Elderly Care on Calmia

Type of visit: Required - 1 Year

At approximately 2:05 PM, Licensing Program Analyst (LPA) Jill Nakagawa made an unannounced annual required inspection of this licensed senior care facility. There were 6 residents currently at the facility. There was one staff. LPA met with House Manager Ron-Mark Adriano and toured the building which was found to be clean and in good repair. LPA toured the grounds and observed all walkways and exits to be unobstructed. All notices that are required to be posted are in a highly visible area. LPA observed activity supplies for resident use, including a piano and karaoke. There was an ample amount of fresh and nonperishable foods as required within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked storage closet. Fire extinguishers were last inspected on 5/14/2025 and fully charged. Smoke detectors were found to be in working order. Carbon Monoxide detectors were present and operational. Medication is centrally stored and secure. Medication Administration Record (MAR)was up to date. Facility is providing a clean and safe environment for residents. LPA reviewed 5 of 6 resident records. All records contained current and signed admission agreements and current physician reports. Medication records are thorough and contained physician's orders for each resident. LPA reviewed 3 personnel files and found them complete, including all training and up-to-date with First Aid. LPA requested updated: LIC500 LIC308 LIC610E Proof of Liability Insurance No deficiencies were found at the time of inspection. Exit interview conducted with Ron-Mark Adriano. Copy of report left at facility.the state’s words, verbatim · CDSS document, Nov 18, 2025

Type of visit: Required - 1 Year

At approximately 3:05 PM, Licensing Program Analyst (LPA) Jill Nakagawa made an unannounced annual required inspection of this licensed senior care facility, licensed for 7 residents. LPA met with House Manager Paulin Pantig and toured the building which was found to be clean and in good repair. LPA toured the grounds and observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Toxins are stored in a locked storage closet. Water temperature measured within regulation between 105 and 120 degrees F at faucets accessible to residents. Fire extinguishers inspected were fully charged. Smoke detectors were found to be in working order. Carbon Monoxide detectors were present. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure. LPA reviewed 5 of 6 resident records. All records contained current and signed admission agreements and current physician reports. Medication records are thorough and contained physician's orders for each resident. LPA reviewed 4 personnel files and found them complete, including all training and up-to-date with First Aid. LPA requested an updated: LIC500 LIC308 LIC610E Proof of Insurance No deficiencies were found at the time of inspection. Exit interview conducted with Paulin Pantig. Copy of report left at facility.the state’s words, verbatim · CDSS document, Dec 4, 2024

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff are not providing a comfortable temperature for the residents

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced at approximately 2:15 PM on 7/24/2024 to deliver findings of the complaint investigation regarding the above allegations and met with House Manager, Paulin Pantig. LPA conducted interviews and made observations. During the visit on 7/10/2024, LPA made the following observations: • Facility's thermostat was inoperable due to power outages throughout the facility. External temperature had been over 105 the last several days; LPA’s thermometer read 91.4 degrees F. at the time of inspection in the dining room of the facility. Continued on 9099-C Substantiated Continued from 9099...... Multiple fans were running in the facility and multiple room air conditioning units were providing cooling to residents’ bedrooms, using extension cords running from neighbors’ homes. Main circuit breaker to the facility was not working properly and main air conditioning unit was inoperable at the time of inspection. Per Licensee, the air conditioning unit had been installed 2 weeks ago and there had been no problems until the extreme heat wave had presented issues to the power grid and the facility had been experiencing intermittent power outages. During the inspection, the Administrator delivered additional portable air conditioning units to the facility, installed window coverings to help keep heat out of facility, contacted PG &E and electrical/air conditioning repair company to correct problems. Due to unreliable and inadequate power source and the facility's inability to power the portable air conditioning units the facility's emergency plan was initiated and residents and staff were evacuated to a nearby hotel until repairs could be made and facility’s temperature could be regulated to within regulation. Based on LPA’s interviews conducted and observations made, the preponderance of evidence standard has been met, therefore the allegation that Staff are not providing a comfortable temperature for residents is substantiated. Based on California Code of Regulations, (Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.”) A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. 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. Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Appeal Rights, and Plan of Corrections Letter discussed and provided to Paulin Pantig, House Manager. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Jul 24, 2024 · control 21-AS-20240710122708

