Elite Elderly Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to conduct an annual required inspection. LPA Valerio was met by Administrator Lani Calagui, and explained the purpose of the visit. LPA Valerio and Administrator toured the facility to ensure compliance with Title 22 regulations. LPA Valerio observed 4 residents in care sitting in the living room with staff and a home health nurse. Residents were enjoying afternoon snacks. The common living room areas were observed to be fully furnished, clean, and free from odors. Resident bedrooms were observed to be clean, organized, and beds with clean linen. Resident bathrooms were observed to be fully stocked with skid mat, hand rails, trash can, hygiene supplies, and paper towels. The faucet delivered hot water within the regulatory range of 105-120.0 degrees F. The kitchen was observed to have working appliances. Staff was observed to be cleaning the pantry and prepping dinner. The facility was observed to have an adequate supply of food along with an emergency supply of food. Alarms on doors were observed to be in working condition. The fire extinguisher was fully charged. LPA Valerio reviewed staff and resident files. All files were observed to up to date with annual documentation. LPA Valerio requested the following annual documentation be sent to CCLASCPSacramentosouthRO@dss.ca.gov: LIC 500, LIC 308, LIC 610, and copy of liability insurance. Per California Code of Regulations (CCR) - Title 22, no deficiencies were cited. An exit interview was held, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 16, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski spoke with facility administrator Lani Calagui over the phone and explained the purpose of the visit. Upon entry, LPA Moleski observed a caregiver working in the facility (S1). LPA Moleski reviewed Guardian records and observed that S1 was not associated to this facility's roster. S1 said they had been working at this facility for nearly three months. LPA Moleski reviewed five resident files (R1-R5) and three staff files (S1-S3). S2 had no personnel record (LIC 501) on file, and also had no first aid/CPR certification on file. S3 had no health screening or tuberculosis test results on file. Two residents (R4 & R5) did not have appraisals on file which were conducted within the last year. R4's most recent appraisal on file was dated 07/26/2019 and R5's most recent appraisal on file was dated 02/24/2024. As of January 1, 2025, reappraisals must be conducted at least once per year for all residents, regardless of diagnosis, per 22 CCR Section 87463(a). LPA Moleski toured the facility with staff and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 73 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 110 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. [continued on 9099-C] LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives. LPA Moleski asked for documentation of emergency disaster drills. Calagui was not sure where these were kept. LPA Moleski was provided the facility's emergency disaster plan, which did not include drill records, but did include the following statement, dated March 1, 2015: "Fire drills will be held monthly with the facility residents as part of our ongoing goal to keep the facility safe." HSC Section 1569.695(c) requires emergency disaster drills to be documented at least once per quarter, however, per 22 CCR 87208(a), "The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so." This facility is hereby cited per 22 CCR Sections 87355(e), 87412(a), 87506(b)(17)(E), and HSC Section 1569.695(c). Due to a violation of criminal record clearance requirements, a $500 civil penalty is hereby assessed. An exit interview was held with Calagui. Appeal rights and a copy of this report were emailed to Calagui for her to sign.the state’s words, verbatim · CDSS document, Apr 29, 2025

Allegation investigated: Facility staff dropped resident during transfer resulting in serious head injury Licensee did not answer communications from resident's family appropriately Licensee restricted resident from having visitors

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 2/12/25 at 3:30pm to conclude the investigation of the above mentioned allegations. LPA met with Lani Calagui and stated the purpose of the visit. Regarding allegation, “Facility staff dropped resident during transfer resulting in serious head injury” the Department obtained medical records which indicated that on 9/5/23 911 was initiated and R1’s family was present at which time R1 admitted transferring from walker to recliner when tripped over feet and fell on right side. This was witnessed by staff. The admitting diagnosis was accidental fall. R1 was discharged 9/7/23 to skilled nursing facility. Unsubstantiated Regarding allegation, “Licensee did not answer communications from resident's family appropriately” LPA obtained information through interviews that the licensee did speak with the family when asked where was R1, however, because the family moved R1 out unexpectedly, the Licensee did not know where R1 was residing. Regarding allegation, “Licensee restricted resident from having visitors” LPA obtained information through interviews on 12/19/24 with LTCO and a review of documentation that R1 made a list of people who R1 allowed to visit the facility. Based on documentation review and interviews the allegation(s) are UNSUBSTANTIATED. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, the preponderance of evidence standards has not been met. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. An exit interview was conducted and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.the state’s words, verbatim · CDSS document, Feb 12, 2025 · control 27-AS-20241219093215

