Dover Valley Residential Care Home

Type of visit: Required - 1 Year

At approximately 9:45 PM, Licensing Program Analyst (LPA) Stevenson arrived unannounced to conduct a required 1-year annual inspection and was greeted by facility Staff Imelda Mallari who has Designation of Facility Responsibility (RP). RP called Administrator who arrived at approximately 9:55 AM to assist with today's inspection Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care. Facility has a Dementia Care Plan, and a Hospice waiver for three (3) and facility currently cares for two(2) hospice residents. Licensee recently modified home and applied for one (1) converted non-ambulatory bedrooms which the fire department granted on 08/13/2025. Facility is now approved for 6 non-ambulatory residents. At approximately 10:15 AM, LPA initiated a tour of the facility with House Manager and observed the following: Facility is a one story home, was a comfortable temperature, bright and facility was without odors. Passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were observed locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Facility also has an emergency generator available. Continued on LIC809-C... Continued for LIC809 LPA observed a number of unzipped and undated meat portions in the refrigerator, as well as, at least one instance of condiment sauce that required refrigeration after opening. A type B citation is being cited for violation of CCR 87555(b)(9) There is a shaded seating area in the backyard with outdoor space for activities. LPA inspected two locked sheds in the backyard which contained care equipment, holiday decorations, tools, and chemicals. LPA observed residents watching TV or reading in the common area and in their bedrooms. LPA observed games available to residents. Facility now has a dedicated internet access device and internet service available to residents in care and the telephone was tested an operational during inspection. At approximately 11:30 AM, LPA conducted file review and observed the following; Four (4) of (4) staff files had all required documentation including medical exams, criminal clearance and TB testing. At approximately 12:15 PM LPA observed the following: Six(6) of 6 residents files and all had required documentation. LPA observed resident (R1) sitting up comfortably in a wheelchair in the living room and dinning area, but is designated as "Bedridden" on their recent Physicians Report. A type B citation for violation of fire clearance CCR87606(c) with licensee asked to ensure R1 has a re-evaluation by their physician by Plan of Correction date and to notify LPA if they cannot secure that appointment. Licensee states that the facility and residents' family members coordinate residents' medical and dental appointments and transportation to and from visits. Medications and medication records were inspected and observed maintained in compliance with regulation. Facility does not handle P&I money LPA obtained the follow documents for the facility file today including: LIC500 Personnel Report LIC9020 Register of Facility Residents Updated Liability Insurance Two (2) LIC 308 Designation of Facility Responsibility Reviewed LIC610D Emergency Disaster Plan Continued on LIC809C Continued from LIC809C Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Edward Gadia and Appeal rights were giventhe state’s words, verbatim · CDSS document, Jan 29, 2026

Type of visit: Office

An office meeting was conducted today, 09/03/2025, in the Santa Rosa Regional Office. The following individuals were present in the meeting: Licensing Program Manager, Bethany Moellers, Licensing Program Analyst, Julie Florio, House Manager, Edward Gadia, and House Co-Manager, Lourdes Gadia. Licnesee/Administrator was unable to attend today's meeting. The Department has received some of the required documents to process a change of administrator to Edward Gadia. . The purpose of the office meeting was to hold an Informal meeting to address the following areas of concern identified by the Department: Administrator oversight Staff training Change of condition Seeking Timely Medical Care for Residents Required Change of Administrator Documents Requested: LIC 308 (Designation of Facility Responsibility) Active and Current Administrator Certificate First Aid Certificate LIC 500 (Personnel Report) Continued on LIC809C... Continued from LIC809... LIC 501 (Personnel Record) LIC 503 (Health Screening Report - personnel)Proof of Negative TB test LIC 9182 (Criminal Record Exemption Transfer Request) LIC 508 (Criminal Record Statement) Copy of Driver's License or Passport that is not expired Statement signed by Licensee requesting Change of Administrator Deficiencies were cited and civil penalties were assessed on Complaint Control Number 21-AS-20250314120850 regarding a violation that the Department determined constitutes the facility not seeking timely medical care for a resident, as defined in Title 22, Division 6, Chapter 8, Article 08. Exit interview conducted with Administrator whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Sep 3, 2025

Allegation investigated: Staff do not ensure that resident is wearing clean clothing

