Forever Young

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Luis De Leon conducted an unannounced required annual inspection visit. LPA met with Administrator Joni Ramos and explained the reason for the visit. Administrator Ramos contacted Licensee Laureta Martiniana who joined the visit a short time after. The facility is licensed to serve six (6) residents, 60 years and over. The facility is approved for six (6) non-ambulatory residents and six (6) hospice waivers. LPA use the Compliance & Regulatory Enforcement Tool (CARE) during today’s inspection. LPA De Leon toured the facility with assistance of administrator Ramos: FACILITY PHYSICAL PLANT The facility is in a residential area and is made up three (3) resident bedrooms, one (1) staff bedroom, three (3) full bathrooms for residents’ use, kitchen, activity area, laundry located in backyard, dining room, living room, front and backyard. There were no body of water observed in the property. REVIEW OF FILES LPA reviewed six (6) out of (6) Resident files which consisted of Admission Agreements, Identification and Emergency Info, Physicians Report, Consent Report, Needs and Service Plan, Personal Rights, and Centrally Store Medication. LPA reviewed five (5) staff files which consisted of Personnel Report, Health Screening, Criminal Record Statements, Fingerprint Clearance, Training, First Aid and CPR. Emergency Disaster Preparedness, Infection Control Plan, and Liability Insurance. (Report continues on page LIC-809C...) Observations during facility tour: Bedrooms were furnished with a bedframe, dresser, lamps, and chairs. LPA observed that there were clean linen, bath towels, and personal hygiene with reasonable closet space available for clients. Wall and floors are in good repair. Hallways were clean and free of obstructions. Kitchen appliances were in working order and clean. There is sufficient two (2) days of perishables and seven (7) day supply of non-perishable food. Dining room has sufficient seating area. Weekly food menu is posted at facility. Toilets, showers, and water faucets are found in compliance with Title 22 regulations for temperature and function. Restrooms were stocked and clean. The water temperature was tested and measured. It was found in compliance with Title 22 regulations between 105º and 120º F degrees. Sharps are locked inside the kitchen and inaccessible to clients. Also, disinfectants and cleaning supplies are locked and secured outside the home inaccessible to clients. Smoke detectors were observed in all bedrooms and carbon monoxide detectors were observed in living room around kitchen area. One (1) fire extinguisher was observed and was fully charged with last inspection on 05/27/2026. Last fire drill and disaster drill were conducted on 07/01/2026. Earthquake drill was done on 04/01/2026. Front and back yards are free of hazards. Back yard has a shaded seating area for clients to enjoy. The medications are centrally stored and locked in the staff room. The facility uses the Medication Administration Record (MAR) log to document medications given. LPA reviewed medications for all six (6) clients. LPA conducted two resident and staff interviews. Per California Code of Regulations, Title 22, and California Health and Safety Code, no deficiencies were observed during the visit. Exit interview was held and a copy of the report was provided to the Licensee Laureta Martinian.the state’s words, verbatim · CDSS document, Aug 17, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Luis De Leon conducted an unannounced required annual inspection visit. LPA met with Administrator Joni Ramos and explained the reason for the visit. Administrator Ramos contacted Licensee Laureta Martiniana who joined the visit a short time after. The facility is licensed to serve six (6) residents 60 years and over. The facility is approved for six (6) non-ambulatory residents and six (6) hospice waivers. LPA use the Compliance & Regulatory Enforcement Tool (CARE) during today’s inspection. LPA De Leon toured the facility with assistance of administrator Ramos: FACILITY PHYSICAL PLANT The facility is in a residential area and is made up three (3) resident bedrooms, one (1) staff bedroom, three (3) full bathrooms for residents’ use, kitchen, activity area, laundry located in backyard, dining room, living room, front and backyard. There were no body of water observed in the property. REVIEW OF FILES LPA reviewed six (6) out of (6) Resident files which consisted of Admission Agreements, Identification and Emergency Info, Physicians Report, Consent Report, Individual Program Plan, Personal Rights, and Centrally Store Medication. LPA reviewed four (4) staff files which consisted of Personnel Report, Health Screening, Criminal Record Statements, Fingerprint Clearance, Training, First Aid and CPR. Emergency Disaster Preparedness, Operation Plan, Hospice and Dementia care plans. Report continues on page LIC-809C All resident rooms were inspected, and LPA observed resident beds, dresser, and chairs in good repair. Adequate linen and personal hygiene supplies are observed with enough closet space for resident’s personal belongings. Sufficient space to accommodate both indoor and outdoor activities was observed. During today’s visit, LPA observed residents participating