George Anne Home

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds, consisting of 6 private client bedrooms, 3 full bathrooms, kitchen/living/dining room. There is a detached staff unit/building that contains a bedroom with one bed, a large room with 2 bunk beds, kitchen, and full bathroom for staff. Awake night staff is employed. Two additional detached storage sheds are in the backyard, and washer and dryer are located in an alcove adjacent to staff unit/building. The spacious backyard is level, paved and landscaped, with 2 gazebos. There are no accessible bodies of water or fire safety hazards observed. A comfortable room temperature is maintained, and lighting is sufficient for safety. Carbon monoxide detectors are present and observed with green lights. First-aid kit is maintained. Medications are stored in hall and kitchen cabinets. Client and some staff records are reviewed. Maria Lu Johnson oversees facility operations, but does not have proof of current RCFE administrator certification. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. A Disaster and Mass Casualty Plan is posted. The following forms/information are requested to be updated returned to CCL by 9/24/26: • LIC 610 Emergency Disaster Plan (page 9, signed and dated) • Staff medication TRAINING topics (per H & S 1569.69) • LIC 308 Designation of Facility Responsibility • LIC 500 Personnel Report • Proof of current liability insurance Deficiencies of the CA Code of Regulations, Title 22 are cited on following pages. Staff training and clients' medications will be reviewed at a later date, due to time constraints.the state’s words, verbatim · CDSS document, Sep 10, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Sep 11, 2026

MAINTENANCE AND OPERATION ... Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F. This requirement is not met, as hot water temperature tested at 126 degrees F in main client bathroom. Licensee failed to ensure water temperature is maintained within regulatory limits, which poses an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: Hot water temperature will be lowered and maintained within range of 105 to 120 degrees F. Proof of correction to be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a) · Plan of correction due date: Sep 11, 2026

STORAGE SPACE ...the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met, as Stove cleaner, kitchen cleaner, Goo Gone, WD-40, wood glue, furniture polish, water proofer are stored in kitchen accessible to clients, & Raid, Ajax cleansers, Clorox are stored in unlocked storage shed in backyard.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: Toxics stored in kitchen were moved to locked under sink cabinet and backyard storage shed was padlocked in LPA's presence Deficiency corrected and cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Sep 24, 2026

ADMINISTRATOR QUALIFICATIONS.. All facilities shall have a qualified and currently certified administrator... This requirement is not met, as there is no proof that a certified administrator is employed. Licensee failed to ensure that a qualified and certified administrator is employed to manage facility operations, which poses a potential health, safety or personal rights risk to clients in care. This deficiency was cited on 7/31/25.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: Proof of correction shall be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Sep 11, 2026

CRIMINAL RECORD CLEARANCE All individuals subject to a criminal record review pursuant to HSC 1569.17(b) shall prior to working, residing or volunteering in a licensed facility...Obtain a CA clearance or a criminal record exemption. This requirement is not met, as criminal record clearances for staff #1 and #2 are not associated to this facility. Licensee failed to ensure that all staff maintain criminal record clearance and association to facility, which poses an immediate health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Sep 10, 2026

Plan of correction: Proof of correction to be sent to CCL BY DUE DATE

Type of visit: POC

To follow up on deficiencies cited on 7/31/25 and 8/27/25, LPA Jeung met with home manager and reviewed documents submitted on 3/24/26 as corrections. The following deficiencies are corrected, and acknowledgement of corrections is issued--4 pages: - CCR 87611 General Requirements for Allowable Health Conditions Administrator acknowledged requirements for providing care for clients with allowable health condition(s) - HSC 1569.626 Documentation submitted shows that all staff received required initial or annual dementia training - HSC 1569.696 Documentation submitted shows that all staff received required initial or annual training on hospice care, restricted health conditions and postural supports - CCR 87465 (i)(1-4) Incidental Medical Care Administrator to ensure ongoing compliance for discarding/destroying medications Deficiencies cited on 8/5/25 and 8/27/25 still exist, and are being recited, as per California Code of Regulations, Title 22, and appear on following pages. - CCR 87411 (f) Personnel Requirements - CCR 87468.1 (a)(13) Personal Rightsthe state’s words, verbatim · CDSS document, Apr 23, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(f) · Plan of correction due date: May 1, 2026

