Five Star RCFE 1

Type of visit: Required - 1 Year

On 03/19/2026 Licensing Program Analyst (LPA) Shakaricka Hughes arrived at the facility to conduct an unannounced annual inspection. LPA Hughes met with the facility administrators Jayson and Amy Caridad. The current census is 5 with 3 facility staff. This facility is a single story building licensed to serve (6) ambulatory and non-ambulatory residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 113.2 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in the entry way and was last serviced on 08/03/2025. LPA observed the facility has a public telephone in the kitchen area and the facility has the required posters posted. Facility thermostat was observed at 76 degrees Fahrenheit. LPA observed toxins and sharp knives located in the kitchen cabinet kept locked and inaccessible to residents. Continuation 809-C LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 2 out of 5 residents medications and the medication administration record (MAR) was complete. The first aid kit was checked and contained the required components. LPA requested resident and staff files for review. LPA reviewed 5 out of 5 resident files and they were complete. LPA reviewed 3 staff files, and the files were observed incomplete as (3) facility staff CPR certification records were not made available during the visit. LPA reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared. The following documents will be email to LPA by 3/27/2026 (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (3) LIC 610 Current Emergency Disaster Plan (4) Proof of Current Liability Insurance (5) LIC 500 Current Personnel Report As a result of this annual visit, the facility is not in compliance with Title 22 Regulations, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with the administrators and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Mar 19, 2026

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.

Allegation investigated: Staff are not giving resident medication as needed

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to deliver findings on this complaint investigation. LPA Moleski met with facility administrator Jayson Caridad and explained the purpose of the visit. This investigation consisted of interviews, observation, and record review. LPA Moleski interviewed Caridad, two additional staff members (S1-S2) and three residents (R1-R3). In an interview, a resident (R1) said they had not received their painkillers when they asked for them, and sometimes only received one painkiller when they should have received two. LPA Moleski reviewed R1’s file, including their medication administration records (MARs) and centrally stored medication records. [continued on 9099-C] Substantiated R1 was admitted to this facility on 12/1/24, according to R1’s admission agreement. R1 came to the facility with an order dated 11/25/24 to take one Oxycodone tablet every six hours as needed. Then, R1 received a change order to take one tablet by mouth twice per day dated 12/4/24. However, on 12/10/24, R1's physician changed the order again to be take two tablets every six hours as needed. R1's latest prescription for Oxycodone, dated 12/17/24, indicated that R1 was to take two tablets by mouth every six hours as needed, and one tablet twice daily. During an audit of R1’s medications on 12/20/24, LPA Moleski observed that R1 had a 60-tablet bottle of Oxycodone, which contained 27 tablets. The bottle was started on 12/5/24, according to R1’s centrally stored medication records. Both routine and PRN doses of the medication were drawn from this same 60-tablet bottle, according to Caridad. R1's MARs indicate R1 received routine doses of Oxycodone twice on Dec. 5 and 6, and once on Dec. 7, for a total of five doses. R1 visited the hospital later that day and remained hospitalized until Dec. 11. R1 received two routine doses of Oxycodone on Dec. 19, and once on the morning of Dec. 20. R1 received a total of eight daily doses of this medication between his admission date and the date of LPA Moleski’s medication audit on 12/20/24. R1's PRN MARs show doses of Oxycodone were given on Dec. 2 [1 tablet] Dec. 3. [1 tablet] Dec. 11 [2 tablets], Dec. 13 [1 tablet at 7:30 a.m. and 1 at 8 p.m.], Dec 14. [1 tablet at 8 a.m. and 1 tablet at 9 p.m.], Dec. 15 [an unknown dose at 9 a.m. and an unknown dose at 9 p.m.], Dec. 16 [an unknown dose at 9 a.m. and 2 tablets at 7 p.m.], Dec. 17 [an unknown dose at 9 a.m. and another unknown dose at 8 p.m.], Dec. 18 [an unknown dose at 4:30; a.m. or p.m. not recorded], Dec. 20 [1 tablet]. This totals 9 confirmed tablets were administered from the bottle opened on the 5th, and anywhere between 6 and 12 additional tablets were administered without a recorded dosage, presuming no more than two tablets were given at the intervals recorded. As stated above, R1 had a prescription order on file to take two tablets every six hours as needed, which means R1 should have been able to receive two tablets upon request, rather than one, starting from 12/10/24. [continued on 9099-C] Between the routine and PRN administrations as described above, R1 may have had anywhere between 23 and 29 total tablets administered between 12/5/24 and 12/20/24. This should have left anywhere between 31 and 37 tablets remaining in the bottle. However, there were 27 tablets remaining in the bottle as of 12/20/24. 22 CCR Section 87465(b)-(d) requires that, for any resident receiving PRN medications, there must be a physician’s note on file specifying the resident’s ability to determine their need for PRN medication, and their ability to communicate their symptoms. Licensees are not permitted to assist residents with self-administration of PRN medications without such a note on file and, unless the resident is determined to have no deficits in their ability to determine their own need for medication and their ability to communicate symptoms, licensees are required to maintain accurate records of dates, times, and dosages of all PRN medications given. R1 had no such note on file as of 12/20/24. According to R1’s LIC 602, R1 suffered from mild cognitive impairment, including confusion and disorientation. The department has determined the following as it relates to the allegation that facility staff are not giving a resident medication as needed: Based on interview, observation and record review, the above allegation is SUBSTANTIATED. A finding that the complaint allegation is substantiated means that the allegation is valid because the preponderance of evidence standard has been met. This facility is hereby cited per 22 CCR Section 87465(a)(4). An exit interview was held with Caridad. Appeal rights and a copy of this report were left with Caridad.the state’s words, verbatim · CDSS document, Apr 10, 2025 · control 27-AS-20241219080650

