Feliz Home

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a continuation of the required annual visit at 10:56 AM. LPA met with facility staff who contacted the facility Co-Administrator Jovilito Gagarin. The Co-Administrator arrived to the facility at approximately 11:10 AM. Entrance interview was conducted and the reason for the visit was explained. Beginning at 11:05 AM the LPA began record review to ensure that facility is in compliance with Title 22 Regulations. The following was observed: RECORD REVIEW: Record review began at 11:05 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Three (3) staff files were reviewed. All staff files contained all required documents and trainings. Four (4) resident files were reviewed. During the initial annual visit on 12/04/2025 LPA observed R1’s bed to contain full bed rails. During today’s (12/10/2025) file review LPA observed that R1 was no longer enrolled with hospice care. LPA informed Co-Administrator that bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. The Co-Administrator expressed understanding and agreed to remove the full length bed rails from R1’s bed. Additionally, LPA observed R1’s appraisal needs and services plan to be dated 07/01/2024. LPA informed the Co-Administrator that reappraisals shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first. The Co-Administrator expressed understanding and agreed to complete an updated Appraisal Needs and Services Plan for R1. Continued on LIC 809C. MEDICATION REVIEW: Medication review began at 11:59 AM. Medications for two (2) of four (4) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and current liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Dec 10, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Dec 11, 2025

87608 Postural Supports (a) ...Postural supports may be used under the following conditions. (5) ... (B) Bed rails that extend the entire length of the bed are prohibited except for ...hospice care... This requirement is not met as evidenced by: Based on observation and record review the licensee did not comply with the section cited above as R1's bed contained full bed rails and R1 was no longer on hospice which poses a potential personal rights violation to persons in care.the state’s words, verbatim · CDSS document, Dec 10, 2025

Plan of correction: Co-Administrator agreed to remove the full bed rails and shorten the rails to half rails and to send LPA proof no later than POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Dec 24, 2025

87463 Reappraisals (a) ...shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first...shall be referred to as the reappraisal. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above as R1's Appraisal Needs and Services plan was dated 07/01/2024 which is more than 12 months from the inspection date which poses a potential health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Dec 10, 2025

