in bathroom downstairs and 117.9 deg F in bathroom upstairs). *****REPORT CONTINUED ON LIC809-C***** Staffing: A total of (4) caregivers including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have the required training and associated to the facility. Personnel Records-Training: Staff files were reviewed for criminal background clearance and training. Only (1) staff record was available during the visit. Staff #1/S1's files have health screening, personnel record and training. Co-administrator has a valid certificate, expires on 03/14/2027. Resident Rights-Information: Resident personal rights are posted. Facility provides internet services to all residents and have access to the facility phone. Planned Activities: The facility provides sufficient space to accommodate both indoor and outdoor activities. Residents are encouraged to participate in a variety of planned activities. Food Service: The kitchen was inspected and has sufficient supply of 2 day perishable & 7 day non-perishable food. There are (2) extra/freezer refrigerators, one in the dining area and one in the 2nd living room. Incidental Medical Services: Residents' medications were reviewed during the visit. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are stored in a locked cabinet and inaccessible to residents. Staff #1 did not properly document the medications (MAR not initialed) administered to the resident on the medication administration record (MAR). Resident Records-Incident Reports: Resident files were reviewed containing admission agreements, Physician's Report, Medical/Functional assessments, Needs and Services Plans, Personal rights, Medical Consent, Medication Records. Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, operation of manual assist devices. Last fire drill was conductedon 07/03/2026. Residents with SHN: (1) resident is bedridden and (2) residents are under hospice care, no one is currently using oxygen. Deficiencies cited and Technical advisories issued. Exit interview was conducted with the co-administrator, Maria Bangash on the phone and a copy of this report along with the appeal rights were provided to Farrah Siddiqui, Caregiver.the state’s words, verbatim · CDSS document, Jul 31, 2026

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 04/28/25, at 09:52 am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. Upon arrival, LPA met Caregiver, Farah Siddiqui. Maria Bangash the designee administrator was called and arrived at 11:30 am. LPA asked for the census, resident, and staff files. The physical plant was toured inside and out at 10:45 am. Living and dining room furniture is accessible for six (6) residents. There is a television and enough seating for six (6) residents. Furniture was observed to be in good condition. There is a fireplace in the living room area that has a black covering. There is smoke detectors/carbon monoxide all over the house. The smoke detectors are hardwired and interconnected and were tested. There is one (1) carbon monoxide against the wall at the entrance of the facility near the dining room area. They were functional. The facility temperature varies between 70-72 degrees Fahrenheit. There are several through out the house. There is one (1) fire extinguisher that is dated April 10, 2025. There is an extra/freezer refrigerator in the dining area. Kitchen area was sufficiently stocked with seven (7) days of perishable and seven (7) days of non-perishable food. There are two (2) refrigerators in the kitchen area. The cabinets have canned goods. Sharps are kept secured and locked in one (1) of the cabinets on your left-hand side. The toxins are kept in the kitchen area in one (1) the cabinets locked and secured also inaccessible to residents on your left-hand side. The first aid kit is located in one of the bottom cabinets in the kitchen area. 809C-continued Medication: The medication is kept in a cabinet area with resident files locked and secured inaccessible to residents in the living room area. Bedrooms: There are nine (9) bedrooms. Four (4) of the bedrooms is single, occupied. One (1) of the bedrooms is shared with a private bathroom. There are four (4) bedrooms upstairs for staff use only. There is two (2) bathrooms upstairs and linen closets. All bedrooms were toured and were properly furnished and have appropriate bedding and linens. There are three (3) other bathrooms for resident use downstairs. The bathrooms have proper toiletry and grab bars. The bathroom temperatures of the water are within regulations reading at 111-119 degree Fahrenheit. Outside/Backyard: There is a shed storage outside locked and secured with a washer and dryer. There is a huge backyard with a white fence. The outside/backyard has furniture for residents with proper seating. The facility has no signal system. The front of the house also has proper seating for the residents Administrative: The Insurance plan is updated as of 08/24/25-08/24/25. At the entrance of the facility there is covid signs and PPE items, Oxygen in Use, No smoking. There is an Ombudsman, YES sign, Disaster/Evacuation Plan, Mitigation Plan, Theft and Loss, Facility sketch and administration certificate against the wall in the dining hall. There is internet and phone access in the dining hall. Let it be noted, there has been changes to the original facility sketch. There was a removal of a garage that was originally in the facility sketch. It is now converted to a three (3) unit living area. This has been addressed previously on a case management and the administrator/Licensee is currently working with the City/Building Permit and has until 05/19/25 to make changes. LPA received a copy of City/Building Permit for Modification Building Ordinances. LPA observed the three (3) unit area and it is currently unoccupied. An exit interview was conducted no citation(s) were issued and a copy of the signed report was given to the Administrator.the state’s words, verbatim · CDSS document, Apr 28, 2025

