Family Feels Residential Care 3

Allegation investigated: Staff did not properly address pests in the facility resulting to infestation.

Amended report for the above allegation. Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced complaint investigation visit and met with designated administrator (DADM) Philipp Perez. LPA stated the purpose of the visit. Licensee/Administrator (LIC/ADM) David Devries was not available at the time of the LPAs visit due to prior commitment. On 03/17/2026, the Department received a complaint with the above allegation(s). On 03/25/2026 the Department conducted an initial investigation visit t the facility and conducted interviews, inspection of the facility and requested for documents. page 1 of 2 Unfounded Amended Report - continued Allegation 2: Staff did not properly address pests in the facility resulting in infestation On 03/25/2026, LPA conducted a facility inspection. During the inspection, LPA observed cockroaches in the food pantry, Room #3, and the staff room. LPA did not observe spiders during the inspection. On 03/25/2026, LPA interviewed S1, S2, and S3. S1 stated pest-control services were performed on 03/24/2026 and reported that cockroaches may remain visible following treatment. S2 stated small cockroaches were observed after returning to employment on 02/02/2026 and reported pest-control treatment was performed. S2 stated spiders had not been observed and S2 was not aware of a resident sustaining a spider bite. S3 stated a resident reported observing a black spider but stated it is not a black widow spider, it was observed outside near the garden area and stated S3 was not aware of a resident sustaining a spider bite.On 03/26/2026, LPA received documentation indicating pest-control services were obtained on 01/29/2026, with treatment performed on 02/02/2026 and 03/24/2026. On 04/24/2026, W1 reported that R1 continued to report the presence of cockroaches and spiders within the facility and reported another resident had allegedly sustained a spider bite several years earlier. No documentation regarding the reported spider bite was provided to LPA. Based on interviews, observations, and records reviewed, R1 stated the phone remained in R1's possession. R1, W1, W2, S1, S2, and S3 did not provide information identifying an individual who used R1's phone. LPA observed cockroaches within the facility and reviewed documentation showing pest-control services were obtained on 01/29/2026, with treatment performed on 02/02/2026 and 03/24/2026. LPA reviewed R2's records and did not observe documentation indicating R2 sustained a spider bite or received hospital services related to a spider bite. This agency has investigated the complaint alleging staff did not properly address pests in the facility resulting in infestation. 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. No deficiencies were cited during today's visit. A copy of the report was provided to DADM Philipp Perez.the state’s words, verbatim · CDSS document, Aug 13, 2026 · control 26-AS-20260317093638

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted a Case Management to address the pest infestation identified during a Complaint Investigation and to amend the complaint report on 06/02/2026. LPA met with Designated Administrator (DADM) Philipp Perez and stated the purpose of the visit. On 03/25/2026, the Department received a complaint alleging that facility staff did not properly address pests, resulting in an infestation at the facility. During the course of the complaint investigation, LPA Partoza conducted a comprehensive review of facility operational and maintenance records. Documentation shows facility staff first observed a roach infestation in January 2026. Records confirm the facility took corrective action by scheduling professional pest treatments on 01/29/2026, 02/02/2026, and 03/24/2026, prior to the complaint being filed. The facility also entered into a one-year pest control service contract and provided monthly proof of ongoing treatments. During today’s visit, LPA observed no roaches. However, a regulatory non-compliance was identified regarding unusual incident reporting. Licensee did not not notify the Department of an active infestation—and that chemical treatments would increase daytime visibility of pests—the facility did not submit a written Unusual Incident Report (UIR) to the Department. Based on California Code of Regulations (CCR )Title 22, Section 87211(a)(1)(D), licensee is required to report any incident that threatens the welfare, safety, or health of residents. Deficiencies is cited during today's visit based (See LIC 809D) A copy of the report was provided to DADM Philipp Perez.the state’s words, verbatim · CDSS document, Aug 13, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Aug 28, 2026

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following (D) Any incident which threatens the welfare, safety or health of any resident...this requirement is not met as evidenced by: Based on records review, licensee did not submit a written Unusual Incident Report (UIR / LIC 624) and notify the Department of a known cockroach infestation observed in 01/2026, which pose/s a potential health safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 13, 2026

Plan of correction: DADM stated that any incident that may affect resident health or safety, including pest infestations will be reported to the Department on a timely manner, staff will be trained in reporting requirement and corrections will be submitted to LPA on the POC due date of 08/28/2026

Allegation investigated: Staff did not safeguard resident's belongings. Staff did not properly address pests in the facility resulting to infestation.