Allegation investigated: Staff serve expired food to residents Staff are not reporting incidents to authorized representatives Staff are verbally abusive to residents

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct an investigation of the above mentioned allegations on 1/17/25 at 8:30am. LPA met with Administrator Lani Calagui and stated the purpose of the visit. Upon arrival LPA observed residents having breakfast which consisted of cantaloupe, french toast, eggs, bananas, with either preferred coffee, water, or tea. Regarding allegation, Staff serve expired food to residents, an interview conducted today with Resident #1 (R1-R4) and Responsible parties (RP1 - RP4) revealed that the food is good and there was no knowledge of any expired food being served. An interview with Administrator revealed that there are no expired foods in the home ever. Staff #1 (S1) stated if the food looks like its not right it is not given to the residents. LPA conducted a review of all foods in the refigerator and pantry which revealed foods in the home are deemed to be of good quality and quantity. Unfounded Regarding allegation, "Staff are not reporting incidents to authorized representatives", an interview conducted today with Resident #1 (R1-R4) and Responsible parties (RP1 - RP4) revealed that they are confident that staff would report any incident should they occur. An interview with Administrator revealed that when residents have an incident the families are notified. Staff #1 (S1) stated Administrator handles the incident reports. Regarding allegation, "Staff are verbally abusive to residents", an interview conducted today with Resident #1 (R1-R4) and Responsible parties (RP1 - RP4) revealed that none of the staff are verbally abusing the residents. An interview with Administrator revealed that there has not been an incident to report. Staff #1 (S1) stated "I am unaware of this occurring. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies observed or cited. Exit interview held, copy of report given. "This agency has investigated the complaint alleging the above mentioned allegations. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis."the state’s words, verbatim · CDSS document, Jan 17, 2025 · control 27-AS-20250116091342

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) conduct an initial complaint visit. 27-AS-20241219093215 on 12/20/24 at 11:15a. LPA met with Joyce Smith, Caregiver and stated the purpose of the visit. Joyce Smith contacted the Administrator regarding the purpose of the visit and that resident #1 (R1) file is not available for review. LPA spoke with Administrator regarding this deficiency. LPA spoke with Administrator Lani Calagui who stated she is out of town and is not able to provide a copy of the file today. Although the licensee understands the records are to be retained for a minimum of 3 years following termination of service to a resident, the records were not readily available for review during this visit and will not be ready during business hours today. Based on admittance by the Licensee the records are not readily available for review or copying this will be cited today on this Case Management visit. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are cited on the 809D during this visit. Licensee was provided a copy of their rights (LIC9058) and their signature acknowledges receipt of these rights. Exit interview held, a copy of report was provided.the state’s words, verbatim · CDSS document, Dec 20, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Dec 24, 2024