On 06/19/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint 21-AS-20250321094711 investigation findings regarding the above allegation and met with Lourdes Gadia, Designated Responsible Party (DRP). Reporting Party (RP) alleges that the facility staff do not ensure that Resident 1 (R1) is wearing clean clothing. LPA Florio conducted 10-day complaint investigation visit on 03/27/2025 and obtained documents, made observations, and conducted interviews. During this visit, R1 was observed wearing clean clothing and no signs of soiled garmets. Additionally, during this visit, it was revealed through interviews with staff and House Manager (HM) and progress notes dated 03/15/2025-03/20/2025 that R1 refused personal care on more than one occasion, somtimes choosing to remain in the same clothes from the previous day. Based on observations made, interviews conducted, and records reviewed, the department received conflicting information. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... Based on interviews conducted and records obtained, the allegation that the facility staff do not ensure that (R1) is wearing clean clothing is UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with DRP, whose signature on form confirms receipt of document(s).the state’s words, verbatim · CDSS document, Jun 19, 2025 · control 21-AS-20250321094711

Allegation investigated: Facility staff did not administer medication as prescribed by doctor

On 06/19/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint 21-AS-20250321094711 investigation findings regarding the above allegations and met with Lourdes Gadia, Designated Responsible Party (DRP). Reporting Party (RP) alleges that the facility staff did not administer medication as prescribed by doctor for Resident 1 (R1). LPA Florio conducted 10-day complaint investigation visit on 03/27/2025 and obtained documents, made observations, and conducted interviews. During this visit it was revealed through an interview with the House Manager (HM) and progress notes dated 03/15/2025-03/20/2025 that R1 refused medications on more than one occasion, R1 liked to count their pills on a napkin on the bedside table and take them when ready, and sometimes this resulted in pills being found in the bed. Continued on LIC9099C... Substantiated Continued from LIC9099... Further, the facility's staff training manual section on their medication administration policy, states "watch the resident take the medication. Stand by until medication is swallowed." Based on the above information, the facility did not administer R1's medications in accordance with their policy, per regulation, or as prescribed by their doctor. Based on interviews conducted and records obtained, the allegation that the facility staff did not administer medication as prescribed by doctor is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D). Exit interview conducted with DRP, whose signature on form confirms receipt of documents. Appeal rights provided.the state’s words, verbatim · CDSS document, Jun 19, 2025 · control 21-AS-20250321094711

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 18, 2025

Incidental Medical and Dental Care: 87465(a)(4) The licensee shall assist residents with self administered medications as needed. This requirement is not met as evidenced by: Based on interviews conducted and documents obtained for R1, the facility staff did not ensure that R1 took their medications as directed by their doctor which poses/posed a potetnial health, safety, and/or personal rights violation to persons in care.the state’s words, verbatim · CDSS document, Jun 19, 2025

Plan of correction: Licensee to submit proof of retraining with all staff on administration of medications in accordance with regulation and the facility's policy. Additionally, this training shall include a review of the required notification procedures when a resident... ...refuses medications, including an update to the facility's policy which accurately reflects regulatory reporting requirements to CCL by POC due date of 07/18/2025.

Allegation investigated: Neglect, lack of supervision, facility did not seek timely medical