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Apr 11, 2025

“(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met as evidenced by: Based on observation, record review, and interview, R1’s medications were mismanaged by facility staff, which poses an immediate health, safety, and/or personal rights risk.the state’s words, verbatim · CDSS document, Apr 10, 2025

Plan of correction: Licensee has already performed staff training regarding medication management. Licensee agrees to send documentation regarding this training to LPA Moleski by POC due date. vincent.moleski@dss.ca.gov

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Jayson Caridad and explained the purpose of the visit. LPA Moleski reviewed four resident files (R1-R4) and three staff files (S1-S3). LPA Moleski observed several residents had appraisals and/or needs and services plans which were not updated within the last 12 months. R1's appraisal and their needs and services plan were dated 08/15/2023, when R1 was admitted. R3's appraisal was undated, but appeared to have been completed when the resident was admitted, around 06/01/2023. R4's appraisal was dated 11/29/2022, when the resident was admitted. LPA Moleski observed that S3's first aid/CPR certification expired as of 10/08/24. While speaking with Caridad, LPA Moleski learned that a resident (S5) had died in mid-February 2025. LPA Moleski asked if there was a death report submitted at the time. Caridad said there was not. LPA Moleski asked to review recent emergency disaster drill records. Caridad said drills had not been conducted or documented. LPA Moleski toured the facility with Caridad 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 74 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 108 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguishers, 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 locked cabinets for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives. LPA Moleski interviewed two staff members (S1-S2) and two residents (R2, R4). This facility is hereby cited per 22 CCR Sections 87463(a), 87211(a)(1), and 87411(c)(1), and HSC Section 1569.695(c). An exit interview was held with Caridad. Appeal rights and a copy of this report were left with Caridad.the state’s words, verbatim · CDSS document, Mar 10, 2025