Allegation investigated: Staff did not ensure leak was fixed properly

On 03/03/25, at 9:40am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Farah Siddiqui, Caregiver. LPA explained the purpose of this visit was to gather information, conduct staff and resident interviews and deliver findings for this complaint. The assistant administrator and administrator were called and informed of the visit. The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 9:55am, LPA toured the physical plant. During the tour, LPA interviewed residents and staff. 9099C-continued Substantiated Regarding the allegation: Staff did not ensure leak was fixed properly. It is being alleged that the downstairs hallway ceiling where residents walk under has water damage and a large hole. LPA interviewed three (3) residents that confirmed they saw the ceiling damaged but say it has now been repaired. LPA also interviewed three (3) staff that confirmed there was water leakage and a big hole in the ceiling due to water leaking from the upstairs. During LPA's physical tour, LPA observed the downstairs ceiling no longer has a hole but still shows the water damage. LPA took two (2) pictures of the ceiling. Therefore, based on the LPA's observations, resident and staff interviews, the above allegation(s) is SUBSTANTIATED at this time. Exit interview was conducted, a citation(s) was issued for the above allegation(s), the appeals rights and a copy of this report was given to the Caregiver.the state’s words, verbatim · CDSS document, Mar 3, 2025 · control 31-AS-20250228154456

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Mar 19, 2025

87303 (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not comply with the section cited above in one area that showed there was water damage, leaks to the ceiling which poses a Potential Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Mar 3, 2025

Plan of correction: The licensee/administrator shall plaster/paint, the ceiling where the water/hole damage was located. The licensee/administrator shall send a picture/repair paperwork to the LPA. POC due date: 03/19/25.

Allegation investigated: Staff are verbally abusing a resident while in care Staff are mistreating resident while in care

On 01/14/25, at 8:45am, Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by Farah Siddiqui, Caregiver. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information, conduct staff and resident interviews and deliver findings for this complaint. The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 9:25am, LPA toured the physical plant. During the tour, LPA interviewed residents and staff. 9099C-continued Unsubstantiated Regarding the allegation: Staff are verbally abusing a resident while in care. It is being alleged that the staff yell and are rude to resident #1 (R1). LPA interviewed three (3) staff that reported R1 is aggressive. Staff #1 (S1) reported that R1 tried to hit them while telling them not to be aggressive to one (1) of the residents. Staff #2 (S2) reported that R1 was always arguing with resident #3 (R3). Staff #3 (S3) reported that R1 had recently moved in but when they did not have the full attention of the staff they would start yelling and try to become aggressive to the other residents. LPA interviewed four (4) residents that confirmed staff have not verbally abused them, yelled at them or ever been rude to them. Resident #3 (R3) reported that R1 would yell at them and threw a cup at them. Furthermore, LPA obtained the Unusual Incident/Injury Report of R1 being aggressive on 01/02/25. Therefore, based on the LPA's observations, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Regarding the allegation: Staff are mistreating resident while in care. It is being alleged that while resident #1 (R1) is being changed they toss a blanket on them. LPA interviewed three (3) staff that confirmed they have never mistreated their residents while in care. LPA interviewed four (4) residents that confirmed they have never been mistreated while in care and/or staff have never tossed a blanket or any type of clothing on them while they are being changed. Therefore, based on the LPA's observations, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Exit interview was conducted, no citation(s) were issued for the above allegation(s), and a copy of this report was given to the Assistant Administrator.the state’s words, verbatim · CDSS document, Jan 14, 2025 · control 31-AS-20250107085344