Resident Records The licensee shall ensure...record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff This requirement is not met as evidenced by: Based on Confirmation from Licensee the file for R1 is unavailable for review or copying. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: Licensee shall submit a copy of R1's complete file to the office by 12/24/24 as well as a written statement indicating the Title 22 regulations will be upheld at all times.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 4/11/24 at 10:00am. LPA observed the Administrator Certificate is on the pending list with Department of Social Services (CCL) and has not been received yet. LPA met with Lani Calagui, Administrator and stated the purpose of todays visit. The facility is licensed for a capacity of 6 non-ambulatory residents of which 3 may receive hospice care services. There is 0 residents receiving hospice care services during this visit. 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 temperature inside the facility was observed to be at 73*F which is within the required range of 68-85*F. The hot water temperature was measured 117.4*F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), smoke and carbon monoxide detectors, and central heating and air in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. LPA reviewed 2 staff and 2 resident files and conducted interviews during this visit. Upon a file review the following items were discussed to be submitted with any changes annually: Licensing fees-Current Criminal Record Clearances LIS536-Current Administrative Organization LIC309-Current Designation of Administrative Responsibility LIC308-Submit Personnel Report LIC500-Submit Affidavit Regarding Client/Resident Cash Resources LIC400-NA Surety Bond LIC402-NA Facility Floor Plan/Plot Plan LIC999-Current Fire Clearance (consistent with terms and limitations of license)-NA Qualifications of Administrator/Facility Manager-Submit Articles of Incorporation/Organization, Constitution and bylaws-NA Partnership Agreement-NA Control of Property-NA Emergency Disaster Plan LIC610-Submit Plan of Operation (Restricted Health Care Plan)-NA Admission Policies and Procedures-NA Health Screening Report-Facility Personnel LIC503-NA Bacteriological Analysis of Private Water Supply-NA In-service Training Program-NA Medication Procedures-NA Transportation Procedures-NA Job Description/Personnel Policies-NA Exemptions/Waivers and Exceptions-Current First aid/CPR certificates-Current Liability Insurance-Submit Infection Control Plan-NA Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited during this visit. Exit interview held. A copy of todays’ report provided.the state’s words, verbatim · CDSS document, Apr 11, 2024

Type of visit: Office

A Non-Compliance Follow-up Meeting was held today via Microsoft Teams 2/27/24 at 1:30pm to discuss the compliance to regulations. The attendees of the meeting were: Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Stephen Richardson, Licensing Program Analyst (LPA) Victoria Brown and Licensee/Administrator Lani Calagui. RM began the meeting by stating the purpose of the meeting and introductions began. Subject areas discussed: -Prior Probation during 2016 -Citations in May 23 and August 23 -(TSP) Technical Support Program response -Catheter use by residents -Staffing/Supervision -Diagnosis of Dementia/wandering -License fees/Annual is coming due -Present questions/concerns to Community Care Licensing (CCL) CCL expectations: -Facility shall continue ongoing self-audits -Facility shall submit prior to acceptance waivers and exception requests; review regulations and requirements -Facility shall ensure exit alarms are audible for residents with wandering tendencies and staffing is awake -Facility shall respond to TSP engagement letter and/or contacts -Facility shall contact CCL/LPA/LPM/On-Duty Worker with any questions or concerns To ensure the facility is successful in remaining in compliance, CCL will submit a TSP referral. At this time, quarterly visits will cease. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies cited. An exit interview was held. Administrator agreed to a copy of this report being provided via email and an electronic email read receipt confirms receiving these documents.the state’s words, verbatim · CDSS document, Feb 27, 2024

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 1/4/24 at 9:00am to conduct a Case Management visit. LPA met with Lani Calagui and stated the purpose of the visit. LPA conducted a tour of the physical plant and observed the residents during this visit. The hot water temp was measured at 105.* F during this visit. LPA observed 1 resident being picked up for medical appointment and 3 others participating in individual activities during this visit. LPA observed 2 day and 7 day nonperishables during this visit. LPA did not observe hazards to residents during this visit. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview held, copy of report giventhe state’s words, verbatim · CDSS document, Jan 4, 2024

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 11/15/23 at 9:30am to conduct a Case Management visit. LPA met with Lani Calagui and stated the purpose of the visit. LPA obtained information that the staffing services agencies that the licensee contacted were over priced. The Licensee hired 4 additional staff but 1 left after 1 month making the decision the job was not a good fit. An email dated 5/23/23 was sent to LPA Maja Jensen indicating the staff requirement has been met. LPA observed an email which included a photo and invoice submitted to Maja Jensen, LPA dated 5/9/23 that the water heater was repaired. This submission met the Departments requirement. LPA observed files of 4 residents and 4 staff for any compliance issues during this visit. LPA also observed an email sent to Maja Jensen, LPA dated 6/1/23 as well as Jennifer Fain, LPA on 8/29/23 as proof that the additional 10 hours of Administrator training on regulations was completed. LPA conducted a tour of the physical plant and observed the residents during this visit. LPA did not observe hazards to residents during this visit. Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies cited. Exit interview held, copy of report giventhe state’s words, verbatim · CDSS document, Nov 15, 2023