Edna's Residential Care III

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:15 A.M. LPA initially met with facility staff Magdalena Duya and Samuel Ybanez. Licensee/Administrator was contacted via telephone and arrived at the facility at 10:55 A.M. Entrance interview conducted. Beginning at 11:20 A.M., the LPA, along with Licensee/Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This facility doesn’t have a staff room; facility will provide 24/7 care. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The following was observed: OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for residents’ use. All exits and passageways were observed to be free of hazards. There were no bodies of water noted. Facility has two total gates; both were observed to be self-latching and closing with clear passageways for emergency exit use. KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives, staff and resident files and medication were observed to be locked inside kitchen cabinets at the time of the visit. At 11:41 A.M. hot water measured at 136.9 degrees Fahrenheit. During today’s visit, the licensee adjusted the thermostats to bring water temperature within the required range. Continued on LIC 809 Continued from LIC 809-C LAUNDRY ROOM/GARAGE: Adjacent to the kitchen is a separate laundry room and locked garage. Cleaning supplies and hygiene products were observed to be locked in a cabinet and properly stored at the time of the visit. Garage was observed and contained extra food, cleaning supplies and emergency food and water. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be inaccessible to residents in care. The facility maintained a comfortable temperature of 73 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed. Individual smoke detectors were tested at 11:46 A.M. and carbon monoxide detector were tested at 11:48 A.M. All alarms were functional at the time of the visit. Fire extinguisher was observed to be fully charged and last serviced on 08/12/2025. BEDROOMS: There are 5 (five) total bedrooms; 1 (one) of which is a shared resident room, 4 (four) are private resident rooms. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: The LPA observed 3 (three) restrooms in the facility; 1 (one) is for shared use and 2 (two) are designated for private resident use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Starting at 11:27 A.M., LPA measured hot water temperature in all restrooms, which were found to be above the required range of 105-120 degrees Fahrenheit. During today’s visit, the licensee adjusted the thermostats to bring water temperature within the required range. RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Four (4) resident records reviewed were complete and contained all required documents. LPA reviewed medical assessments for Resident #1 and #2 indicating no capacity for self-care. During today’s visit, both residents were observed self-feeding. Continued on LIC 809-C Continued from LIC 809-C Licensee will contact primary physicians to update medical assessments. Additionally, LPA observed that three (3) out of four (4) Needs and Service Plans were not signed by the residents or their responsible persons. Four (4) staff files reviewed were complete and contained all required documents. However, LPA observed two caregivers did not have a valid CPR on file. Technical Violation (TV) issued. MEDICATION REVIEW: Medications for four (4) residents were observed. Medications are centrally stored and locked in a cabinet in the kitchen. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. EMERGENCY DISASTER PLAN/INFECTION CONTROL PLAN: LPA reviewed the facility emergency disaster plan and infection control plan, both of which were complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill documented on 10/02/2025. During today's visit, LPA gathered the following items: Personnel Record (LIC500), Facility Roster (LIC9020A) and a copy of the facility's liability insurance. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 4, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:20 A.M. LPA initially met with facility staff Magdalena Duya. Licensee/Administrator was contacted via telephone and arrived at the facility at 10:51 A.M. Entrance interview conducted. Beginning at 10:52 A.M., the LPA, along with Licensee/Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This facility doesn’t have a staff room, facility will provide 24/7 care. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The following was observed: OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. All exits and passageways were observed to be free of hazards. There were no bodies of water noted. Facility has two total gates; both were observed to be self-latching and closing with clear passageways for emergency exit use. KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives, staff and resident files and medication were observed to be locked inside kitchen cabinets at the time of the visit. At 11:23 A.M. hot water measured at 116.4 degrees Fahrenheit. LAUNDRY ROOM/GARAGE: Adjacent to the kitchen is a separate laundry room and locked garage. Garage was observed and contained extra food, cleaning supplies and storage. Emergency food and water was observed. Cleaning supplies and hygiene products were observed to be locked in a cabinet and properly stored at the time of the visit. Continued on LIC 809-C Continued from LIC 809 COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be inaccessible to residents in care. The facility maintained a comfortable temperature of 71 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed. Smoke detector was tested at 12:28 P.M. and carbon monoxide detector was tested at 11:01 A.M. and both were functional at the time of the visit. Fire extinguisher was observed to be fully charged and last serviced on 08/08/2024. BEDROOMS: There are 5 (five) total bedrooms; 1 (one) of which is a shared resident room, 4 (four) are private resident rooms. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: The LPA observed 3 (three) restrooms in the facility; 1 (one) is for shared use and 2 (two) are designated for private resident use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. Between 10:58 A.M. and 11:17 A.M. hot water temperature was measured in all restroom and measured within the required range. Continued on LIC 809-C Continued on LIC 809-C RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 5 (five) resident records reviewed were complete and contained all required documents. LPA observed that the Administrator has been using the Resident Appraisal (LIC603A) form in place of the required Appraisal/Needs and Service Plan (LIC625). Licensee stated that the LIC6003A has been utilized for several years and was unaware of the requirement for a LIC625 form. The LPA emailed the Administrator a copy of the LIC625 and explained that LIC 625 shall be completed annually or whenever there is a change in the resident’s condition. Technical advise issued. Four (4) staff files reviewed were complete and contained all required documents. MEDICATION REVIEW: Medications for five (5) residents were observed. Medications are centrally stored and locked in a cabinet in the kitchen. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. Medications were observed to be maintained and administered in compliance with regulation. INTERVIEWS: Throughout the visit, LPA interviewed 2 (two) staff and 2 (two) residents and a visitor. During today's visit, LPA gathered the following items: Personnel Record (LIC500), Facility Roster (LIC9020A). A copy of the facility's liability insurance. Emergency disaster drills are conducted quarterly, with the last drill documented on 08/01/2024. No deficiencies cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 30, 2024