Allegation investigated: Staff did not ensure the facility was free from mold Staff moved residents personal property without consent

On 09/17/24, at 9:25am, Licensing Program Analyst (LPAs) Gina Saucedo and Angelica Segovia arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by caregiver Farrah Siddiqui. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information, conduct staff and resident interviews and deliver findings for this complaint. The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 10:15am, LPAs toured the physical plant. During the tour, LPA's interviewed residents and staff. 9099C-continued Substantiated This is the addendum of the licensing report previously issued on 09/17/24: Regarding the allegation: Staff did not ensure the facility was free from mold. It is being alleged that there is mold coming from the air conditioner and floors. Although, four (4) out of five (5) resident interviews and one (1) staff interview determined that they have not seen any mold in any of the air conditioners or floors, LPAs were able to verify the mold that was in one (1) of the resident’s rooms behind a refrigerator. Therefore, based on the LPA's observations and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time. Regarding the allegation: Staff moved residents’ personal property without consent. It is being alleged that the resident’s property was taken from their room and not returned to them. Although, Four (4) out of five (5) resident interviews confirmed that there was no personal property moved without their consent, LPAs were able to verify that resident # 1 (R1) did live at the above facility. The assistant administrator did state that R1 lived at the above address but did not have a file for them. LPA could not verify a file for R1 because the assistant administrator confirmed that R1 was not a resident but a person that lived there. In addition, staff # 2 (S2) did verify with the LPAs that R1 did reside at the above facility for about two (2) months. Therefore, based on the LPA's observations and resident interviews, the above allegation(s) above is SUBSTANTIATED at this time. Exit interview conducted, appeal rights and copy of report signed and delivered to the Administrator.the state’s words, verbatim · CDSS document, Oct 30, 2024 · control 31-AS-20240911090516

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Sep 18, 2024

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on the observation and record review the licensee did not comply with the section cited above in one out of one area of mold/mildew which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: Administrator/Licensee will need to send the removal/cleaning of the mold/mildew from behind the refrigerator and flooring in resident's room. POC Due Date: 09/18/24

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(a) · Plan of correction due date: Oct 2, 2024

(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all such articles or cash resources. This requirement is not met as evidenced by Based on the observation and record review the licensee did not comply with the section cited above in handling of 1 out 5 resident's property which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: Administrator/Licensee will reimburse resident/former resident of all personal items POC Due Date: 10/02/24

Type of visit: Case Management - Deficiencies

On 10/09/24, at 9:00am Licensing Program Analyst (LPAs) Gina Saucedo, Angelica Segovia and Licensing Program Manager (LPM) Troy Agard conducted an unannounced visit to this facility for deficiencies. During the Physical Tour and Records Review, LPA's and LPM observed: A health screening was missing for one (1) of the staff currently working/associated with the above facility. A Physician's Report was missing not showing the tuberculosis screening for one (1) of the residents. The Facility was in disrepair missing ceiling panels in the kitchen, the fireplace covering has to be attached a broken sliding door in one (1) of the resident's room is broken and a broken door leading to the entrance/exit of the facility has to be repaired. A staff that does not have the proper documentation/association to work at the above facility. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D. Exit interview conducted, appeal rights and copy of report signed and delivered to the Administrator.the state’s words, verbatim · CDSS document, Oct 9, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 9, 2024

87303 (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not ensure four (4) out of four (4) damages at the facility to be in repaired at all times which poses a Potential Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 9, 2024

Plan of correction: The licensee/administrator shall repair the ceiling panel in the kitchen, the fireplace covering to be attached and the broken sliding door in the resident's room, the broken door to the entrance/exit of the facility by POC due date: 10/23/24. The licensee/administrator shall send a picture/repair paperwork to the LPA.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87458(b)(1) · Plan of correction due date: Oct 9, 2024