Plan of correction: Co-Administrator agreed to complete an updated Appraisal Needs and Services Plan for R1 send LPA proof no later than POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct the required annual visit at 12:31 PM. LPA met with facility staff who contacted the facility Co-Administrator Jovilito Gagarin. The Co-Administrator arrived to the facility at approximately 12:45 PM. Entrance interview was conducted and the reason for the visit was explained. Beginning at approximately 12:45 PM the LPA, along with the Co-Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: OUTDOOR SPACE/GARAGE: The facility has one (1) emergency exit gate located on the side of the home; LPA observed clear passageways for emergency exit use. The facility had adequate shaded seating outdoors for resident use. LPA observed the garage to contain extra oxygen supplies, care supplies, emergency water supplies, and an extra fridge/freezer. LPA observed the garage’s entrance to the interior of the facility to be locked and inaccessible to clients in care. KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured under-sink cabinet to contain cleaning chemicals and a secured drawer to contain knives and other sharp objects. Continued on LIC 809C. COMMON AREAS: This included the living room, hallway, office, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contained an appropriately screened fireplace and activities for resident use. LPA observed a camera located in the living room LPA confirmed with the Co-Administrator that audio is not recorded. The hallway was observed to be clean and free from any obstructions. The hallway included a closet which contained the facility’s washer and dryer and a locked storage cabinet which contained laundry and cleaning chemicals. Additionally, the hallway contained storage cabinets which contained extra linens for resident use. The office was observed to be locked and inaccessible to clients in care and contained resident/facility files. The dining area was observed to be equipped with adequate seating for resident use. The dining area/living room contained all required postings. LPA observed the dining area to contain a wall mounted fire extinguisher that was fully charged and serviced on 11/05/2025. The facility’s combination fire and carbon monoxide alarms were tested at 01:40 PM and were functional at the time of the visit. All exits in the facility were observed to contain functioning auditory alarms. BEDROOMS: There are four (4) bedrooms in the facility; two (2) are dual occupancy and two (2) are single occupancy resident rooms. LPA and the facility Co-Administrator toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. BATHROOMS: There are two (2) bathrooms at the facility. One (1) is designated as a shared/common resident bathroom and one (1) is a private resident bathroom. Both resident bathrooms were observed to be clean and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured to be between 113.5 and 117.3 degrees Fahrenheit, which is in compliance with regulation. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as they pertain to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 10/02/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Co-Administrator. Continued on LIC 809C. INTERVIEWS: LPA interviewed one (1) resident. The resident interviewed stated that the staff treat them well and are attentive to their needs. The resident interviewed had no concerns with the facility. LPA interviewed one (1) staff member. The staff member interviewed was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse Due to time constraints LPA will return at a later date to conduct file review, medication review, and to collect copies of pertinent documentation. No deficiencies were observed during today’s inspection. Exit interview conducted and copy of the report was issued.the state’s words, verbatim · CDSS document, Dec 4, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management Incident inspection at the facility today. The LPA met with Licensee representative Jovilito Gagarin and explained the reason for the inspection. On 07/31/2025, Community Care Licensing (CCL) received an Unusual Incident/Injury Report (LIC 624) pertaining to Resident #1 (R1). The report stated that on 07/27/2025, about 4 pm, R1 while seated at the couch at the living room attempted to get up and fell on the floor on the right side of his body hitting the floor. A cut and bruise on the right elbow had resulted from that accident. Two staff (S1, S2) observed the incident. It was further reported that R1's responsible person was contacted the same day and notified of the incident. On, 07/29/25, R1's responsible party took R1 to the hospital and at the time of the report R1 was still at the hospital. On 08/01/25, LPA Cortez conducted an interview with Licensee representative, Jovilito Gagarin telephonically , who stated they were informed from R1's responsible person that R1 had sustained a fracture. Additionally, Mr. Gagarin stated that R1 is a fall risk, and the week before R1 fell at the facility they had fallen at their responsible person home and believe the fracture was sustained from that fall. During today's visit, the LPA conducted interviews with Licensee representative Jovilito Gagarin, two (2) staff, one (1) resident, and R1's responsible person (telephonically). The report will continue on LIC809-C, 2nd page. Mr. Gagarin revealed that when they were informed of the incident, he had asked staff it it was serious because if it was they would have to call 911 and staff had informed them it was not so serious. Additionally, he revealed that after informing R1's responsible person (RP) about the incident, they asked the RP if they wanted them to call 911 and the RP asked them if it was serious and they replied no and the RP notified them they would visit R1 the following day. Lastly, Mr. Gagarin revealed that Staff accessed R1's body by pressing it and R1 did not screamed therefore they were not in excruciating pain. S1 and S2 revealed that they did not witness R1's fall as one was in the kitchen and the other in the laundry room and R1 was sleeping in one of the recliners in the living room, they heard the fall and immediately went to the resident. After R1's fall, R1 complained about pain the same day and the following day and S1 applied warm water with a rag on his body. S1 revealed they notified their boss about the incident and it's up to the boss to determine if 911 is called or not. Both staff revealed that R1 had a prior fall just days before at R1's RP's home and believe R1 sustained a fracture then. A telephonic interview with R1's RP revealed that they were notified of R1's fall and was told that everything was under control. However when they visited on 7/28, R1 was passed out and could not wake up, on 7/29 R1 had a scheduled doctor's appointment and the RP and staff could not get R1 up and were not able to get R1 to their doctor's appointment. RP notice something was wrong and R1 could not put weight on their leg, and was not able to walk. Prior to the fall R1 was able to walk short distances with their walker. Lastly, the RP revealed that they were never asked if staff needed to call 911, and that they were only told that an assessment had been done. They did not know the severity of the incident until Wednesday when they took R1 to the Emergency Room and was notified that R1 had a broken hip. RP also revealed that R1 had sustained two falls at their home a week prior to R1's fall at the facility and would fall once to twice a week at their home and believes the facility provides adequate care for R1. The investigation revealed that on 7/27/25, R1 sustained a fall for which the facility staff did not obtain medical care, and on 07/29/2025, when R1's RP took R1 to the emergency room R1 was diagnosed with a broken hip. Based on the information obtained the Department found sufficient evidence to support that staff did not seek medical assistance for R1 in a timely manner. Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC 809-D). Exit interview conducted, appeal rights discussed, and a copy of this report issued.the state’s words, verbatim · CDSS document, Aug 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Aug 22, 2025

(a) plan for incidental medical and dental care shall be developed by each facility. The...:(1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Based on staff interviews and records review the Licensee did not comply with the regulation above, staff did not seek medical assistance for R1 on 7/27/25, after a fall despite complaints of pain which posed an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 18, 2025