PERSONNEL REQUIREMENTS ... verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than 6 months prior to or 7 days after employment or licensure. A report shall be made of each screening, signed by the examining physician. This requirement is not met, as health screening for staff #6 was not maintained and not submitted after citations issued on 9/3/24 and 8/27/25. Licensee failed to ensure that health screenings are maintained for all staff, which poses a potential health, safety or personal rights risk.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: Current health screening for staff #6 (AC) will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.1(a)(13) · Plan of correction due date: May 1, 2026

PERSONAL RIGHTS Residents in all RCFEs shall have the personal right to have access to individual storage space for private use. This requirement is not met, as facility records are stored in client room #4. Licensee failed to ensure that client's room is for client's personal use and not used by staff. This poses a potential health, safety or personal rights risk to clients in care.This was cited on 8/5/25 and 8/27/25 and not corrected. Clients' rooms will be reserved for clients' belongings only, and not for storage of facility equipment or supplies.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: Plan/proof of correction to be sent to CCLD BY DUE DATE.

Type of visit: Case Management - Other

Based on review of information provided by licensee Peter Gong and discussed during office meeting on 1/13/26, deficiencies of the California Code of Regulations, Title 22 are cited by LPA Jeung. Citations appear on following pages.the state’s words, verbatim · CDSS document, Apr 23, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87205(a) · Plan of correction due date: May 1, 2026

ACCOUNTABILITY OF LICENSEE GOVERNING BODY The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. This requirement is not met, as Mr. Gong stated emphatically that he "does not work there" at facility. Licensee failed to exercise general supervision over facility operations, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: Plan of correction to be submitted to CCLD BY DUE DATE and implemented

From the deficiency page — Deficiency type: Type B · Section cited: CCR87161(a)(2) · Plan of correction due date: May 1, 2026

RESUBMISSION OF APPLICATION A new application shall be made whenever there is any change in conditions or limitations described on the current license, including, but not limited to any change in the licensee. This requirement was not met, as Articles of Organization were filed with the CA Secretary of State on 11/16/2016, but the Dept. was not notified of the change, and a new application was not made. Licensee failed to apply for licensure as an LLC, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: Plan of correction to be submitted to CCLD BY DUE DATE and implemented.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405 · Plan of correction due date: May 1, 2026

ADMINISTRATOR QUALIFICATIONS & DUTIES The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)... Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met, as demonstrated by repeated non-compliance of licensing requirements. Licensee failed to ensure that facility administrator possesses the ability to oversee facility operations in conformity with Title 22 requirements, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: Plan of correction to be submitted to CCLD BY DUE DATE and implemented.

Type of visit: Case Management - Deficiencies

During case management visit and inspection of medication storage in hallway and kitchen, LPA Jeung observed that medications are accessible to residents in care. Deficiency of the California Code of Regulations, Title 22 is cited on a following page.the state’s words, verbatim · CDSS document, Apr 23, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Apr 23, 2026

INCIDENTAL MEDICAL CARE Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met, as plastic 7-day pill dispenser is observed in unlocked kitchen drawer, which is accessible to clients. Licensee failed to ensure that medications are inaccessible to residents, which poses an immediate health or safety risk to clients in care.the state’s words, verbatim · CDSS document, Apr 23, 2026

Plan of correction: Pill dispenser was removed from unlocked drawer in LPA's presence and secured where medications are not accessible to residents. Deficiency corrected and cleared in LPA's presence

Type of visit: Office

An informal meeting was convened in the San Bruno regional office today. In attendance are: - Licensee Peter Gong - Licensing Program Manager April Cowan - Licensing Program Analyst Audrey Jeung - Licensing Program Analyst Murial Han - Licensing Program Analyst Grace Donato The following concerns are discussed: - Ownership change from individual proprietorship to Limited Liability Corporation - Plans of Correction of deficiencies cited during annual visit 7/31/25 and subsequent case management visits - Administrator qualifications Outstanding deficiencies cited on 8/27/25 are identified and a copy of Facility Evaluation Report is given to licensee. Mr. Gong agreed to submit plans/proof of corrections to CCLD within TEN DAYS. Licensee will also create and implement a plan to address the above concerns; written plan to be submitted to CCLD within TEN DAYS.the state’s words, verbatim · CDSS document, Jan 13, 2026

