Emmaus Care II

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility and conducted the visit with Licensee, Janette Monillas. LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant and measured at 108 F.. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. However, not all medications had orders. There was a padlock on the side gate. Licensee explained it was locked for safety. The padlock was removed during the visit. No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA reviewed multiple staff and resident records/files. Confidential records were stored in locked areas. Continued on LIC 809C. Quarterly disaster drills were not conducted and documented. Staff did not have required training on file. Deficiencies were observed and cited during today's annual inspection, along with a civil penalty. Also, Advisory Notes were issued. An exit interview was conducted with Licensee, Janette Monillas to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Sep 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Sep 16, 2026

Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not comply with the regulations adopted by the State Fire Marshal when the side gate was locked with a padlock for 2 of 2 residents [R1-R2], which posed an immediate health and safety and personal rights violation to residents in risk.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee explained the padlock was in place for safety. The immediate threat was removed by the licensee removing the padlock during the visit, POC corrected.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(e) · Plan of correction due date: Oct 13, 2026

Incidental Medical and Dental Care. For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information Based on record review and interviews, the licensee did not obtain written orders for all resident medications for 1 out 2 residents [R1], which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee stated they will obtain medication orders for resident by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1565(c) · Plan of correction due date: Oct 13, 2026

A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter...scenarios. An actual evacuation...during a drill. While a facility...shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not conduct a quarterly disaster drill for 8 out 8 staff, which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee stated they will conduct a quarterly disaster drill with all staff in attendance and submit proof of training by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.625(b)(2) · Plan of correction due date: Oct 13, 2026

Staff training; legislative findings; contents. In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Based on records review, the licensee did not ensure 8 out of 8 staff had current training on file, which posed a potential health and safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: Licensee stated they will provide proof of staff training by POC due date.

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

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to conduct a Case Management - Legal/Non-compliance visit. LPA was granted entry into the facility by Licensee, Janette Monillas. During today's visit, LPA toured the facility and observed residents in care. No health or safety issues were observed at this time and no citations were issued. The licensee was knowledgeable with the following topics: 87628 Diabetes; 87457 Pre-Admission Appraisal; 87612 Restricted Health Conditions; 87632 Hospice Care Waiver. LPA also covered 87615 Prohibited Health Conditions. No deficiencies were issued. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Licensee, Janette Monillas whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Sep 15, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility and conducted the visit with Licensee, Janette Monillas. LPA, accompanied by licensee, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant and measured at 115 F.. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per the licensee no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed multiple staff and residents. LPA reviewed multiple staff and resident records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Licensee, Janette Monillas to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Sep 25, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility and conducted the visit with Licensee, Janette Monillas. LPA, accompanied by staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. Hot water temperature at taps accessible to residents were all compliant and measured at 111 F.. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, and/or fireplaces accessible to residents. Medications were labeled, as required, and stored in locked areas. No pools or bodies of water were observed on the premises. Per the licensee, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed multiple staff and residents. LPA reviewed multiple staff and resident records/files. The interviews did not raise any significant licensing concerns. The reviewed files contained required documents. Confidential records were stored in locked areas. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Licensee, Janette Monillas to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.the state’s words, verbatim · CDSS document, Sep 27, 2024