Devoted Hearts Senior Care Home LLC #2

Type of visit: Required - 1 Year

On 02/19/26, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA introduced self, stated the purpose of the visit and met with staff Diana Fernandez. Licensee/Administrator Leticia Jackson was called and arrived shortly. All six residents were present during inspection. LPA toured facility with Licensee. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. A sample of residents’ and all staff files were reviewed. All residents’ bedroom were toured and observed to have the required furnishings and with adequate lightning. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature is maintained at 34 degrees F. Fire extinguisher was observed with a service date: 01/12/26. Last fire drill was completed on 01/15/26. First aid kit observed with required items. LPA toured kitchen and observed cleaning chemical stored and locked in laundry closet. The bathrooms were toured. Room 4 bedroom sliding door exit was observed blocked by a metal stick. Non-skid mats and grabbed bars were observed in hall bathroom. Non-skid mats were not observed in master bathroom shower. Hot water temperature was tested at 106.4 degree F in the master bathroom and maintained at 106 degree F in hall bathroom. Extra linens and towels were observed. Medications observed locked under television in television stand. Outside of facility toured. Adequate outdoor seatings available for residents. Carbon monoxide and smoke detector operational during visit. A civil penalty is being cited, per California Code of Regulations, Title 22, Division 6, see attached 421IM. A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. Exit Interview conducted. The following documents requested to be updated and submitted to Fresno CCL by 02/25/26: Lic 308, Lic 500, Lic 610E, current liability insurance, and Administrator certificate. A copy of this report and appeal rights was provided to Licensee, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Feb 19, 2026

Type of visit: Case Management - Deficiencies

On 10/06/25, Licensing Program Analyst (LPA) M. Yang arrived to conduct case management visit and met with Administrator/ Licensee Leticia Jackson. During the course of the investigation for complaint on 09/09/25, interviews were conducted, records were reviewed, and facility was toured. During tour of the facility, the garage refrigerator was observed not cleaned with food grime. On 09/09/25 visit, LPA was informed R1 was at the hospital. R1 and R2 are receiving hospice care. R2 was observed with full rail bed. Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6. An exit interview was conducted. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Oct 6, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: Oct 27, 2025

HSC 1569.625(b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when all personnel training was not observed on file, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 6, 2025

Plan of correction: Facility shall ensure all staff are trained and training documents are on file. Licensee stated all staff training will be completed by 10/27/25. Staff trainings record shall be submitted to the Fresno CCL by POC due date 10/27/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(f) · Plan of correction due date: Oct 20, 2025

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. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when LPA reviewed staff files and no health screening were observed on file for 3 out of 4 staff, which poses a potential health or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 6, 2025

Plan of correction: Licensee will submit proof of S1, S2, and S3's health screening to Fresno CCL office by POC due date 10/20/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a) (1) · Plan of correction due date: Oct 10, 2025

87211(a) (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 report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on record review and interviews: the licensee did not ensure a written was submitted to the Fresno CCL office within 7 days of occurrence on 09/09/25 when R5 went to the hospital, this poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 6, 2025

Plan of correction: Licensee agrees to submit a plan detailing steps the facility will take to ensure the requirements of Reporting requirements are met by the POC due date 10/10/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(21) · Plan of correction due date: Oct 7, 2025

87555 (b)(21) Freezers of adequate size ...They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures. This requirement is not met as evidenced by: Based on observation, the refrigerator in the garage was observed dirty food grime inside on the bottom.the state’s words, verbatim · CDSS document, Oct 6, 2025

Plan of correction: Staff cleaned the garage refrigerator during visit. POC cleared during visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87633(b) · Plan of correction due date: Oct 10, 2025

87633(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident… This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above when LPA review R1’s file, whose currently receiving hospice care with no current hospice care plan on file, which poses a potential health or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 6, 2025

Plan of correction: Licensee will obtain R1’s hospice care plan and submit it to Fresno CCL by POC due date 10/10/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(3) · Plan of correction due date: Oct 10, 2025

87608 (a)(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: This requirement is not met as evidenced by: Based on observation and records reviewed, R3 who do not received hospice care were observed with half with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.the state’s words, verbatim · CDSS document, Oct 6, 2025

Plan of correction: Licensee removed half rails during visit. POC cleared during visit.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Oct 13, 2025

87506 (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on records review, two out of 6 residents do not have appraisals and needs and services plan on file, which poses/posed a potential health and safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Oct 6, 2025

Plan of correction: Licensee will complete and obtain appraisal and needs and services plan for R2 and R3 by POC due date. Copies will be submitted to Fresno CCL by POC due date 10/13/25.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(5)(B) · Plan of correction due date: Oct 10, 2025

87608(a)(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on observation and records reviewed, R2 who receives hospice care were observed with full rail with no doctor’s order, which poses/posed a potential health and safety and personal rights risk to the resident in care.the state’s words, verbatim · CDSS document, Oct 6, 2025

Plan of correction: Licensee will obtain order for full rail bed for R2 and submitted to the Fresno CCL by POC due date 10/10/25.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.618(c)(3) · Plan of correction due date: Oct 7, 2025

1569.618 (c)(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: All staff files were reviewed, and interviews conducted, staffs not have current First Aid and CPR certification, this poses an immediately health and safety risk for the residents in care.the state’s words, verbatim · CDSS document, Oct 6, 2025

Plan of correction: Licensee shall ensure that all staff have current First Aid/ CPR certification. Proof of all staff First Aid/ CPR certification is to be submitted to the Fresno CCL by 10/07/25.

Type of visit: Prelicensing

On 03/20/25, Licensing Program Analyst (LPA) M. Yang conducted an announced Pre-licensing and Component III inspection. LPA introduced self, stated the purpose of the visit, and met with Licensee/ Administrator Leticia Jackson. The facility is 4 bedroom and 2-bathroom home. Fire clearance was granted for 6 Non-Ambulatory for total of 6 capacity. All four residents were present during this inspection. LPA toured the facility with Licensee. Facility temperature is set to 70 degrees F. Common areas were furnished and had adequate seating and lighting available. A fire extinguisher was observed and has a service date of 07/20/24. Kitchen was toured and observed to have dishes, plate, and utensils. Medications were kept locked and inaccessible to residents under television stand. Medication was checked and MAR were reviewed. Refrigerator temperature maintained at 35 degrees F. LPA observed a 2-day supply of perishable foods and a 7 day supply of non-perishable foods. First aid kit was observed and contained all required items. Knives were observed to be locked and secured in kitchen drawer. Cleaning supplies and chemicals were observed to be in a locked laundry closet. LPA observed an extra supply of bed linens and personal hygiene products. All bedrooms were observed to have required furnishings. Bathrooms toured. All bathrooms are observed with securely fastened grab bars and non-skid mat. Hot water measured at 109 degrees F in bathroom master bathroom and 109.9 degrees F in the hall bathroom. Outside of observed side gate to be self-closing and self-latching and with adequate outside seatings. Smoke detectors and carbon monoxide detectors were observed to be operational during this inspection. All residents record reviewed to have Admission Agreements, Physician Reports, Pre-Appraisal, and Emergency Identification Information. All staff records were reviewed to have a criminal record clearance. Facility phone number 661-491-3032. Component III was conducted during today's pre-licensing visit. I have found that the applicant has met all pre-licensing requirements. LPA will submit documentation to CAB in Sacramento for final review prior to license being issued.the state’s words, verbatim · CDSS document, Mar 20, 2025

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 4 COMP II Participants: Leticia Jackson (Managing Member/Administrator) Interview Method: Virtual interview via Microsoft Teams On February 21, 2025, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Feb 21, 2025