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(b)(2) · Plan of correction due date: Jul 24, 2024

87303 Maintenance and Operation:(b) A comfortable temperature for residents shall be maintained at all times. (2)The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C)and 85 degrees F(30 degrees C).. This requirement was not met as evidenced by: interviews conducted, and observations made, Licensee did not ensure that temperatures in the facility were within regulation. Facility temperatures were observed by LPA to be 91.4 degrees on 07/10/2024.the state’s words, verbatim · CDSS document, Jul 24, 2024

Plan of correction: Licensee to put in writing their plan in the event of a future power outage and provide proof of training to staff of said plan to CCL by 7/26/2024.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced at Elderly Care on Calmia on 12/19/2023 for the purpose of addressing a deficiency. LPA met with staff member. During recent inspection on 12/07/2023 LPA toured the facility and observed changes in the facility's layout due to the addition of a wall in kitchen area; which added an additional bedroom to the facility. A new facility sketch was not submitted to the Department, and an inspection by the Fire Department was not requested as per regulation. (See LIC 809D and Civil Penalty). The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Civil Penalty assessed in the amount of $500.00 (See LIC 421M dated for December 19, 2023) Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in additional civil penalties. Exit interview conducted with the and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 19, 2023

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced at Elderly Care on Calmia on 12/19/2023 for the purpose of addressing a deficiency. LPA met with staff member. During recent inspection on 12/07/2023 LPA toured the facility and observed changes in the facility's layout due to the addition of a wall in kitchen area; which added an additional bedroom to the facility. A new facility sketch was not submitted to the Department, and an inspection by the Fire Department was not requested as per regulation. (See LIC 809D and Civil Penalty). The following deficiencies were observed (See LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Civil Penalty assessed in the amount of $500.00 (See LIC 421M dated for December 19, 2023) Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in additional civil penalties. Exit interview conducted with the and appeal rights provided. **An immediate civil penalty in the amount of $500 was assessed today for the fire clearance violation. Deficiencies cited (see LIC809-D page) from the California Code of Regulations, Title 22, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Appeal Rights Provided. LPA is requesting the submission of the following: LIC200 Updated facility sketch Request for Fire Department Inspection Exit interview conducted with Paulin Pantig, House Manager, whose signature on this documentthe state’s words, verbatim · CDSS document, Dec 19, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Dec 19, 2023

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.This requiement was not met as evidenced by: facility's floor plan and operations. This presents an immediate health, safety and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, Dec 19, 2023

Plan of correction: Licensee to submit required documents needed (formal request, LIC 200, update facility sketch) to request a fire clearance inspection for facility's changes. . Licensee to submit a statement that they understand the regulation and shall be in future compliance. POC due date12/20/2023 to CCL. *** An immediate Civil Penalty in the amount of $500 was assessed.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jill Nakagawa arrived unannounced to conduct an inspection. There was two staff members at the time of inspection. Administrator was contacted via phone. House Manager Paulin Panting arrived within 20 minutes. LPA Nakagawa found the facility to be clean and well organized. The 5 residents were clean and dressed appropriately, and participating in activities and then sharing dinner and conversation. The bedrooms were clean and furnished as per regulation. Residents had personal items to make their rooms homey. Camera was in use in resident room; sign was posted. The kitchen was clean and well-appointed with plenty of cooking equipment. There was an ample supply of perishables and non-perishables as required per regulation. The bathrooms were equipped with handsoap and paper towels. One bathroom was undergoing repairs, but the other bathrooms in the facility were operable, minimizing the impact on residents. The facility's backyard was free of debris and had a nice outside space with tables and chairs and raised gardens for residents' enjoyment, as well as several fruit trees and a variety of plants. LPA reviewed 5 resident files and found them to be complete. All personnel files were not available at the time of inspection, but the one reviewed was complete. (Continued on 809-C) LPA requested the following documentation: LIC 308 Disaster Plan Proof of Liability Insurance Updated Facility Sketch Request for Fire Inspection Personnel files There were no citations issued at the time of this inspection.the state’s words, verbatim · CDSS document, Dec 7, 2023