D'Nalor Care Homes

Allegation investigated: Licensee allowing three residents to share a single bedroom.

On 05/28/2026 at 2:15PM, Licensing Program Analyst (LPA) L. Alexander conducted a subsequent visit with Administrator, Roland Wilson, to deliver the findings of the above allegation. LPA explained the purpose of the visit with Mr. Wilson. During the investigation, the Department obtained and reviewed the following documents from the facility: Register of Facility Residents dated 07/01/2025; Personnel Report (LIC 500) dated 01/31/2026; emails titled “R-3.1 Approval Not Requiring Automatic Sprinklers” dated 10/12/2018 and 10/02/2019; City of Oakland Fire Marshal letter dated 10/12/2018 regarding “Exception Request for Automatic Sprinklers on R-3.1”; copies of RCFE licenses reflecting capacity increases from four (4), five (5), and six (6) residents; City of Oakland Fire Marshal Fire Life Safety Inspection letter dated 11/25/2019; facility sketch; and Program Flexibility waiver request dated 04/07/2026. Substantiated LIC9099-C (Page 2) Allegation: Licensee allowing three residents to share a single bedroom. Finding: Substantiated On 02/10/2026, Witness 1 (W1) reported that on 02/03/2026, an on-site audit was conducted at D’Nalor Care Homes, LLC. During the physical inspection of the facility, it was observed that one resident bedroom was occupied by three residents. On 02/18/2026, Staff 1 (S1) stated that the facility had been granted a fire clearance permitting three residents to share a single bedroom. LPA reviewed facility records, including fire clearance documentation, RCFE licenses, facility sketches, and correspondence from the City of Oakland Fire Marshal’s Office. However, the documents reviewed did not support or validate that an approved fire clearance exception had been granted allowing three residents to occupy one bedroom. Pursuant to California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, Section 87307(a)(2)(D) states: “Resident bedrooms shall be provided which meet, at a minimum, the following requirements: Not more than two residents shall sleep in a bedroom.” Based on LPA observations, interviews conducted and records reviewed, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, May 28, 2026 · control 15-AS-20260210153003

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(2)(D) · Plan of correction due date: Jun 11, 2026

87307 Personal Accommodations and Services (a) Living accommodations... The facility shall...provide comfortable living accommodations and privacy for the residents... (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (D) Not more than two residents shall sleep in a bedroom. This requirement is not met as evidenced by: Based on observations, interviews, and records reviewed, the Licensee failed to ensure compliance with California Code of Regulations, Title 22, Section 87307(a)(2)(D), which requires that no more than two residents sleep in a bedroom. During the investigation, it was determined that three residents were occupying one bedroom without documentation supporting an approved fire clearance exception. This poses a potential risk to the health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, May 28, 2026

Plan of correction: Administrator agrees to ensure compliance by placing another bed in Bedroom #1. Administrator will send a photo of new bedroom set-up to CCLD by POC due date.

Allegation investigated: Staff took away resident's personal phone

On 04/03/2026 at 9:10 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to deliver the findings on the above allegation. LPA met with Administrator, Roland Wilson, and explained the purpose of the visit. During the course of investigation, LPA interviewed staff, residents, and witnesses. LPA obtained and reviewed documents including but not limited to Personnel Report (LIC500), Resident Roster, Staff Contact Information, residents' physician report (LIC602A), Identification and Emergency Information (LIC601), service plan, Personal Rights (LIC613-C), Client/ Resident Personal Property and Valuables (LIC621), communication between responsible party/ family members, Ongoing Resident Notes, and incident reports. Continue to LIC9099-C… Substantiated Continued from LIC9099-C… Allegation: Staff took away resident's personal phone It was alleged that staff took away resident’s personal phone. Based on interviews conducted, ADM revealed that R1 always has access to the facility phone and is able to use the phone. However, ADM confirmed that R1’s personal phone has been taken away due to R1’s behavior of excessively calling emergency services, family, friends, etc. at random times throughout the day and night. 3 of 5 staff members interviewed all stated that there have been times when paramedics or police would come randomly due to R1’s call. Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Apr 3, 2026 · control 15-AS-20260121110338

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(12) · Plan of correction due date: Apr 17, 2026

87468.1(a)(12)Personal Rights of Residents in All Facilities To wear their own clothes; to keep and use their own personal possessions, including their toilet articles; and to keep and be allowed to spend their own money. This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above by taking R1's personal phone away which poses a potential personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 3, 2026

Plan of correction: By POC date, the Administrator agrees to create a plan with R1's family in regards to R1's phone, give R1's phone back, and continue to allow R1 to use the facility phone whenever R1 requests for it. Proof of correction will be sent to CCLD.