87458(b)(1)-The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis/secondary diagnosis,...results of an examination for communicable tuberculosis, other diseases...This requirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not ensure one (1) out of six (6) residents to have their Physican's Report and tuberculosis paperwork which poses a Potential Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 9, 2024

Plan of correction: The licensee/administrator shall have and retain the proper paperwork for each resident for three (3) years and send copy of tuberculosis to the LPA by POC due date: 10/23/24

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(f) · Plan of correction due date: Oct 9, 2024

87411(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.This requirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not ensure one (1) out of five (5) staff had a health screening which poses a Potential Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 9, 2024

Plan of correction: The licensee/administrator shall have and retain the proper paperwork for each staff and send a copy of health screening to the LPA by POC due date: 10/23/24

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Oct 9, 2024

Criminal Clearance 87355(e)(1) 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 requirement is not met as evidenced by: Licensee failed to obtain criminal clearance/background association for an indvidual that is currently working as a staff which poses an Immediate Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Oct 9, 2024

Plan of correction: LPA requested adminstrator to remove the individual from the facility area as soon as possible. Within 24 hours licensee must inform RO that the individual is removed and will not return to facility without criminal record clearance and association. A $500.00 civil penalty will be assessed at the time of this visit.

Allegation investigated: Staff did not treat resident with respect

On 09/17/24, at 9:25am, Licensing Program Analyst (LPAs) Gina Saucedo and Angelica Segovia arrived at the facility to conduct an unannounced, initial complaint visit and was greeted by caregiver Farrah Siddiqui. LPA disclosed the purpose of the visit. LPA explained the purpose of this visit was to gather information, conduct staff and resident interviews and deliver findings for this complaint. The investigation consisted of the following: LPA Saucedo asked for the census, requested the staff and resident roster. At 10:15am, LPAs toured the physical plant. During the tour, LPA's interviewed residents and staff. 9099C-continued Unsubstantiated Regarding the allegation: Staff did not treat resident with respect. Staff are being disrespectful and aggressive to the residents. Four (4) out of five (5) residents confirmed that they are treated with respect and there has been no aggression towards them from staff. One (1) resident and two (2) staff did confirm that resident #1 (R1) was aggressive and disrespectful to resident # 2 (R2). Therefore, based on the LPA's observations, resident and staff interviews, the above allegation(s) above is UNSUBSTANTIATED at this time. Exit interview conducted, signed and delivered to the Assistant Administrator. The information on this page was deleted to make a correction(s).the state’s words, verbatim · CDSS document, Sep 17, 2024 · control 31-AS-20240911090516

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On 09/17/24, Licensing Program Analyst (LPAs) Gina Saucedo and Angelica Segovia conducted unannounced, initial visit to this facility in conjunction with a complaint control #31-AS-20240911090516 LPA met with the Caregiver, Farrah Siddiqui and explained the reason for the visit. During the physical tour, LPA conducted a review of records and no incident report-Unusual Incident/Injury Report was sent to Community Care Licensing Department-(CCLD) for any of the residents that have recently gone to a hospital and incidents in the house that involved police activity. Furthermore, there has been changes to the original facility sketch. There was a removal of a garage that was originally in the facility sketch. It is now converted to a three (3) unit living area and has a white gate surrounded the area. The original facility sketch had a clearance for a garage. In addition, there is an individual living in one (1) of the three (3) living areas that is not background cleared. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D. Exit interview conducted, appeal rights and copy of report signed and delivered to the Assistant Administrator.the state’s words, verbatim · CDSS document, Sep 17, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Sep 18, 2024

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:This requirement is not met as evidenced by: Based on the observation and record review, the licensee did not comply with the section cited above in regards to the garage being converted into three (3) living areas which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 17, 2024

Plan of correction: Administration/Licensee will need to contact the fire department to receive immediate fire clearance. POC 09/18/24

From the deficiency page — Deficiency type: Type A · Section cited: CCR87208(a) · Plan of correction due date: Sep 18, 2024