On 06/11/2025, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint 21-AS-20250314120850 investigation findings regarding the above allegation and met with Edward Gadia, House Manager. Reporting Party (RP) alleges that the facility did not seek timely medical for Resident 1 (R1). LPA Florio conducted 10-day complaint investigation visit on 03/19/2025 and obtained documents, made observations, and conducted interviews. During this visit it was revealed through an interview with the House Manager (HM) that there was a pressure injury present “probably a stage 1-2” that had not yet been evaluated and staged by R1’s primary care physician (PCP). Continued on LIC9099C... Substantiated Continued from LIC9099... Per progress noted dated 03/14/2025, HM was verbally notified by R1’s PCP to begin monitoring, turning, and repositioning R1, at which time HM observed the pressure injury. Further interviews with R1 and Staff 1 (S1), revealed that the facility was aware of R1's discomfort and the injury that was forming for at least a week prior to R1’s wound being evaluated and staged by their PCP and that visit was initiated by R1’s family on March 19, 2025. On March 24, 2025, LPA received a copy of R1’s Doctor’s Orders indicating the pressure injury was a “stage 2” pressure injury. Based on interviews conducted and records reviewed, the facility was unable to provide proof of a medical assessment being sought for R1 in the time prior to the staging which resulted from the family’s efforts, (see LIC9099D). An immediate civil penalty in the amount of $500 if being issued during today's visit, (see LIC421IM). R1 was sent to the hospital for generalized weakness on 03/20/2025. At that time R1's family notified facility that R1 would not be returning. Based on interviews conducted and records obtained, the allegation that the facility did not seek timely medical for R1 is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D). The House Manager was informed that civil penalties are under review by the Department per Health and Safety Code 1569.49 (f). Exit interview conducted. Copy of report discussed and provided to House Manager, whose signature on form confirms receipt of documents. Appeal rights provided. Continued from LIC9099A... Further interviews with R1 and Staff 1 (S1), revealed that the facility was aware of R1's discomfort and the injury that was forming for at least a week prior to R1’s wound being evaluated and staged by their PCP and that visit was initiated by R1’s family on March 19, 2025. On March 24, 2025, LPA received a copy of R1’s Doctor’s Orders indicating the pressure injury was a “stage 2” pressure injury. Based on interviews and record review, the facility was unable to provide proof of a medical assessment being sought for R1 in the time prior to the staging which resulted from the family’s efforts. On 03/20/2025 R1 was sent to the hospital for generalized weakness. At that time R1's family notified the facility that R1 would not be returning. Based on interviews conducted and records reviewed, the department received conflicting information. Based on interviews conducted and records obtained, the allegation that the facility failed to observe change of condition for R1 is UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted. Copy of report discussed and provided to Licensee, whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jun 11, 2025 · control 21-AS-20250314120850

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(2) · Plan of correction due date: Jun 12, 2025

Incidental Medical and Dental Care 87465(a)(2) The licensee shall provide assistance in meeting necessary medical and dental needs…. This requirement is not met as evidenced by: Based on facility not ensuring R1 was sent out for timely medical evaluation of observed changes to R1's condition, resulting R1's family seeking medical attention and diagnosis of a stage 2 pressure injury, which posed an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 11, 2025

Plan of correction: Licensee to submit self-certification that regulations 87465 Incidental Medical and Dental Care and 87466 Observation of a Resident have been reviewed with facility staff and are understood to CCL by POC due date 06/12/2025.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Julie Florio conducted a case management- incident inspection, on 3/27/25 at approximately 2:30 PM, and was greeted by Myrna Tugade, House Supervisor. LPA spoke with facility House Manager, Edward Gadia who arrived at approximately 3:00 PM. LPA was informed that the Licensee/Administrator is currently out of the country on vacation. LPA is conducting a case management visit to obtain more information regarding concerns the Department has about Administrator Qualifications and Duties due to recent complaints and incident reports received as well as observations made during LPA's initial annual inspection visit dated 2/27/2025 and subsequent visit on 03/19/2025. During the 02/27/2025 visit, LPA requested facility submit change of administrator documentation to CCL as required to be reported to the Department within 30-days of any such change. The Department has not yet received this request or information from the facility. Today, House Manager states that a change of administrator request and supporting documentation was submitted to the Department via email communications with a previous LPA in 2023. Today, LPA reviewed staff records and obtained copies of documents including a personnel roster/report. Additionally, LPA conducted interviews with two residents and two staff members present during today's visit. Based on observations made today and during the above mentioned facility visits, documents obtained, and interviews conducted, LPA needs to conduct further file review and investigation and will return to the facility at a later date to resolve this issue. No deficiencies are being cited during today's inspection. Exit interview conducted with House Manager, whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 27, 2025

Type of visit: Case Management - Annual Continuation

At approximately 1:45 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management -- annual continuation visit to review resident files, staff files, and medications and medication logs, and met with Edward Gadia, House Manager. At approximately 2:00 PM, LPA conducted file review. Four (4) staff and five (5) resident files were reviewed and LPA observed the following: Four (4) staff files reviewed were observed to have the required documentation per Title 22 regulations. LPA informed House Manager that all staff files shall have a physician health screening and proof of negative TB results and a record of the initial 40 hours of training completed to bring the facility back into compliance. The House manager agreed to bring the facility back into compliance with regulation immediately. All staff have proof of current First Aid and House Manager will have all staff complete CPR training to ensure there is always at least one CPR certified staff member on shift at the facility per regulation. LPA reviewed five (5) of five (5) resident files which were each observed to contain all the required documents per regulation. House manager agreed to ensure all care plans are reviewed and signed by each residents' responsible party no less than annually to remain in compliance with regulation. House Manager states that the facility and residents' family members coordinate residents' medical and dental appointments and transportation to and from visits. Medications and medication records were inspected and observed maintained in compliance with regulation. Facility does not handle P&I. No deficiencies cited during today's inspection. Exit interview conducted with House Manager whose signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 19, 2025