on chair exercises and karaoke. Licensee stated that residents also participate on board games, reading, and community walks. Walls and floors are in good repair. Common areas are observed for the ability to safely serve the needs of the residents without obstruction. Smoke detectors and carbon monoxide detectors are tested and operational in resident’s rooms and common areas. Facility temperature was comfortable. Bathrooms are clean and operational. The hot water temperature was tested in the residents' bathrooms and was within the required range of 105-120 degrees F. Showers were free of mold/mildew, had adequate lighting, and there are sufficient toiletries that are accessible to residents. Last fire drill was done on 4/4/25 and earthquake drill on 4/9/25. One (1) Fire extinguisher is fully charged, last serviced on 5/30/25. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables. Physician order for modified diet is on file. Sharps are locked under stove and are inaccessible to resident. Cleaning supplies and grooming supplies were observed locked in cabinet. Backyard and front yard are clean, free of debris. No large bodies of water were observed. Facility provides telephone landline and internet for the residents. There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Staff have sufficient on-going training that meets the annual requirement. The medications are centrally stored and in their original containers. LPA reviewed six (6) out of three (6) residents’ medications. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during today’s visit. Exit interview was held and a copy of the report was given to Administrator Laureta Martiniana.the state’s words, verbatim · CDSS document, Jun 24, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Tyler Reyes conducted a case management visit in order to reissue citations for deficiencies observed during the annual inspection visit conducted on 05/30/2024. LPA Reyes met with Licensee Laureta and explained the reason for the visit. On 5/30/24 LPA Reyes conducted an unannounced required annual inspection. During the review of medications, LPA Reyes observed that the medication for Resident 1 (R1) was not administered according to the physician’s prescribed instructions. There were instances where medication was not administered on the scheduled dates and the medication sheet for May 2024 showed not all doses were documented. Based on LPA Reyes's review of R1’s Medication Sheet for the month of May 2024. LPA Reyes observed R1s medications were still inside the Bubble Pack and the May 2024 Medication Sheet was initial by staff as medication were administered, therefore staff did not administer R1s medications per physician orders for R1s medications listed below. Staff 1 (S1) stated to LPA that the reason for not administering or documenting the missed medication for the May 2024 Medication Sheet was just missed. · R1’s AM Medication –Simethicone 80MG (Take 1 Tablet By Mouth 4 Times Daily) were still in the bubble pack for the following dates: 05/01/24 through 05/22/24, 05/24/24 and 05/30/24, . · R1’s AM Medication - QUEtiapine Fumarate 50MG (Take 1 Tablet By Mouth Daily) were still in the bubble pack for the following dates: 05/01/24 through 05/17/24, 05/22/24 through 05/24/24, and 5/30/24. Refer to LIC 809C for continuation of report ·R1’s Noon Medication - Simethicone 80MG (Take 1 Tablet By Mouth 4 Times Daily)were still in the bubble pack for the following dates: 05/01/24 – 05/25/24, · R1’s PM Simthicone 80MG (Take 1 Tablet By Mouth 4 Times Daily) were still in the bubble pack for the following dates 05/01/24 through 05/24/24 and 05/29/24. · R1’s Bedtime Mediation - Melatonin 5MG (Take 1 Tablet By Mouth Daily) were still in the bubble pack for dates 05/01/24 through 05/05/24, 5/13/24 through 05/16/24, 5/21/24 through 05/24/24, and 5/29/24. · R1s Bedtime Medication Simethicone 80 MG (Take 1 Tablet By Mouth 4 Times Daily)were still in the bubble pack for the following dates: 05/01/24 through 05/25/24 and was still in R1’s bubble pack. During 05/30/24 visit, LPA Reyes collected copies of R1’s file and pictures of R1’s missed medication. Licensee Laureta provided LPA Reyes with the following documents in-service training for all staff on medication, and that R1’s physician was notified on 5/31/24. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC 809D for details. Exit interview was conducted with Licensee. Licensing report and appeal rights were discussed and provided to facility Licensee.the state’s words, verbatim · CDSS document, Jul 18, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Jul 18, 2024

87465 Incidental Medical Care (c) resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication...(2) Once ordered by the physician the medication is given according to the physician's directions. Based interview and record review of medications conducted on 5/30/24, LPA Reyes observed that the medication for Resident 1 (R1) was not administered according to the physician’s prescribed instructions. There were instances where medication was not administered on the scheduled dates and the medication sheet for May 2024 showed not all doses were documented. Staff 1 (S1) stated to LPA that the reason for not administering or documenting the missed medication for the May 2024 Medication Sheet was just missed.the state’s words, verbatim · CDSS document, Jul 18, 2024