Type of visit: POC

To follow up on deficiencies cited on 7/31/25, 8/5/25 and 8/14/25, LPA Jeung met with administrator and licensee to review documents submitted as corrections. Deficiencies not yet corrected are being recited, as per California Code of Regulations, Title 22, and appear on following pages. Licensee agreed to avail of Technical Support Program assistance. LPA to make referral to TSP, and licensee will be contacted by TSP staff to arrange for consultation.the state’s words, verbatim · CDSS document, Aug 27, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Aug 28, 2025

PERSONAL RIGHTS Residents in all RCFEs shall have... the ... personal right to be accorded safe, healthful &comfortable accommodations, furnishings & equipment. This requirement is not met, as client in room #5 is observed in bed with recliner chair & wheelchair placed next to bed, preventing her from getting out of bed. Licensee failed to ensure that clients are accorded safe & healthful accommodations, which poses an immediate health, safety or personal rights risk to clients in care. This was cited on 8/5/25, and "explanation" was submitted on 8/6/25, not correction.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Clients cannot be restricted from getting out of bed. Recliner and wheelchair were relocated in LPA's presence. Plan of correction shall be submitted to CCLD BY DUE DATE, affirming that clients have the right to not be confined in bed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87207 · Plan of correction due date: Aug 28, 2025

FALSE CLAIMS No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility... This requirement was not met, as facility staff obtained personal and confidential information by falsely stating that the information was required by state licensing. Licensee failed to prevent staff from making false claims, which poses an immediate health, safety or personal rights risk to clients in care. This was cited on 8/14/25 and not addressed in plan of correction submitted on 8/18/25.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Plan/proof of correction to be submitted to CCLD BY DUE DATE describing how licensee will ensure that staff are at all times disseminating truthful statements regarding the facility and operations.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c) · Plan of correction due date: Sep 5, 2025

PRE-ADMISSION APPRAISAL Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance/Retention LimitS. This requirement is not met, as there is no signed appraisal on file for client #5, who was admitted 3 years ago. This poses a potential health, safety or personal rights risk to clients. This was cited on 9/3/24 and 7/31/25.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Appraisal for client #5 will be completed, signed and dated BY CLIENT OR REPRESENTATIVE AND FACILITY REPRESENTATIVE, and copy will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.695(b) · Plan of correction due date: Sep 5, 2025

HEALTH & SAFETY CODE A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement is not met, as there is no documentation that staff received training on responding to emergencies, which poses a potential health, safety or personal rights risk to clients in care. This deficiency was cited on 9/3/24 and 7/31/25, and proof of correction was not submitted.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Staff shall receive emergency response training and proof of correction to be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Sep 5, 2025

REAPPRAISALS The pre-admission appraisal... shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition... and to keep the appraisal accurate. This requirement is not met as reappraisals for ALL clients are missing or dated more than 12 months ago. Licensee failed to ensure that annual reappraisals are done, which poses a potential health, safety or personal rights risk to clients. This deficiency was observed on 9/3/24 & 7/31/25, & proof of correction was not submitted.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: SIGNED AND DATED Reappraisals for clients #1, #3, #5 will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87611(b)(1-3) · Plan of correction due date: Sep 5, 2025

GENL REQUIREMNTS HEALTH COND. The licensee shall complete & maintain a current, written record of care... that includes, but is not limited to... Documentation from the physician of... Stability of the medical condition, Medical condition which requires incidental medical services, Method of intervention...skilled professional...who will perform the procedure if the resident needs assistance; names...phone number of...skilled professionals providing services, Emergency contacts. Client #4 has gall bladder stoma & there is no info about care or condition. This was cited on 7/31/25.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Plan of correction to be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69(a) · Plan of correction due date: Sep 5, 2025

HEALTH AND SAFETY CODE ...employee shall complete 10 hours of initial training...consist of 6 hours of hands-on shadowing training...prior to assisting with the self-administration of medications, & 4 hours of other training or instruction, as described in subdivision (f)...be completed within the first 2 weeks of employment. This requirement is not met, as training records are not available for review. Licensee failed to maintain documentation that staff have received medication training, which poses a potential health, safety or personal rights risk. This was cited on 9/3/24 & 8/5/25.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Proof of required medication training for ALL staff who handle medications will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.626(a) · Plan of correction due date: Sep 5, 2025