This report is being amended due to new information for the 2nd allegation. See new LIC9099 for the amended report. Licensing Program Analyst (LPA) Maria (Mita) Partoza, conducted an unannounced complaint investigation visit and met with designated administrator (DADM) Philipp Perez. LPA stated the purpose of the visit. Licensee/Administrator (LIC/ADM) David Devries was not available at the time of the LPAs visit due to prior commitment. On 03/17/2026, the Department received a complaint with the above allegation(s). On 03/25/2026 the Department conducted an initial investigation visit at the facility and conducted interviews, inspection of the facility and requested for documents. Unsubstantiated On 03/25/2026, LPA interviewed S1, S2, and S3. S1 stated pest-control services were performed on 03/24/2026 and reported that cockroaches may remain visible following treatment. S2 stated small cockroaches were observed after returning to employment on 02/02/2026 and reported pest-control treatment was performed. S2 stated spiders had not been observed and S2 was not aware of a resident sustaining a spider bite. S3 stated a resident reported observing a black spider but stated it is not a black widow spider, it was observed outside near the garden area and stated S3 was not aware of a resident sustaining a spider bite. On 03/26/2026, LPA received documentation indicating pest-control services were obtained on 01/29/2026, with treatment performed on 02/02/2026 and 03/24/2026. On 04/24/2026, W1 reported that R1 continued to report the presence of cockroaches and spiders within the facility and reported another resident had allegedly sustained a spider bite several years earlier. No documentation regarding the reported spider bite was provided to LPA. Based on interviews, observations, and records reviewed, R1 stated the phone remained in R1's possession. R1, W1, W2, S1, S2, and S3 did not provide information identifying an individual who used R1's phone. LPA observed cockroaches within the facility and reviewed documentation showing pest-control services were obtained on 01/29/2026, with treatment performed on 02/02/2026 and 03/24/2026. LPA reviewed R2's records and did not observe documentation indicating R2 sustained a spider bite or received hospital services related to a spider bite. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted and a copy of the report was provided to Designated Administrator (DADM) Philipp Perez. page 3 On 03/25/2026, LPA interviewed 3 staff (S1, S2, and S3). S1 stated that resident 1 (R1)'s cellular phone remained in R1's possession and stated that staff has their own cell phones and residents uses the house phone. S2 stated R1 previously had a cellular phone, reported the phone service was discontinued by a sibling, and stated R1 uses the facility telephone. S3 stated R1 previously had a cellular phone, reported the phone service was discontinued by a family member, and stated residents generally use the facility telephone. S2 and S3 stated they did not have information regarding the reported phone activity, and S3 stated no residents were observed using R1's cellular phone. S2 and S3 both stated they have their own cell phone. On 03/25/2026, LPA interviewed resident 1 (R1). R1 presented the cellular phone identified in the complaint and stated the phone remained in his/her possession. R1 stated the phone was used to communicate with family members, healthcare providers, government agencies, and financial institutions. R1 stated no staff or residents used the phone. R1 stated the increase involved usage minutes rather than additional calls and stated the telephone numbers on the device were familiar to R1. On 04/05/2026, 04/22/2026, and 04/24/2026, W1 reported concerns regarding increased phone activity and stated a phone carrier investigation remained pending. W1 did not provide documentation identifying unauthorized phone usage or the individual who allegedly used the phone. On 04/22/2026, LPA interviewed witness 2 (W2). W2 stated conversations with R1 may last one to two hours and did not identify an individual who allegedly used R1's phone. Allegation 2: Staff did not properly address pests in the facility resulting in infestation. -This allegation is being amended due to new information . See new LIC 9099. On 03/25/2026, LPA conducted a facility inspection. During the inspection, LPA observed cockroaches in the food pantry, Room #3, and the staff room. LPA did not observe spiders during the inspection. page 2the state’s words, verbatim · CDSS document, Jun 2, 2026 · control 26-AS-20260317093638