Type of visit: Case Management - Annual Continuation

LPA Conway Final printed report before completing the "Inspection Tool". An annual continuation was generated to be able to complete the Inspection Tools and generate Notes and Technical Advise. Please find annual report under LIC 809 - FER - Visit Date 10/30/2024 Visit Type REQUIRED - 1 Year **Recorded** and two continuation LIC 809-C - FER - Visit Date 10/30/2024 **Recorded**the state’s words, verbatim · CDSS document, Oct 30, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:24AM. LPA initially met with facility staff. Licensee/Administrator was contacted via telephone and arrived at the facility at 09:45AM. Entrance interview conducted. Beginning at 10:14AM, the LPA, along with Licensee/Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Smoke detector was tested at 10:04AM and carbon monoxide detector was tested at 10:05AM and both were functional at the time of the visit. Fire extinguisher was observed to be fully charged and last serviced on 03/16/2023. OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. All exits and passageways were observed to be free of hazards. KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. Emergency food and water was observed. Adjacent to the kitchen is a separate laundry room and locked garage. Garage was observed and contained extra food, cleaning supplies and storage. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be inaccessible to residents in care. Report Continued on LIC 809-C BEDROOMS: There are 5 (five) total bedrooms; 1 (one) of which is a shared resident room, 4 (four) are private resident rooms. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: The LPA observed 3 (three) restrooms in the facility; 1 (one) is for shared use and 2 (two) are designated for private resident use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in the shared resident restroom and measured within the required range. RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 5 (five) resident records reviewed were complete and contained all required documents. 3 (three) staff files reviewed were complete and contained all required documents. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually, as required. Emergency drills are conducted quarterly, with the last drill documented on 11/01/2023. MEDICATION REVIEW: Medications for 2 (two) residents were observed. Both 2 (two) of 2 (two) residents' medications were observed to be maintained and administered in compliance with regulation. INTERVIEWS: Throughout the visit, LPA interviewed 2 (two) staff and 2 (two) residents. During today's visit, LPA gathered the following items: LIC 500 A copy of the facility's liability insurance No deficiencies cited. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Nov 18, 2023