HEALTH AND SAFETY CODE RCFEs shall meet...training requirements, as described in Section 1569.625, for all direct care staff...12 hours of dementia care training, 6 of which...completed before...working independently with residents, and the remaining 6 hours of which shall be completed within the first 4 weeks of employment. This requirement is not met, as training records are not available for review. Licensee failed to maintain documentation that staff have received dementia training, which poses a potential health, safety or personall rights risk. This was cited on 9/3/24 and 8/5/25.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Proof of required dementia training for all staff will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.696(a) · Plan of correction due date: Sep 5, 2025

HEALTH AND SAFETY CODE All RCFEs shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. This requirement is not met, as training records are not available for review. Licensee failed to maintain documentation that staff have received this training, which poses a potential health, safety or personall rights risk. This was cited on 9/3/24 and 8/5/25 and not corrected.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Proof of required training on hospice care, restricted health conditions and postural supports for all staff will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(f) · Plan of correction due date: Sep 5, 2025

PERSONNEL REQUIREMENTS ... verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than 6 months prior to or 7 days after employment or licensure. A report shall be made of each screening, signed by the examining physician. This requirement is not met, as 6 out of 6 staff files were missing health screenings and TB test results. Licensee failed to ensure that health screenings are maintained for all staff, which poses a potential health, safety or personal rights risk. This was cited on 9/3/24 and not corrected.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Copies of health screenings and TB test results for staff #1, #3, #6 will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(1)(4) · Plan of correction due date: Sep 5, 2025

INCIDENTAL MEDICAL CARE All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met, as staff write on RX labels. Licensee failed to ensure that staff do not write on Rx labels, which poses a potential health, safety or personal rights risk to clients in care. This was cited on 8/5/25 and not corrected.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Staff shall cease writing on Rx labels. Plan/proof of correction to be sent to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(i)(1-4) · Plan of correction due date: Sep 5, 2025

INCIDENTAL MEDICAL CARE Rx medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician & documented in the resident’s record nor disposed of... shall be destroyed in the facility by the facility administrator & another adult who is not a resident. Both shall sign a record, to be retained for at least 3 years, which lists... specific information. This requirement is not met, as Rx meds for former client observed in kitchen cabinet, which poses a potential health, safety or personal rights risk. This was cited 8/5/25.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Medications of former residents must be destroyed, and witnessed and documented as per requirements. Proof of correction to be sent to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(13) · Plan of correction due date: Sep 5, 2025

PERSONAL RIGHTS Residents in all RCFEs shall have the personal right to have access to individual storage space for private use. This requirement is not met, as facility records are stored in client room #4. Licensee failed to ensure that client's room is for client's personal use and not used by staff. This poses a potential health, safety or personal rights risk to clients in care. This was cited on 8/5/25 and not correctedthe state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Clients' rooms will be reserved for clients' belongings only, and not for storage of facility equipment or supplies. Plan/proof of correction to be sent to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(e)(1-4) · Plan of correction due date: Sep 5, 2025

INCIDENTAL MEDICAL CARE For every Rx and non Rx medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the MD order & the label shall contain ...specific information. This requirement is not met, as MD orders are not maintained for C3 OTC Senna and C6 Senna Plus. Licensee failed to ensure that MD orders are maintained for OTC meds, which poses a potential health, safety or personal rights risk. This was cited 8/5/25.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: MD orders for C3 Senna and C6 Senna Plus to be sent to CCLD BY DUE DATE.

Type of visit: Case Management - Deficiencies

In response to information obtained during phone call with a resident's responsible party, LPA Jeung initiated this case management visit, as deficiencies of the California Code of Regulations, Title 22 occurred. Citations are documented on following pages.the state’s words, verbatim · CDSS document, Aug 14, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87207 · Plan of correction due date: Aug 15, 2025

FALSE CLAIMS No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility... This requirement was not met, as facility staff obtained personal and confidential information by falsely stating that the information was required by state licensing. Licensee failed to prevent staff from making false claims, which poses an immediate health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Aug 14, 2025

Plan of correction: Plan/proof of correction to be submitted to CCLD BY DUE DATE describing how licensee will ensure that staff are at all times disseminating truthful statements regarding the facility and operations.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87506(c)(1) · Plan of correction due date: Aug 15, 2025

RESIDENT RECORDS All information & records obtained from or regarding residents shall be confidential. The licensee shall be responsible for storing...records & for safeguarding the confidentiality of their contents. The licensee & all employees shall reveal or make available confidential information only upon the resident's written consent or... designated representative. This requirement was not met, as staff shared unsolicited personal and confidential client information via text to another client's responsible party. Licensee failed to ensure the confidentiality of client information, which poses an immediate health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Aug 14, 2025

Plan of correction: Licensee shall submit plan/proof of correction to CCLD BY DUE DATE describing how licensee will ensure that staff are at all times protecting the confidentiality of resident records.