Type of visit: Prelicensing

On 4/22/24, at 10:37am, Licensing Program Analyst (LPA) Arvin Villanueva arrived to this facility unannounced to conduct a pre-licensing visit. LPA initially met with a staff on duty and explained the purpose of the visit. The licensee and administrators, Amy Rose Caridad, Jayson Caridad and Grace Foundo were notified of the visit and arrived shortly after. During this visit, present were 2 residents in care with 2 staff on duty. The facility has an approved hospice waiver for 4 residents. Additionally, the facility is fire cleared for 6 non-ambulatory residents. PHYSICAL PLANT: At 10:45am, LPA and staff on duty toured the physical plant of the facility. The facility is a single-story home located in a residential neighborhood. Physical plant is consistent with the submitted facility sketch/floor plan. Facility temperature was observed to be at 79 degrees F upon arrival. Indoor and outdoor passageways are free of obstruction. Entrances/exits, ramps, open porches and backyard are well-lit. There are no bodies of water was observed. The side gate is self-latching and in good repair. Disinfectants, cleaning supplies, toxic products, and sharp objects were all observed to be locked and inaccessible to resident in care. Fire alarm and carbon monoxide detectors were observed to be operating properly. The backyard is secure and has adequate space for outdoor activities. LPA observed laundry supplies and equipment including washer and dryer and are observed to be in good repair. BEDROOMS: There are 6 resident bedrooms and 1 staff room. All bedrooms were observed to be fully furnished, clean and in good repair. There is appropriate lighting in the facility and in each room. Residents bedrooms were observed to be large enough to allow passage between and comfortable usage of beds and other required furniture. Currently 3 of the 6 resident bedrooms are unoccupied. Con't to LIC809-C... BATHROOM: There is one bathroom in the master bedroom and one bathroom in the hallway. Hot water temperatures were taken in both bathrooms and are within regulatory temperature between 105-120 degrees F. Bathtubs, showers and toilets have grab bars. Showers are equipped with non-skid flooring. SUPPLIES: There is a sufficient supply of hygiene items such as soap and toilet paper. The facility maintain an adequate supply of clean linen, including beddings, bath towels, hand towels and wash cloths. ACTIVITIES: Facility is observed to have adequate activity supplies and equipment for residents, including access to internet. There is an outdoor activity area equipped for outdoor use. There is a comfortable and appropriately furnished area for residents to entertain friends and relatives. FOOD SERVICE: Kitchen and dining room were observed to be clean, sanitary and odorless. Trash cans were observed to have lids. Kitchen areas were observed to be clean, and free of litter, vermin and insects. Food preparation areas have operating ventilation. Toxic substances and cleaning supplies were observed to be properly stored, locked and inaccessible to residents. Freezer was observed to be at 0 degrees F. Refrigerator was observed to be at 40 degrees F. The facility maintains a 7 day non-perishable and 2 day perishable food supply. RECORDS: There is a confidential storage of personnel and resident records at the facility. LPA reviewed 3 resident files and 6 staff files. 3 out of 3 resident files were observed to be within regulatory standard. Technical advisory was provided to obtain and include PRN Authorization in the resident files. 6 of 6 staff files were observed to be within regulatory standard including having current first aid/CPR certificates. MEDICATION: LPA observed medications to be centrally stored, locked and inaccessible to residents in care. LPA conducted a medication audit for 2 residents. Audited medications were observed to be complete and are recorded in the centrally stored medication record. LPA observed first aid kit, including dressings, bandages, thermometer, scissors, tweezers, and current first aid manual. ADMINISTRATION: Facility is observed to have Theft and Loss Program poster. Also observed were Licensing Complaint Poster and Resident Personal Rights poster. DEMENTIA CARE: Heating devices including the fireplace are inaccessible to residents in care. Outdoor activity space is completely enclosed by a fence with self-closing latches and gates. Every exit has an auditory device in place to monitor exits. COMPONENT III: Conducted at the Pre-Licensing visit, on 4/22/24 at Five Star RCFE Inc 1, information provided about how to operate the facility within substantial compliance. An exit interview was conducted with Jayson Caridad, and a copy of this report was provided. Accordingly, LPA Villanueva will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.the state’s words, verbatim · CDSS document, Apr 22, 2024