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Maria Partoza conducted an unannounced annual inspection and met with the Designated Administrator (DADM) Philipp Perez and stated the purpose of the visit. The facility is licensed to serve adults age 60 and over, 6 ambulatory of which 6 may be non-ambulatory and hospice waiver for 6. LPA observed 2 staff and 6 residents. Residents were in their respective rooms and resting at the time of the visit. 4 out of 6 was asleep and 1 out of 6 refused to be interviewed, and 1 out of 6 was outside smoking. LPA toured the facility, including common areas, resident rooms, kitchen, bathrooms, garage, and outdoor spaces. The kitchen was clean and organized; knives and chemicals were locked. Food supply met requirements (2 days perishable, 7 days non-perishable). Medications were locked and inaccessible to residents; first aid kit was complete. Fire, smoke, and carbon monoxide systems were operational; hallways were clear and well-lit. Kitchen and bathroom water temperature measured at 118.2°F. Bathrooms had grab bars and non-skid mats; resident rooms had adequate storage. Fire, smoke, and carbon monoxide systems were operational; hallways were clear and well-lit. The facility has room temperature of 84 degrees F. The facility is equipped with a fire extinguisher that was last inspected on 08/12/2025. Outdoor areas were free of hazards; laundry appliances were functional, and cleaning supplies were secured. LPA observed roaches inside one of the condiment cabinets. DADM stated that the fumigation process is ongoing and one is scheduled for 6/3/2026. DADM placed an industrial fan inside the facility to maintain room temperature at less then 85 degree F. LPA issued a technical assistance for 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), or in areas of extreme heat to 30 degrees F less than the outside temperature. DADM stated that he/she have notified the licensee regarding the air conditioning system at the facility. LPA reviewed 3 out of 6 resident and 2 out of 2 staff records, including medication logs, admission agreements, care plans, personal and incidentals, health screenings, and staff training. All staff have required clearances and certifications. The facility conducts fire and earthquake drill quarterly for each shift. Last drill practice training was on conducted on 04/23/2026. No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with DADM and a copy Philipp Perez of the report was provided. end of report page 2 of 2the state’s words, verbatim · CDSS document, Jun 2, 2026

Type of visit: Case Management - Deficiencies

On 03/25/2026, Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced visit to address a complaint that was filed with the Department on 03/17/2026. This case management is not part of the complaint. This case management - deficiencies is based on LPAs observation at the time of the visit. During the visit LPA was accompanied by the designated administrator Philipp Perez. Licensee/Administrator (LIC/ADM) David Devries is not available at the time of the visit due to prior commitment. The facility is licensed to serve adults age 60 and over with a capacity of 6, of which may be ambulatory and 6 may be non-ambulatory and a hospice waiver for 6. LPA conducted inspection inside and outside, including but not limited to the kitchen, dining area, 4 out 4 resident bedroom, 2 out 2 bathrooms, 1 staff room, exterior perimeters, and interior area of the facility. During inspection, LPA observed no tripping hazard on the hallways and emergency exits. LPA observed Arm and Hammer laundry detergent and Downy liquid cloth softener not locked in the laundry area that is located in the pass through from the inside towards the garage area and accessible to residents in care. S1 stated one of the resident likes to do their laundry at night that's why they leave the detergents inside the cabinet and not locked. LPA observed a steak knife that was not locked and is accessible to residents in care in the left corner drawer of the counter located in the kitchen. LPA observed the kitchen vent was covered with accumulated oil residue. page 1 of 2 see LIC 809C LPA observed the screen of the sliding door was frayed and has a hole that can fit a hand (Room #3). The facility has a side ramp and a ramp at the back to accommodate non-ambulatory individuals. The ramp's railing is not sturdy when touched lightly. LPA observed a green colored lighter on top of a table next to an frayed upholstered arm chair located at the back of the property by the exit sliding door. LPA observed frayed upholstered recliner next to the back ramp railing a chair that is broken next to the fence, and a power lifting press bench with frayed leatherette cover, cobwebs and rust. LPA inspected 5 bedrooms, 4 are for residents and 1 is for staff. 2 out of the 4 are shared and 2 are not shared. 1 out of the four has a bathroom and 1 shared bathroom in the hallway. The bathroom are equipped with grab bars and anti-slip mats. A sign that residents are not allowed in the garage is visible and door is kept closed and locked. LPA observed a carbon monoxide alarm system and a broken smoke alarm system at the entry hallway. The facility has 2 days of perishable food and 7 days of non-perishable foods. LPA observed a fire extinguisher that was last inspected on 08/12/2025 located near the kitchen, a dried pumpkin by the fireplace was also observed. LPA observed 3 out of 6 residents having breakfast on the dining table. LPA covered clear plastic container with each person's name written on a sticker. 2 out of 6 was asleep and 1 out of 6 was outside. When asked what is inside the clear container. The 3 residents and 2 out of 3 staff stated that the container is used for resident's medications. Staff 1 (S1) stated that the medications for breakfast are pre-poured or pre-prepared in the evening and given during breakfast. LPA reviewed 2 out of 2 staff record. 2 out of 2 staff have cleared criminal background and fingerprint record and are associated with the facility. 1 out 2 staff have a 1st Aid/CPR certification that will expire on June 08,2026. 1 out of 2 staff was recently hired and is currently in training. LPA reviewed 4 out of 6 resident record, the records were complete and up to date. Deficiencies are cited during today's case management - deficiencies based on California Code of Regulations (CCR) Title 22 See LIC 809D. An exit interview was conducted with designated administrator (DADM) Philipp Perez. A copy of the report and appeal's rights were provided. page 2 of 2 end of reportthe state’s words, verbatim · CDSS document, Mar 25, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Mar 26, 2026

