Gardenia Homes 1

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Administrator (ADM) Josephine Yong. LPA stated the purpose of the visit. LPA toured the interior and exterior of the facility with ADM to include the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. All exit and passageways were free and clear of obstruction. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed refrigerator temperature at 38 F and Freezer at 0 F. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested by facility staff. Fire extinguishers were last serviced on 4/13/2026. The facility emergency drill log was reviewed. The facility's last drill was conducted on 7/8/2026. During inspection of the interior of the facility, LPA observed a storage room located across from the laundry room to have a futon with a blanket and pillow, personal belongings (Clothing, shoes, toiletries, coffee pot and food). ADM stated the room is being used as a break room for staff, which does not match what is listed on the facility sketch. The facility sketch indicates the room is a Storage room. Page 1 of 2 ADM denied staff living in the room. A deficiency is being issued today, see LIC809D for more information. LPA toured 9 resident bedrooms. All 9 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 2 resident bathrooms. All 2 bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPA measured water temperature with a range from 106.3 F to 112.4 F. LPA reviewed 3 resident records. LPA reviewed 3 resident’s Centrally Stored Medication and Destruction Records (CSMDRs). LPAs reviewed 3 staff records. A deficiency was cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Administrator Josephine Yong and a signed copy of this report, and appeal rights were provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, Sep 15, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Sep 16, 2026

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This was not met as evidenced by: The facility is using a storage room as living quarters for a staff member, without an approved fire clearance which poses and immediate health and safety risk to persons in care.the state’s words, verbatim · CDSS document, Sep 15, 2026

Plan of correction: ADM will submit a written plan of correction to ensure compliance with the facility fire clearance. ADM states she will submit a written request for an updated fire inspection or she will remove all staff personal belongings and put the room back to storage. POC due by 9/16/2026 to CCLD.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year Visit and met with Administrator Josephine Yong. During visit, LPA toured the facility inside and out. LPA toured the kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA reviewed the first aid kit and found it to be complete. LPA Marrufo toured 9 out of 9 resident bedrooms. Each bedroom had working lights and available bedding and clothing storage areas. LPA toured three out of three resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks ranged from 114 F to 120 F. LPA tested the carbon monoxide and smoke detectors in the hallways and bedrooms. Each detector functioned properly when tested. LPA toured the outside area and found the exits to be clear of obstructions. See LIC809-C page for more information. Page 1 of 2. LPA reviewed the Centrally Stored Medication and Destruction Records (CSMDR) for 6 residents. 4 out of 6 CSMDR were complete. Resident R1's CSMDR was missing one prescribed medication. R2's CSMDR was missing 1 prescribed medication. LPA reviewed 6 resident records and found them to be complete. LPA reviewed 6 staff records. Four out of six staff records were complete. Staff S1-S2 were missing current first aid certifications. S2 was missing a health screening form. The emergency disaster drill log indicates the last drill was conducted on 07/05/2025. LPA Marrufo requests that updated copies of the following documents be submitted to the department within seven calendar days: LIC500 Personnel Report LIC308 Designation of Administrative Responsibility Liability Insurance LIC610E Emergency Disaster Plan Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information. This report was reviewed with Administrator Josephine Yong and a copy of this report and appeal rights were provided. Page 2 of 2. END REPORTthe state’s words, verbatim · CDSS document, Sep 22, 2025

Type of visit: Prelicensing

Licensing Program Analyst (LPA) David Marrufo conducted a follow up Pre-Licensing visit and met with Administrator Josephine Yong. During visit, LPA Marrufo reviewed 4 staff records and 7 resident records and found them all to be complete. LPA observed the water flowing unobstructed in the bathroom sink that was clogged during the prior visit. The Pre-Licensing deficiencies have now been resolved. Pre-Licensing is now complete. This report was reviewed with Administrator Josephine Yong and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 22, 2024

Type of visit: Prelicensing

Licensing Program Analyst (LPA) David Marrufo conducted a Pre-Licensing visit and met with Josephine Yong, Administrator. LPA Marrufo reviewed the Component III presentation with Administrator Yong during visit. LPA Marrufo toured the facility inside and out. The kitchen had a perishable food supply of at least two days and a non-perishable food supply of at least seven days. The first aid kit was found to be complete. LPA Marrufo tested the smoke/carbon monoxide detector system and found it to be functional when tested. The outdoor area was toured and the exits were clear of obstructions. LPA Marrufo toured 3 out of 3 resident bathrooms. Each bathroom had functioning lights and available soap and paper towels. The water temperatures in 2 out of 3 bathrooms were 115 F and 119 F. During visit, LPA Marrufo observed 1 out of 3 resident bathroom sinks was clogged. LPA Marrufo reviewed records for residents R1-R5 and found residents R2, R3, and R5 did not have completed Safeguard for Property and Valuables forms. Resident R3 had a prescribed medication that was not in R3's Centrally Stored Medication and Destruction Record. During visit, the licensee of the new facility stated that the rest of the 13 resident records are not separated and completed in their own resident records. LPA reviewed the staff record of staff S1, which was found to be complete. The licensee of the new facility license stated the 4 out of 5 remaining staff did not have separate and complete personnel records. Pre-Licensing is incomplete with deficiencies to be resolved by 07/17/2024. A follow-up Pre-Licensing LIC809 will be generated upon resolution of deficiencies. This report was reviewed with Josephine Yong and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jul 10, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Change of Ownership Capacity: 14 Census (if any clients in care): 11 COMP II Participants: JOSEPHINE YONG Interview Method: Telephone interview On July 02, 2024, 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, Jul 2, 2024