Divine Manor Care

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) LaVette Farlow conducted an unannounced case management visit. LPA Farlow arrived at the facility to conduct a complaint investigation for compliant control 56-AS-20251230081815. LPA met with Lead Staff Lanperia "Ria" Simamora and was granted entry to the facility. During the investigation, Community Care Licensing Department discovered that the staff did not have access to residents file for review. LPA inquired about the residents file from Ria and she informed me that the Licensee is the only one with access to the file. Ria stated she does have the resident MARS. LPA Farlow contacted the Licensee Shreeta Yadav, and inquired about the residents file. Shreeta informed LPA that she only has access to residents file due to problems in the past and sensitive information in the file. LPA informed Shreeta it is required that the file are maintained at the facility and are available for review upon request. Due to LPA's inability to access and review residents files a deficiency was issued. During today’s visit, one (1) Type B deficiencies to the facility were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report, LIC809, LIC809D, Appeal Rights were discussed and provided to Lead Staff Lanperia "Ria" Simamora.the state’s words, verbatim · CDSS document, Jan 7, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Jan 14, 2026

87506(a) The licensee shall ensure... complete, and current record is maintained for each resident in the facility or ...readily available to facility staff and to licensing agency staff. Based on interview and observation, the licensee did not comply with the section cited above as evidence by not maintaining residents file and having files readily available for review, which poses a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 7, 2026

Plan of correction: Licensee agrees to maintain and ensure residents files are accessible and readily available for review.The Licensee agrees to submit a statement of understanding of the regulation by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Administrator Shreeta Yadav and was granted entry to the facility. At the time of the visit there was two (2) staff present, and five (5) residents present. The facility is an five (5) bedroom, four (4), bathroom home, with a kitchen/dining area, living room, and attached garage. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (6) current census (5). LPA was accompanied by Facility Administrator, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be 110.11 degrees F The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside Med-cart inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. LPA observed last fire/disaster drill was conducted on 10/1/25. LPA also observed emergency disaster plan to be updated. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Shreeta Yadav.the state’s words, verbatim · CDSS document, Dec 2, 2025

Allegation investigated: Resident developed pressure ulcer while in care. Facility were not ensure residents care needs were being met.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Administrator Shreeta Yadav and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records. First allegation: Resident developed pressure ulcer while in care. Regarding the allegation stated above LPA conducted a review of records pertaining to Resident #1 during the review of records LPA observed that R#1 was admitted at Divine Manor on 9/9/2022 During further review LPA discovered based on Resident #1 documentation (pre-appraisal, physicians report), R#1 was admitted at the Facility with a stage 2 pressure ulcer already present. Furthermore, LPA observed that R#1 was receiving treatment for the wound by Home Health, documentation further indicated that no new ulcers were developed. In addition, LPA observed that R#1 was discharged on 9/29/2022. Furthermore, records also demonstrated that on 9/22/2022 per home health progress notes R#1 wound was improving based on treatment. Unsubstantiated Second allegation: Facility were not ensuring residents care needs were being met. Regarding the allegation stated above LPA conducted interviews with R#2, R#3, and R#4, LPA went over the allegation stated above and R#2-4, informed LPA that they have no concerns, and that the facility meets their care needs on the daily. In addition, R#2-4 informed LPA that they enjoy living at the facility and that they feel safe. LPA conducted interviews with S#1 and S#2 LPA went over the allegation stated above and staff #1-2 denied the allegation and informed LPA that staff always ensures that residents needs are always being met. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated. Unsubstantiated: meaning that 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. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Administrator Shreeta Yadav at the end of the visit.the state’s words, verbatim · CDSS document, Sep 17, 2025 · control 56-AS-20221031145150