The state marks this report as 5 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

At approximately 12:30 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by facility Staff. Edward Gadia, House Manager was contacted via telephone and arrived at approximately 12:45 PM. Facility is a Residential Care Facility for the Elderly (RCFE) with six (6) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for three (3), and is approved for 6 non-ambulatory residents. Facility does not currently have any Hospice residents in care. At approximately 1:00 PM, LPA initiated a tour of the facility with House Manager and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperatures in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, and hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were observed locked. Facility has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There is a shaded seating area in the backyard with outdoor space for activities. LPA inspected two locked shed in the backyard which contained care equipment, holiday decorations, tools, and chemicals. LPA observed residents watching TV or reading in the common area and in their bedrooms. LPA observed games available to residents and House Manager states staff take the residents in the yard for exercise and facility staff discuss current events with residents daily. Facility does not have an internet access device designated for resident use, but House Manager agrees to purchase one immediately to bring the facility into compliance with regulation. Facility has internet service available to residents in care and the telephone was tested an operational during inspection. Continued on LIC809-C... Continued from LIC809C... Facility's fire extinguisher was observed charged and was last serviced 07/2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts quarterly disaster drills, and the most recent drill was conducted 12/2024. LPA observed the facility's infection control plan, several first aid kits, PPE, and emergency supplies. Facility has a generator for emergency preparedness. LPA reviewed facility's emergency disaster plan last updated 02/2024. House Manager stated they would like to update the facility Administrator to himself. Also, House Manager states that facility may be submitting an application for change of ownership within the next month. LPA discussed what needs to be submitted to CCL by the Licensee for this change to occur. LPA will return at a later date to complete the annual inspection. LPA will review resident files, staff files, and medications and medication logs during that visit. Facility does not manage P&I. Required Change of Administrator Documents: LIC 308 (Designation of Facility Responsibility) Active and Current Administrator Certificate First Aid Certificate LIC 500 (Personnel Report) LIC 501 (Personnel Record) LIC 503 (Health Screening Report - personnel) Proof of Negative TB test LIC 9182 (Criminal Record Exemption Transfer Request) LIC 508 (Criminal Record Statement) Copy of Driver's License or Passport that is not expired Statement signed by Licensee requesting Change of Administrator Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: LIC610D - Emergency Disaster Plan (updated) No deficiencies were cited during inspection. Exit interview conducted with House Manager whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Feb 27, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced to conduct an annual inspection utilizing the full CARE inspection tool. LPA met with caregivers Emily Rapadas and Edgar Rapadas who contacted Administrator, Edward Gadia, who arrived to the facility shortly afterwards. LPA explained the purpose of the visit. LPA and Administrator discussed changing Administrator on file. LPA requested a copy of Administrator Certificate to confirmed certification and will notify facility's assigned LPA of the following change. During today's inspection, LPA and Administrator conducted a tour of the interior and exterior of the facility to ensure the health and safety of residents in care. Areas toured included but not limited to: six resident bedrooms, two bathrooms, laundry room, staff room, office, kitchen, backyard and the common areas. LPA observed knives, toxins, and medications to be locked and inaccessible to residents in care. LPA observed the exterior of the facility to be free from tripping hazards. LPA observed smoke alarms and carbon monoxides to be present and in operating condition. LPA observed facility to have ample supple of linens, and Personal Protective Equipment. LPA observed facility to have 2+ days of perishable and 7+ days of nonperishable foods. In areas toured, no immediate health safety and personal rights violation was observed. LPA conducted a personnel and resident file review. LPA observed facility to have the required documents present on file. CARE inspection tool completed and facility is found to be in compliance. No deficiencies cited. At this time, LPA request a copy of LIC 500, Administrator Certificate and liability insurance to be emailed to LPA Yang by Friday February 16, 2024. Exit interview conducted and a copy of the report will be emailed to Administrator.the state’s words, verbatim · CDSS document, Feb 12, 2024