Plan of correction: Licensee reprovided LPA Reyes with the following documents in-service training for all staff on medication, and that R1’s physician was notified.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tyler Reyes conducted an unannounced required annual inspection using the CARE tools. LPAs met with Administrator Martiniana Laureta and explained the reason of the visit. The facility is a Residential Facility for the Elderly(RCFE) licensed to serve 6 clients age range 59 and over, non-ambulatory only and an approved hospice waiver for 6. Currently, there are there are two (2) residents placement. The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Operational Requirements, Physical Plant/Environment Safety, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Planned Activities, Food Service, Incidental Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs (SHN). During the visit LPA observed the following: Infection Control: The facility staff are using appropriate hand hygiene and wearing gloves while assisting residents. There is a visitor sign-in/ screening station located in the main entrance. Staff are cleaning and disinfecting often for high touched surfaces. Facility has sufficient PPE supplies, has an Infection Control Plan and Mitigation Plan.Bathrooms have hand washing signs, soap and paper towels. Facility Administrator is adhering to infection control requirements. Refer to LIC 809C for continuation of report Operational Requirements: Fire Drills are conducted every three months, the last fire drill was conducted on 04/09/2024. Emergency Disaster/ Earthquake Drills are also conducted every three months and the last one was conducted on 04/09/2024. Facility Administrator is adhering to operational requirements. Physical Plant & Environment Safety: The home is located in a residential area, the single-story facility consisting of: three bedrooms, living room, kitchen, dining room, laundry area, and office area. All resident rooms were checked. All resident beds have the required linens which were in good condition at the time of the visit. All bedrooms had sufficient closet/ storage space. Bathrooms are clean and operational and were observed to be within Title 22 regulations. Facility toilets and water faucets worked properly. Shower was free of mold/mildew, adequate lighting, and sufficient toiletries are accessible to clients. Bathrooms are clean, sanitary and operational with grab bars and non skid mats in place. Water temperature properly measured at 111F*. Facility temperature was comfortable throughout the facility. LPA observed the facility to be clean and in good repair. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and no bodies of water present. Medications are stored, locked and inaccessible to residents. Hazardous toxins and/or items are inaccessible to clients, fire extinguisher is fully charged. Exit, walkways and/or passageways, front yard is free of debris and/or hazards. A shaded area with chairs is provided for residents in the front porch of the facility Staffing: There is sufficient staffing at the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed staff files for Facility Administrator. Staff have current CPR/first aid training and sufficient on-going training that meets the annual requirement. Staff have their Health Screening and Tuberculosis Screening on file. Staff are also trained on Abuse Reporting. Administrator certificates expires 3/27/2025. Refer to LIC 809C for continuation of report Resident Records-Incident Reports: LPA reviewed Client files for R1 through R6. Resident files are maintained at the facility and have the following documents in their files : Admission agreements, Physician's Reports, Appraisals, TB clearance, Functional Capability Assessment/Appraisals, hospice care plans, and emergency information. Resident Rights-Information: RCFE complaint poster and Personal rights were observed posted in the facility. Per Facility Administrator, facility provides wi-fi services for facility residents. Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. Indoor and outdoor activities are performed daily. Food Service: Sufficient food supply is stored in the kitchen and pantry areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies. Physician order for modified diet is on file. Sanitation practices and kitchen cleanliness was observed. Incidental Medical Services: Six (6) centrally stored 30-day supply of medications were reviewed. Medical and dental transportation is provided by facility and family members. Disaster Preparedness: Emergency and Disaster Plan LIC610E is in place. The last quarterly fire/emergency drill was completed on 04/09/2024. Residents with SHN : Two (2) residents receive hospice care.Appraisals were observed in resident files. No residents have prohibited health conditions. Deficiencies were cited per California Code of Regulations, Title 22. See LIC 809D for details. An exit interview was conducted. This report and appeal rights were discussed and provided to facility Licensee/Administrator, whose signature on this form confirm receipt of these documents.the state’s words, verbatim · CDSS document, May 30, 2024