Type of visit: Case Management - Health Checks

On 02/04/2025 Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit to the facility to initiate a Case Management Health and Safety Check. LPA Hernandez was granted entry to the facility by staff Raymond Munsayac. LPA Hernandez met with Administrator Shreeta Yadav and explained the purpose of today's visit. During today's visit LPA Raquel Hernandez toured the facility. All (5) residents were present at the facility during Health and Safety Check. No immediate health and safety concerns were observed. LPA Hernandez observed indoor and outdoor passageway and no health are safety hazards were observed. LPA Hernandez observed sufficient staff to provide proper care and supervision to residents in care. LPA Hernandez inspected food supply and observed more than two (2) days supply of perishable food and more than seven (7) days supply of non-perishable food. Additionally, LPA Hernandez received documentation pertaining to incident reported. An exit interview was conducted with Administrator Shreeta Yadav and a copy of this report (LIC809) was discussed and provided.the state’s words, verbatim · CDSS document, Feb 4, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) LaVette Farlow arrived unannounced to conduct the required annual visit to the facility. LPA met with Caregiver, Roldan Kiseo, and introduced self and stated purpose of the visit. Caregiver Roldan notified Administrator of my arrival and state the house manager will be arriving to the facility. LPA met with Carmen Holden and explain the purpose of the visit and a tour was conducted. LPA was informed that there are currently 5 residents in care and (1) resident in the hospital. The facility has 5 resident bedrooms, 3 bathrooms, kitchen, dining area, living room, attached garage, and backyard. LPA completed a walk through of facility, review of records and medication audit. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 107.2, 105.2, 109.1 and 107.7 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, 3 fire extinguishers and emergency kit. Posters such as; the personal rights, ombudsman and emergency disaster plans were posted in a common area. LPA observed cleaning supplies, toxins, sharps, and other dangerous items locked in cabinets made inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed in a secured filing cabinet and inaccessible to residents. LPA observed two (2) out of two (2) residents MARS were not properly initialed. Technical violation issued. There are no firearms, ammunition, swimming pool or bodies of water. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: LPA observes that the facility did not maintain a sufficient amount of non-perishable and perishable food supply for 7 days for number of residents in care. Technical violation issued. Dishes, cups, and utensils were also stored properly. Yards/Outside: Two shaded patio, a side gate with self-latching handle on the right and left side of the house that leads into the backyard. All outdoor pathways were free of obstructions. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed staff files for First Aid/CPR certifications, criminal record clearances, trainings, and health screenings. LPA observed the Emergency Disaster Plan not signed and dated. Technical violation issued. LPA observed emergency drills not conducted on each shift. Technical violation issued. Three technical violations were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, and LIC9102TV were discussed and copies were provided to Administrator Shreeta Yadav.the state’s words, verbatim · CDSS document, Nov 22, 2024

Allegation investigated: Facility staff failed to provide residents proper supervision resulting in excessive falls and serious injuries Facility staff are not adequately trained

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Raymond Munsayac, Caregiver and explained the purpose of the visit. During the course of the investigation, records were reviewed, and interviews were conducted with facility staff members and residents. On August 25, 2020, Community Care Licensing received a complaint alleging facility staff failed to provide residents proper supervision resulting in excessive falls resulting and serious injuries and facility staff are not adequately trained. Regarding the allegation that “facility staff failed to provide residents proper supervision resulting in excessive falls and serious injuries”, facility records revealed that facility reported falls for Residents #2 and #3 to licensing and facility staff provided first aid, notified Hospice Agency for R2, called 911 for medical attention for R3. Interviews with staff denied that facility staff failed to provide proper supervision resulting in excessive falls and serious injuries, interviews with R3 could not corroborate allegation and R2 is not able to be interviewed. . Regarding allegation that “facility staff are not adequately trained”, facility records revealed that that facility staff had been trained on providing care, supervision, medication management. Interviews with staff denied that facility staff are not adequately trained. Interviews with R3 could not corroborate allegation and R1,R2 is not able to be interviewed. Therefore, the allegations of facility staff failed to provide residents proper supervision resulting in excessive falls and serious injuries and facility staff are not adequately trained is Unsubstantiated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Raymond Munsayac and a copy of this report along with LIC811- Confidential Names list was provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 16, 2024 · control 18-AS-20200825133437

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Administrator Shreeta Yadav and was granted entry to the facility. At the time of the visit there was two (2) staff present, and five (5) residents present. The facility is an five (5) bedroom, four (4), bathroom home, with a kitchen/dining area, living room, and attached garage. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (6) current census (5). LPA was accompanied by Facility Administrator, to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be 110.11 degrees F The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside Med-cart inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed five (5) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. Based on the observations made during today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Facility Administrator Shreeta Yadav.the state’s words, verbatim · CDSS document, Dec 11, 2023