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:This requirement is not met as evidenced by: Based on the observation, interview and record review, the licensee did not comply with the section cited above in submitting an application for the conversion of the garage into three (3) separate living units which poses/posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 17, 2024

Plan of correction: The licensee will submit a written declaration explaining the steps that they are going to take to complete the project. POC 09/18/24

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87305(a) · Plan of correction due date: Sep 18, 2024

Prior to construction or alterations, all facilities shall obtain a building permit.This requirement is not met as evidenced by: Based on the observation and record review the licensee did not comply with the section cited above in one out of one area of contruction-removal of a garage and new construction which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 17, 2024

Plan of correction: Administrator/Licensee will need to send the building permit to LPA Sauced0. POC 09/18/24

From the deficiency page — Deficiency type: Type A · Section cited: CCR87211(a)1(A) · Plan of correction due date: Sep 18, 2024

87211 (a)(1)(A)Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports... including, but not limited to, the following:(1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below... This requirement is not met as evidenced by: Based on the LPA observation and interviews the licensee/administrator did not ensure resident reports to be submitted to CCLD from the above facility involving multiple incidents which poses an Immediate Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Sep 17, 2024

Plan of correction: An Unusual Report is to be sent to Community Care Licensing Department within seven (7) days regarding any resident injuries/hospitalizations while in care, police reports POC 09/18/24

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Sep 18, 2024

Criminal Clearance 87355(e)(1) 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 requirement is not met as evidenced by: Licensee failed to obtain criminal clearance/background for the individual that is living in one (1) of the three (3) living areas attached to the above facility which poses an Immediate Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Sep 17, 2024

Plan of correction: LPA requested adminstrator to remove the individual from the facility area as soon as possible. Within 24 hours licensee must inform RO that the individual is removed and will not return to facility without criminal record clearance and association. A $500.00 civil penalty will be assessed at the time of this visit.

Type of visit: Required - 1 Year

On 06/10/24, at 9:40 am., Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. Upon arrival, LPA met Caregiver, Saeeda Khan. Maria Bangash the designee administrator was called and arrived at 11:15 am. LPA asked for the census, resident, and staff files. The physical plant was toured inside and out at 10:25 am. Living and dining room furniture is accessible for six (6) residents. There is a television and enough seating for six (6) residents. Furniture was observed to be in good condition. There is a fireplace in the living room area that has a covering. There is smoke detectors/carbon monoxide all over the house. The smoke detectors are hardwired and interconnected and were tested. There is one carbon monoxide against the wall at the entrance of the facility near the dining room area. They were functional. The facility temperature at 73 degrees Fahrenheit. There is one fire extinguisher that is dated January 2024. There is an extra/freezer refrigerator in the dining area. There is an Ombudsman, YES sign, Disaster/Evacuation Plan, Mitigation Plan, Theft and Loss, Facility sketch and administration certificate against the wall in the dining hall. There is internet and phone access in the dining hall. Kitchen area was sufficiently stocked with seven (7) days of perishable and seven (7) days of non-perishable food. There is two (2) refrigerators in the kitchen area. The cabinets have canned goods. Sharps are kept secured and locked in one (1) of the cabinets on your left-hand side. The toxins are kept in the kitchen area in one (1) the cabinets locked and secured also inaccessible to residents on your left-hand side. The first aid kit is located in one of the bottom cabinets in the kitchen area. Medication: The medication is kept in a cabinet area with resident files locked and secured inaccessible to residents in the living room area. 809C-continued Bedrooms: There are eight (8) bedrooms. Four (4) of the bedrooms is single, occupied. One (1) of the bedrooms is shared with a private bathroom. There are three (3) bedrooms upstairs for staff use only there. There is two (2) bathrooms upstairs and linen closets. All bedrooms were toured and were properly furnished and have appropriate bedding and linens. There are two (2) other bathrooms for resident use downstairs. The bathrooms have proper toiletry and grab bars. The bathroom temperatures of the water are within regulations reading at 115-119 degree Fahrenheit. Outside/Backyard: There is a shed storage outside locked and secured with a washer and dryer. There is a huge backyard with a white fence. The outside/backyard has furniture for residents with proper seating. The facility has no signal system. The front of the house also has proper seating for the residents Administrative: There is no annual fee that is due right now. The Insurance plan is updated as of 08/24/23-08/2024. At the entrance of the facility there is covid signs and PPE items, Oxygen in Use, No smoking. An exit interview was conducted no citation(s) were issued and a copy of the signed report was given.the state’s words, verbatim · CDSS document, Jun 10, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Melissa Spaeth and Licensing Program Manager (LPM) Troy Agard conducted an unannounced visit regarding Complaint #31-AS-20220315122504. During the physical plant tour at 11:10 am, LPA Spaeth and LPM Agard observed a knife sitting out on the kitchen table. The following deficiency was issued per CA code of Regulations, Title 22. See 9099-D included with this report. The exit interview was conducted and the appeal rights were issued. A copy of the signed report was given.the state’s words, verbatim · CDSS document, Mar 25, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Mar 25, 2024