Plan of correction: Licensee will submit a plan how you will ensure residents receive timely medical assistance. Submit to CCL by 08/19/2025.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Rankin arrived at 8:32 am to conduct a 1-year annual visit to the facility above. LPA met with Administrator Jovilito Gagarin and explained the purpose of the visit. Upon arrival 2 staff were noted as being present as well as two nurses conducting visits. Residents were eating or being assisted in the living room area. Around 9:12 am a tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit: Physical Plant & Environment Safety: The facility has 4 resident bedrooms, 2 bathrooms and currently occupies 4 residents with 2 live in staff. The facility has smoke and carbon monoxide detectors that were tested and working properly during the visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats. The pathways are clear of any obstructions. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked under sink and in the laundry room. The facility has a fenced backyard for client use with plenty of shade. The fire extinguishers were charged and last inspected in November of 2024. Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance which expires on 1/17/2025. The facility is approved for a capacity of 6. The fire clearance is granted for 6 Non-Ambulatory. Recent hospice increase is approved for 5. Personnel Records & Training: Staff files had current 1st Aid/CPR, file reviewed for required documentation, files were found complete. Administrator certificates expires 08/08/2025. Current staff have only worked for the facility for the past month, medication and dementia training are complete, additional training is scheduled to be completed in the next 2 weeks. Resident Records & Incident Reports: Facility does submit incident reports to the department when required. LPA reviewed 4 resident files, ensured updated Appraisals Needs and Services Plan were documented, and all other required documents were available. Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables, to meet the food service requirement. All food is covered, stored, and marked. Food, snacks, and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Incidental Medical Services: Facility provides assistance in arranging transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed and discussed residents’ medications, medication practices and documentation, all are in compliance. Disaster Preparedness: The current emergency disaster form was reviewed and discussed with administrator. The facility conducts quarterly disaster drills. Emergency exits and telephone numbers were posted. Additional review of this document is being done to ensure staff assignments are clear and resources for outages are available. Residents with Special Health Needs: The facility does accept dementia residents in care. The facility has 1 gate, it was self-closing and self-latching. Facility currently has one residents on oxygen. The facility currently has 3 hospice resident in care. The facility does not have any residents receiving Home Health services at this time. The facility does not have delayed egress. Exit interview conducted and copy of report printed for Administrator.the state’s words, verbatim · CDSS document, Dec 12, 2024

The state marks this report as 7 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Teresa Camara conducted a pre-licensing visit to this property at 12:30 p.m. LPA met with applicant representatives Jesusa Carbajal, Amelita Gagarin, and Jovilito Gargarin. The applicant has obtained fire clearance for 6 (six) non-ambulatory residents with a facility capacity of 6 (six). The proposed facility has a pending Dementia care plan and a pending hospice care waiver for 3 (three) residents. Applicant completed component II interview on 11/17/2023 and component III was completed on 11/29/2023. LPA inspected the proposed facility for Fire Safety, Personal Accommodations, and Food Service. All hard-wired combination smoke alarm and carbon monoxide detectors were tested at 1:05 p.m. and function properly. Fire extinguisher was observed to be fully charged and serviced 10/24/2023. Paint, windows, blinds, and floors are in good repair. There are no firearms on the premises. The common living and dining areas are clean and properly furnished. The fireplace is double sided and has screens on both sides. The office is located in the family room; records will remain in a locked cabinet. A working telephone is present. All required postings were observed in the common area. All chemicals and cleaning supplies were observed in the laundry room locked cabinets, the locked cabinet under the kitchen sink and a locked cabinet in the garage. A locked medication closet is in the hall adjacent to the dining room; it contained a first aid kit. The garage was observed to be locked and inaccessible to future residents and contained emergency water and supplies. The proposed facility has 4 (four) bedrooms total, of which 2 (two) are private rooms and 2 (two) are shared rooms. All bedrooms observed were furnished and contained beds, chairs, bedside tables and lamps. All beds have appropriate linens. There is also an ample supply of linens, towels and paper products. The proposed facility has 2 (two) bathrooms, 1 (one) is designated for shared resident use and 1 (one) for private resident use. LPA observed night-lights were present in the hallways. Hot water measured at 116.1*F. (continued on 809-C) (continued from 809) The kitchen contained a sufficient supply of dishes, glasses and utensils. There is a sufficient supply of non-perishable food and water. The refrigerator temperature was 39*F and freezer was 0*F. Knives were stored in a locked cabinet under the stove top. Building and grounds were observed. There is a covered patio area for residents' use. Outdoor exit gate was observed to be self-closing and self-latching. All passageways were observed to be clear of any hazards. This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 1, 2023

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 0 COMP II Participants: Amelita Gagarin, Jesusa Carbajal Interview Method: Telephone interview On November 17, 2023, 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 the understanding of the California Code Title 22 Regulations. 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. Restricted/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Nov 17, 2023