Type of visit: POC

To follow up on deficiencies cited on 7/31/25--for which civil penalty of $100 accrued daily for one deficiency starting on 8/5/25--and 8/5/25, LPA Jeung reviewed corrections that were submitted to licensing office on 8/13/25. The following deficiencies are corrected, and acknowledgement of corrections is issued--5 pages: - Section 87204 Limitations - Capacity & Ambulatory Status Updated MD report for Client #1 states that client is Non-ambulatory Civil penalty of $700 is assessed today, which represents civil penalty of $100/day for period 8/6/25 through and including 8/12/25. See LIC421FC. - Section 87608 Postural Supports MD orders for half bed rails for clients #1, #3, #5, #6 were sent to CCLD - Section 87506 Resident Records Emergency information for clients #1, #2, #4 were sent to CCLD - Section 87411 Personnel Requirements Proof of current first-aid training for staff #2, #3, #4, #5, #6 sent to CCLD - 87465 Incidental Medical Care First-aid manual is observed at facility Continued on next page The following deficiencies cited on 7/31/25 still exist, as plan of corrections was not submitted to CCLD: - CCR 87457(c) Pre-Admission Appraisal Appraisal for client #5 will be completed, signed and dated BY CLIENT OR REPRESENTATIVE AND FACILITY REPRESENTATIVE - Health and Safety Code 1569.695(b) - Health and Safety Code 1569.695(c) - 87463(a) Reappraisals Appraisals for all clients will be completed, signed and dated BY CLIENT OR REPRESENTATIVE AND FACILITY REPRESENTATIVE - CCR 87611(b)(1-3) General Requirements for Allowable Health Conditions - CCR 87412(a)(1-13) Personnel Records The following deficiencies cited on 8/5/25 still exist, as plan of corrections was not submitted to CCLD: - CCR 87468.1(a)(1) Personal Rights "Explanation" was submitted, but affirmation that clients have the right to NOT be confined in bed was NOT submitted - Health and Safety Code 1569.69(a) - Health and Safety Code 1569.626(a) - Health and Safety Code 1569.696(a) - CCR 87411(f) Health screenings were not submitted for 6 staff - CCR87618(b)(1)(B) - CCR 87465(h)(1)(4) - CCR 87468.1(a)(13) - CCR 87465(i)(1-4) - CCR 87465(e)(1-4) Administrator Maria Johnson is advised that failure to correct the cited deficiencies on or before the Plan of Correction due date may result in a civil penalty assessment. As per phone conversation, additional time is needed to submit corrections. Written request shall be submitted to CCLD by close of business TODAY, with requested revised due date.the state’s words, verbatim · CDSS document, Aug 14, 2025

Type of visit: Case Management - Annual Continuation

To complete annual inspection of 7/31/25, LPA Jeung reviewed Centrally Stored Medications Records and staff training records. However, training records are not available to review. Deficiencies of the California Code of Regulations, Title 22, are cited on following pages. Due to multiple and repeated deficiencies cited, information about the CCLD Technical Support Program is recommended and provided to administrator, to provide assistance and training in meeting regulatory requirements. LPA will facilitate referral to TSP assistance upon request from facility.the state’s words, verbatim · CDSS document, Aug 5, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69(a) · Plan of correction due date: Aug 12, 2025

HEALTH AND SAFETY CODE ...employee shall complete 10 hours of initial training...consist of 6 hours of hands-on shadowing training...prior to assisting with the self-administration of medications, & 4 hours of other training or instruction, as described in subdivision (f)...be completed within the first 2 weeks of employment. This requirement is not met, as training records are not available for review. Licensee failed to maintain documentation that staff have received medication training, which poses a potential health, safety or personal rights risk. This was cited on 9/3/24, as staff #6 did not have medication training.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Proof of required medication training for all staff will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.626(a) · Plan of correction due date: Aug 12, 2025