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure...cleaning solutions ...knives.. are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on LPA observation during inspection, the LIC/ADM did not ensure that the Arm&Hammer laundry detergent, Downy Softener and steak knife are in locked storage and are not left unattended when not in use.the state’s words, verbatim · CDSS document, Mar 25, 2026

Plan of correction: DADM, stated that he/she will ensure that LIC/ADM is aware of the deficiency and will have LIC/ADM submit a written plan of correction to address the deficiency regarding storage of laundry detergents and sharp objects by the POC due date of 03/26/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(a) · Plan of correction due date: Mar 26, 2026

87303 Maintenance & Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on LPAs observation during facility inspection, LIC/ADM did not ensure that the facility is kept maintained by not addressing the following: back ramp rail sturdiness, frayed sliding door screen in room #3, kitchen vent is kept free from accumulated residue, smoke alarm isthe state’s words, verbatim · CDSS document, Mar 25, 2026

Plan of correction: properly installed,upholstered furnitures, and excercise equipment that were placed outdoors are in good and usable condition. for the safety and well-being of residents, employees and visitors. DADM, stated that he/she will ensure that LIC/ADM is aware of the deficiency and will have LIC/ADM submit a written plan of correction to address the deficiency regarding maintenance of the facility by the POC due date of 03/26/2026.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(5) · Plan of correction due date: Mar 26, 2026

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:(5)Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Based on LPAs observation and staff statement, resident's morning medications are pre-prepared the night before and given to residents in the morning during breakfast. The LIC/ADM did not ensure that resident's medication are stored in its original receivedthe state’s words, verbatim · CDSS document, Mar 25, 2026

Plan of correction: container and not transferred between container. DADM, stated that he/she will ensure that LIC/ADM is aware of the deficiency and will have LIC/ADM submit a written plan of correction to address the deficiency regarding transfering of medication between containers by the POC due date of 03/26/2026.