Type of visit: Case Management - Other

On 04/02/2026 at 9:45 AM, Licensing Program Analyst (LPA) P.Manalo arrived unannounced to conduct a Case Management visit. LPA met with Administrator, Roland Wilson and explained the purpose of the visit. While LPA P. Manalo conducted a complaint investigation (15-AS-20260121110338), LPA was informed from W1 that staff do not have access to the medication cabinet. During the visit, LPA interviewed S1, S2, and Administrator. LPA reviewed S1's medication training from 2025. Interview with 3 of 3 all stated that they know where the key is for the medication cabinet and have access to it if needed. Interview with ADM revealed that in each shift there is a delegated lead staff to provide the medications if needed to the residents and both ADM and S1 confirmed that the medication is distributed right away once dispensed. LPA and ADM discussed medication training topics with all staff members even if the staff is not delegated lead staff in case of emergencies. No deficiencies cited. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 3, 2026

Type of visit: Required - 1 Year

On 11/21/25 at 1:45 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Debra Harvey, Care Staff, and explained the purpose of the visit. LPA spoke with Administrator, Roland Wilson and will continue annual at a later date.. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the kitchen sink was measured at 108.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 10/22/25. First aid kit was observed to be complete. Emergency Disaster Plan was last posted on 11/04/25. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 21, 2025

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Resident was given an insulin injection by staff who is not an appropriately skilled professional

On 1/22/25 at 2:45 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a 10 day complaint investigation and deliver findings in regard to the allegation above. LPA met with Roland Wilson, Administrator and explained the purpose of the visit. During the course of the investigation LPA interviewed facility resident (R1) and facility staff (S1 and S2) and reviewed R1's file and facility schedule for January 2025. R1's physician’s report documented that R1 is capable of administering her own insulin. LPA interviewed R1 who stated that she administers her insulin mostly “on my own.” Staff adjust the dosage but do not assist with the injection itself. Facility staff also stated that R1 administers her insulin by herself and that they never touch her needles. Staff also stated that they make sure that R1 disposes of her needles properlyin the sharp disposal container in the kitchen. ***report continujes on LIC9099C*** Unsubstantiated ***report continues from LIC9099*** LPA also reviewed the staff schedule for Saturday 1/11/25 to confirm staff on duty and S1 and S2 were the staff on duty. This agency has investigated the complaint alleging resident was given an insulin injection by staff who is not an appropriately skilled professional. We have found that the complaint was unsubstantiated. 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, therefore the allegation is UNSUBSTANTIATED. Exit interview conducted, a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 22, 2025 · control 15-AS-20250113161430

Type of visit: Required - 1 Year

On 11/21/24 at 10:15 AM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Roland Wilson and explained the purpose of the visit. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the kitchen sink was measured at 108.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 11/05/24. Emergency Disaster Plan was last posted on 10/28/24. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 11/02/24. LPA reviewed 3 residents records and 5 staff records; all were complete. LPA also reviewed a sample of resident’s medications. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 21, 2024

Type of visit: Required - 1 Year

On 11/15/23 at 12:00 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Roland Wilson and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory residents. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 3 total bedrooms of which all bedrooms are occupied by the residents. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 74 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 110.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 11/01/23. Emergency Disaster Plan was last posted on 11/07/23. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 11/07/23. LPA reviewed 5 residents records and 5 staff records, all were complete. LPA also reviewed a sample of resident’s medications. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 11/22/23: LIC 610E Emergency Disaster Plan No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 15, 2023