Elderly Guest Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sommer arrived unannounced to conduct a Required - 1 Year visit on 10/3/2025. LPA Hayes was met by staff and later met with Licensee,Sarah Jane Egante and stated the purpose of today’s visit. The facility is licensed for a capacity of 6. The census was 6. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The most recent emergency drill was conducted on 09/21/25 at 9:00am with 8 residents. The temperature inside the facility was observed to be at 77*F, which is within the required range of 68-85*F. The hot water temperature was measured at 109.6 *F which is within the required range of 105-120*F. LPA observed fire extinguisher serviced 03/31/25 by River City Fire. Smoke and carbon monoxide detectors, and central heating and air where observed in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The medication administration record (MAR) was reviewed and found to have accurate documentation of administered medications provided to residents. Staff were observed cooking, cleaning and assisting residents in care. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA Hayes observed the backyard of the facility to be clean and free of hazards. There were shaded areas and fruit and vegetable gardens for residents to enjoy. Fencing was in good repair. There were no bodies of water. The facility living room was clean and free of obstruction. Continued on 809C LPA Hayes reviewed 5 resident files and 2 staff records during this visit. LPA Hayes requested the following annual documents for the facility file: LIC 500 Personnel Report, LIC 308 Designation of Responsibility, LIC 610 Emergency Disaster Plan, LIC 999 Facility Sketch, Copy of Liability Insurance. Per California Code of Regulations (CCR) - Title 22, 0 deficiencies are being cited today. An exit interview was held, and a copy of the report was provided to Licensee,,Sarah Jane Egante.the state’s words, verbatim · CDSS document, Oct 3, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kimberly Viarella conducted a case management visit to the facility on today's date for the purpose of delivering an Order To Licensee/Facility of Immediate Exclusion from all Facilities. LPA handed the Order to Licensee/Facility of Immediate Exclusion From Facility letter to Staff (S2). S2 stated that S1 had stopped by the facility that morning, but was not present at this time. LPA explained that if facility staff (S1), were present in the facility, S1 needed to leave immediately. S1 is to be removed from all shifts and disassociated from the facility in Guardian. No deficiencies were cited during today’s visit and copy of this report was provided along with a copy of the Declaration of Service.the state’s words, verbatim · CDSS document, Sep 17, 2025

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct a case management visit. LPAs Moleski and Williams met with facility administrator Eric Serrano and explained the purpose of the visit. LPAs Moleski and Williams reviewed facility files and obtained copies of resident records pertaining to five residents (R1-R5). Two residents diagnosed with dementia (R1, R3) had LIC 602s on file with exam dates more than one year in the past. R1's LIC 602 indicated that R1 was examined by a physician on 4/3/23. R1 has dementia, according to the LIC 602. R3's LIC 602 indicated that R3 was examined by a physician on 9/27/22. R3 has dementia, according to the LIC 602. Serrano could not produce a more recent LIC 602 for either of these residents during this visit. This facility is hereby cited per 22 CCR Section 87705(c)(5). An exit interview was held with Serrano. Appeal rights and a copy of this report was left with Serrano.the state’s words, verbatim · CDSS document, Oct 21, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(c)(5) · Plan of correction due date: Oct 28, 2024

" (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs." This requirement was not met as evidenced by: Based on record review, two dementia residents did not receive annual medical assessments, which poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Oct 21, 2024

Plan of correction: Licensee agrees to provide LPA Moleski with updated LIC 602s by POC due date. vincent.moleski@dss.ca.gov

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 10/18/24 at 1:15pm and met with Applicant Elderly Guest Home Sarah Jane Egante and Administrator Eric Serrano and stated the purpose of the visit. This visit is to conduct a Pre-Licensing Inspection. LPA was allowed entry into the facility that will be licensed and fire cleared for a capacity of 6 residents of which 4 maybe non-ambulatory. Rooms 1,5,6,7 can accommodate non-ambulatory residents and room 2 is for staff. Administrator certificate expires on 8/26/26. LPA observed that the facility has submitted a Infection Control Plan. LPA observed a Designation of Facility Responsibility (LIC308) on file. LPA and Sarah Jane Egante and Eric Serrano toured and inspected the physical plant inside and outside to ensure there are no health and safety concerns. LPA observed the kitchen area, dining area, bedrooms and bathrooms, storage areas, and laundry rooms. LPA observed knives/sharps area to be locked. LPA observed required furniture, and lighting throughout the facility. The hot water temperature measured at 113.8 *F which is within the required range of 105-120*F. The temperature inside the facility measured 72*F which is within the required range of 68-85*F. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. The first aid kit included supplies such as sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA observed area for centrally stored medications to be locked. LPA observed the fire extinguisher(s), smoke and carbon monoxide detector(s). Facility also has central heating and air. Component III conducted - There are no objections to licensure at this time. -Licensure pending. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. An exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 18, 2024

Type of visit: Office

Facility Type: RCFE Application Type:CHOW Capacity:6 Census (5): COMP II Participants: Name, Title Interview Method: Telephone On [10/03/2024], applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Oct 3, 2024