HEALTH AND SAFETY CODE RCFEs shall meet...training requirements, as described in Section 1569.625, for all direct care staff...12 hours of dementia care training, 6 of which...completed before...working independently with residents, and the remaining 6 hours of which shall be completed within the first 4 weeks of employment. This requirement is not met, as training records are not available for review. Licensee failed to maintain documentation that staff have received dementia training, which poses a potential health, safety or personall rights risk. This was cited on 9/3/24, as staff #6 did not have dementia training.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Proof of required dementia training for all staff will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.696(a) · Plan of correction due date: Aug 12, 2025

HEALTH AND SAFETY CODE All RCFEs shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. This requirement is not met, as training records are not available for review. Licensee failed to maintain documentation that staff have received this training, which poses a potential health, safety or personall rights risk. This was cited on 9/3/24 and not corrected, as staff #6 did not have proof of training on hospice care, restricted health conditions.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Proof of required training on hospice care, restricted health conditions and postural supports for all staff will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(f) · Plan of correction due date: Aug 12, 2025

PERSONNEL REQUIREMENTS ... verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than 6 months prior to or 7 days after employment or licensure. A report shall be made of each screening, signed by the examining physician. This requirement is not met, as 6 out of 6 staff files were missing health screenings and TB test results. Licensee failed to ensure that health screenings are maintained for all staff, which poses a potential health, safety or personal rights risk. This was cited on 9/3/24 and not corrected.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Copies of health screenings and TB test results for all staff will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87618(b)(1)(B) · Plan of correction due date: Aug 12, 2025

OXYGEN ADMINISTRATION ..."No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas. This requirement was not met, as there were no oxygen in use signs posted on 7/31/25 during initial annual inspection, which poses a potential health, safety or personal rights risk.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Oxygen in use signs will be posted at entrance and bedroom door. Proof of correction to be sent to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(1)(4) · Plan of correction due date: Aug 12, 2025

INCIDENTAL MEDICAL CARE All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met, as staff write on RX labels. Licensee failed to ensure that staff do not write on Rx labels, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Staff shall cease writing on Rx labels. Plan/proof of correction to be sent to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Aug 6, 2025

PERSONAL RIGHTS Residents in all RCFEs shall have... the ... personal right to be accorded safe, healthful &comfortable accommodations, furnishings & equipment. This requirement is not met, as client in room #5 is observed in bed with recliner chair and wheelchair placed next to bed, preventing her from getting out of bed. Licensee failed to ensure that clients are accorded safe & healthful accommodations, which poses an immediate health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Clients cannot be restricted from getting out of bed. Recliner and wheelchair were relocated in LPA's presence. Plan of correction shall be submitted to CCLD BY DUE DATE, affirming that clients have the right to not be confined in bed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(13) · Plan of correction due date: Aug 12, 2025

PERSONAL RIGHTS Residents in all RCFEs shall have the personal right to have access to individual storage space for private use. This requirement is not met, as facility records are stored in client room #4. Licensee failed to ensure that client's room is for client's personal use and not used by staff. This poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Clients' rooms will be reserved for clients' belongings only, and not for storage of facility equipment or supplies. Plan/proof of correction to be sent to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(i)(1-4) · Plan of correction due date: Aug 12, 2025

INCIDENTAL MEDICAL CARE Rx medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician & documented in the resident’s record nor disposed of... shall be destroyed in the facility by the facility administrator & another adult who is not a resident. Both shall sign a record, to be retained for at least 3 years, which lists... specific information. This requirement is not met, as Rx meds for former client observed in kitchen cabinet, which poses a potential health, safety or personal rights risk.the state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: Medications of former residents must be destroyed, and witnessed and documented as per requirements. Proof of correction to be sent to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(e)(1-4) · Plan of correction due date: Aug 12, 2025

INCIDENTAL MEDICAL CARE For every Rx and non Rx medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain ...specific information. This requirement is not met, as MD orders are not maintained for C3 OTC Senna and C6 Senna Plus. Licensee failed to ensure that MD orders are maintained for OTC meds, which poses a potential health, safety or personal rights riskthe state’s words, verbatim · CDSS document, Aug 5, 2025

Plan of correction: MD orders for C3 Senna and C6 Senna Plus to be sent to CCLD BY DUE DATE.