87309 Storage Space (a) Disinfectants, cleaning solutions…and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Based on LPA Spaeth’s and LPM Agard’s observations, a kitchen knife was left on the kitchen counter which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 25, 2024

Plan of correction: LPA Spaeth and LPM Agard observed the caregiver locked the knife in a kitchen drawer.

Type of visit: Required - 1 Year

On 01/10/24, at 08:50 a.m., Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. Upon arrival, LPA met Caregiver, Rafiga Bibi. Maria Bangash the designee administrator was called arrived at 10:15 a.m. LPA asked for the census, resident, and staff rosters. Living and dining room furniture is accessible for six (6) residents. There is a television and enough seating for six (6) residents. Furniture was observed to be in good condition. There is a fireplace in the living room area that has a covering. There is smoke detectors all over the house. The smoke detectors are hardwired and interconnected and were tested. There is one carbon monoxide against the wall at the entrance of the facility near the dining room area. They were functional. The facility temperature at 72 degrees Fahrenheit. There is one fire extinguisher that is dated January 2024. There is an extra refrigerator in the dining area. There is an Ombudsman, YES sign, Evacuation Plan, Mitigation Plan and administration certificate against the wall in the dining hall. There is internet and phone access in the dining hall. Kitchen area was sufficiently stocked with seven (7) days of perishable and seven (7) days of non-perishable food. There is one refrigerator in the kitchen area. The cabinets have canned goods. Sharps are kept secured and locked in one of the cabinets on your left-hand side. The medication is kept in the kitchen area on your right-hand side in one of the cabinets locked and secured inaccessible to residents. The toxins are kept in the kitchen area in one the cabinets locked and secured also inaccessible to residents. The first aid kit is located in one of the bottom cabinets in the kitchen area. 809C-continued Bedrooms: There are eight (8) bedrooms. Four (4) of the bedrooms is single, occupied. One (1) of the bedrooms is shared with a private bathroom. There are three (3) bedrooms upstairs for staff use. All bedrooms were toured and were properly furnished and have appropriate bedding and linens. There are two (2) other bathrooms for resident and staff use. The bathrooms have proper toiletry and grab bars. The bathroom temperatures of the water are within regulations reading at 115-119 degree Fahrenheit. Outside/Backyard: There is a shed storage outside locked and secured with a washer and dryer. There is no garage. The outside/backyard has furniture for residents with proper seating. The facility has no signal system. There is a SPA that has a covering but no fence, accessible to residents. Administrative: There is no annual fee that is due right now. The Insurance plan is updated as of 08/24/23-08/2024. At the entrance of the facility there is covid signs and PPE items. An exit interview was conducted, two different citations were issued-one for staff not having current and/or CPR/Firstaid and one for the SPA/Jacuzzi not having a fenced area, locked inaccessible to the residents. A copy of this report was given to the administrator with the appeal rights.the state’s words, verbatim · CDSS document, Jan 10, 2024