Type of visit: Required - 1 Year

On 06/24/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection. LPA met with administrator Rita Garcia and explained the purpose of today's visit. There are 3 staff present, one being the administrator, and 6 residents present. This facility is licensed for ages 60 years and over. All may be non-ambulatory. Hospice waiver for 6. There are no residents on hospice at time of inspection. LPA was allowed entry into the facility. This is a single level facility. Annual fees are current. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked in the kitchen cabinet below the sink along with cleaning supplies. Medications are locked in a file cabinet in the main living room area. Perishable and non-perishable food items are observed as in place. There is an additional freezer and refrigerator, along with canned food supplies in the garage. First aid kit is observed as complete with required items. LPA observed fire extinguisher in the dining room with an inspection tag dated 08/09/24. The fire extinguisher is charged and within operable range, smoke detector/carbon monoxide detectors are observed in place through out the facility, and central heating/cooling system. There is a fire pull station located by the front door of the facility. PPE and additional food supplies are observed as in place. Continued on next page. Laundry area is also observed as fully operational located beneath the facility. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Last emergency/disaster drill was conducted on 06/07/2025. Water temperature was measured at 120F in a common bathroom in the main hallway. Shower floor is observed to have non-skid flooring. LPA observed rooms at random and all appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place. Oxygen signs are in place as needed. LPA reviewed 6 resident files and also reviewed 3 staff files on this day. Per resident files reviewed they are current with orders for bed rails. Per staff files reviewed all files. Staff have current first aid but no training records showing ongoing or continuing training. Client medications are inspected and are current including facility medication administration records. Administrator certificates are observed as current expiring on 01/05/2026. The following updated forms are requested to be submitted to CCLD by 07/03/2025: • Copy of updated Administrator Certificates • LIC308 Designation of responsible staff person • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule • Copy of liability insurance Technical violations are given on this day on the attached LIC9102TV pages. Report is reviewed with Rita Garcia and a copy is provided.the state’s words, verbatim · CDSS document, Jun 26, 2025

Type of visit: Required - 1 Year

On 6/21/2024 at 1:20 p,m. Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced required 1 year inspection and was met by Administrator (ADM) Rita Garcia and stated the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) licensed to serve ages 60 and over, capacity for 6 ambulatory of which 6 may be non-ambulatory and 6 hospice waiver. The facility has 6 residents that have mental illness and neurocognitive impairment. 1 of 2 staff were present at the time of the visit. 6 residents were present at the facility. out of 6 is under the age of 60, 6 out of 6 are-ambulatory, 2 out of 6 have mild neurocognitive impairment. LPA and ADM toured the facility inside and outside, including but not limited to the following: Kitchen, dining, laundry, garage, 4 resident room, 1 staff room, 2 bathrooms, backyard and the exterior walkways. LPA observed the Personal Rights disclosure, Long Term Care Ombudsman (LTCO) and Centralized Complaint and Information Bureau (CCIB) of the CA Department of Social Services (CDSS) prominently posted on the wall, visible to visitors, resident and staff. The temperature inside the home was at 70 degrees F. LPA observed the kitchen to be organized, and sanitary with working appliances. Knives were kept in a secure locked area and not easily accessible to residents. The laundry area is located in the garage, cleaning supplies and laundry detergents are kept in a secure locked place not easily accessible to residents in care. The facility has 2 days of perishable food and 7 days of non-perishable food. page 1 of 2 (see LIC 809C) LPA inspected the residents' bedrooms and observed 4 out of 4 bedrooms have furniture and closet space for resident's personal belongings, bed frames with mattress and bed linens. 4 Out of 4 resident room is sanitary, organized and are free from debris. LPA observed that the bathroom floors were scrubbed and sanitized. LPA observed the shower curtain in one of the bathroom has brown residue at the bottom. ADM stated the shower curtain will be replaced. During the tour, LPA observed that Bedroom #4 vertical window blinds were in disrepair. The planks were taped and 3 of the planks were split in half and taped together. ADM stated the licensee will be notified that the vertical blinds needs replacement. LPA with ADM tested the water temperature for kitchen and bathrooms, water temperature was measured at 119.7 degree F. LPA with ADM inspected the laundry area and observed washer and dryer are in good working condition. LPA observed that the medication is in a locked cabinet. The facility has a first aid cabinet with first aid supplies and accessible to staff. The side door and sliding door to access the backyard opens easily and are free from obstruction. LPA observed ramps and walkways are free from obstruction. LPA observed the backyard area to be free from debris and is maintained. The facility is in a compound with two other facility under the same ownership. LPA reviewed facility record and 2 out of 2 staff record, and 3 out of 6 resident records. The disaster training conducted on 6/10/2024. Residents files were complete and updated. Residents' medications are labeled and current. Staff record were up to date with certification and training. LPA reviewed the facility resident roster and 2 out of 6 are under the age of 60. The facility did not submit an exception request and did not submit exception request licensing to admit and retain resident 2 (R2) who is under the age of 60. Deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22, see LIC 809D. An exit interview was conducted with administrator (ADM) Rita A Garcia. A copy of the report and appeals rights were provided. Page 2 of 2 end of reportthe state’s words, verbatim · CDSS document, Jun 21, 2024