Type of visit: POC

To follow up on deficiencies cited during annual inspection on 7/31/25, LPA Jeung reviewed deficiencies, which were to be corrected by 8/4/25. The following deficiency is corrected: - Section 87405 Administrator Qualifications & Duties As per information on CCLD Administrator Certification website, Ms. Johnson has current RCFE administrator certificate Acknowledgement of correction is provided--one page. The following deficiency still exists: - Section 87204 Limitations - Capacity & Ambulatory Status Client #1 is deemed to be bedridden per MD, and facility is not licensed to serve bedridden clients Civil penalty of $100 is assessed today and will continue to accrue at $100/day until CCLD is notified of correction. See LIC421FC.the state’s words, verbatim · CDSS document, Aug 5, 2025

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds, consisting of 6 private client bedrooms, 3 full bathrooms, kitchen/living/dining room. There is a detached staff unit/building that contains a bedroom with one bed, a large room with 2 bunk beds, kitchen, and full bathroom for staff. Awake night staff is employed. Two additional detached storage sheds are in the backyard, and washer and dryer are located in an alcove adjacent to staff unit/building. The spacious backyard is level, paved and landscaped, with 2 gazebos. There are no accessible bodies of water or fire safety hazards observed. A comfortable room temperature is maintained, and lighting is sufficient for safety. Carbon monoxide detectors are present and tested as operable. First-aid kit is maintained. Medications are stored in hall and kitchen cabinets. Client and staff records are reviewed. Maria Lu Johnson oversees facility operations, but does not have valid RCFE administrator certification. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. A Disaster and Mass Casualty Plan is posted. The following forms/information are requested to be updated returned to CCL by 8/7/25: • LIC 610 Emergency Disaster Plan (page 9, signed and dated) • Staff medication TRAINING topics (per H & S 1569.69) • LIC 308 Designation of Facility Responsibility • LIC 500 Personnel Report • Proof of current liability insurance Deficiencies of the CA Code of Regulations, Title 22 are cited on following pages. Staff training will be reviewed at a later date, due to time constraints.the state’s words, verbatim · CDSS document, Jul 31, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87204(a) · Plan of correction due date: Aug 4, 2025

LIMITATIONS - CAPACITY & AMBULATORY STATUS A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. This requirement is not met, as client #1 is determined by MD to be bedridden, but facility is not licensed for bedridden clients. Licensee failed to ensure operation within limits of license, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: Plan/proof of correction to be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87457c) · Plan of correction due date: Aug 7, 2025

PRE-ADMISSION APPRAISAL Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance/Retention LimitS. This requirement is not met, as there is no signed appraisal on file for client #5, who was admitted 3 years ago. This poses a potential health, safety or personal rights risk to clients. This was cited on 9/3/24.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: Appraisal for client #5 will be completed, signed and dated BY CLIENT OR REPRESENTATIVE AND FACILITY REPRESENTATIVE, and copy will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.695(b) · Plan of correction due date: Aug 7, 2025

HEALTH & SAFETY CODE A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster. This requirement is not met, as there is no documentation that staff received training on responding to emergencies, which poses a potential health, safety or personal rights risk to clients in care. This deficiency was cited on 9/3/24 and proof of correction was not submitted.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: Staff shall receive emergency response training and proof of correction to be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.695(c) · Plan of correction due date: Aug 7, 2025

HEALTH & SAFETY CODE A facility shall conduct a drill at least quarterly for each shift...type of emergency... shall vary. An actual evacuation...is not required... Documentation... shall include the date, the type of emergency covered...names of staff participating in the drill. This requirement is not met, as documentation of emergency drills does not clearly indicate what was done, which poses a potential health, safety or personal rights risk to clients in care. This deficiency was cited on 9/3/24 and proof of correction was not submitted.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: Proof of correction to be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Aug 7, 2025

POSTURAL SUPPORTS A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. This requirement is not met, as there are no MD orders maintained for 4 out of 6 clients who have half bed rails. Licensee failed to maintain MD orders for use of half bed rails, which poses a potential health, safety or personal rights risk to clients in care. This deficiency was cited on 9/3/24 and proof of correction was not submitted.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: MD orders for half bed rails for clients #1, #3, #5, #6 will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(h)(1-2) · Plan of correction due date: Aug 7, 2025

REAPPRAISALS The licensee shall request that all residents receive an annual routine visit with a licensed medical professional... every 12 months...Documentation.. shall be added to the resident's record...of a resident's refusal...shall be added to the resident's record. This requirement is not met, as MD assessments for 3 out of 6 client were done over 3 years ago or not maintained. Licensee failed to ensure annual MD assessments, which poses a potential health, safety or personal rights risk. NO MD report for C2, MD reports for C5 & C6 dated 2022. This deficiency observed 9/3/24.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: Copies of SIGNED AND DATED MD reports for clients #2, #5, #6 to be sent to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(a) · Plan of correction due date: Aug 7, 2025

REAPPRAISALS The pre-admission appraisal... shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition... and to keep the appraisal accurate. This requirement is not met as reappraisals for ALL clients are missing or dated more than 12 months ago. Licensee failed to ensure that annual reappraisals are done, which poses a potential health, safety or personal rights risk to clients. This deficiency was observed on 9/3/24 and proof of correction was not submitted.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: SIGNED AND DATED Reappraisals for ALL clients will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Aug 7, 2025

RESIDENT RECORDS Each resident’s record shall contain…Resident's legal name…Social Security number, Date of admission…Last known address, Birthdate, Religious preference, if any…Names, address, and telephone numbers of the resident’s representative … to be notified in case of emergency, Name, address, phone number of physician and dentist to be called in an emergency. This requirement is not met, as there is no emergency informatiion maintained for 3 out of 6 clients, which poses a potential health, safety or personal rights risk. No emergency info for C1, C2, C4the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: Emergency information to be completed and copies to be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87611(b)(1)(2)(3) · Plan of correction due date: Aug 7, 2025

GENL REQUIREMNTS HEALTH COND. The licensee shall complete & maintain a current, written record of care... that includes, but is not limited to... Documentation from the physician of... Stability of the medical condition, Medical condition which requires incidental medical services, Method of intervention...skilled professional...who will perform the procedure if the resident needs assistance; names...phone number of...skilled professionals providing services, Emergency contacts. Client #4 has gall bladder stoma & there is no information about care or condition.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: Plan of correction to be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(a) · Plan of correction due date: Aug 4, 2025

ADMIN QUALIFICATIONS DUTIES All facilities shall have a qualified and currently certified administrator. This requirement is not met, as proof of a certified RCFE administrator is not available. Licensee failed to ensure there is a certified RCFE administrator, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: Proof that facility employs a certified RCFE administrator will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a)(1-13) · Plan of correction due date: Aug 7, 2025

PERSONNEL RECORDS The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain specific information. This requirement is not met, as staff records for 6 out of 6 files reviewed are missing job applications, health screenings, including TB test results, criminal record statements. Licensee failed to ensure required staff records are maintained, which poses a potential health, safety or personal rights risk to clients. This was observed on 9/3/24 and not corrected.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: STAFF RECORDS WILL BE MAINTAINED FOR ALL STAFF, AND PROOF THAT REQUIRED STAFF RECORDS ARE MAINTAINED FOR ALL STAFF WILL BE SENT TO CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(c)(1) · Plan of correction due date: Aug 4, 2025

PERSONNEL REQUIREMENTS Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met, as 5 out of 6 staff do not have proof of current first aid training, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: Proof of current first aid training for Staff #2, #3, #4, #5, #6 to be sent to CCLD BY DUE DATE.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(8) · Plan of correction due date: Aug 7, 2025

INCIDENTAL MEDICAL CARE ... a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be...approved by the American Red Cross, or shall contain at least... current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. This requirement is not met, as there is no first-aid manual available, which poses a potential health, safety or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jul 31, 2025

Plan of correction: Current first-aid manual will be maintained and proof of correction to be sent to CCLD BY DUE DATE

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds, consisting of 6 private client bedrooms, 3 full bathrooms, kitchen/living/dining room. There is a detached staff unit/building that contains a bedroom with one bed, a large room with 2 bunk beds, kitchen, and full bathroom for staff. Awake night staff is employed. Two additional detached storage sheds are in the backyard, and washer and dryer are located in an alcove adjacent to staff unit/building. The spacious backyard is level, paved and landscaped, with 2 gazebos.. There are no accessible bodies of water or fire safety hazards observed. A comfortable room temperature is maintained, and lighting is sufficient for safety. Carbon monoxide detector is tested and operable. First-aid kit is maintained and complete. Medications are stored in hall and kitchen cabinets, and Centrally Stored Medications Records are maintained. Client and staff records are reviewed. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Maria Lu Johnson is a certified RCFE administrator that oversees facility operations. The following forms/information are requested to be updated returned to CCL by 9/17/24: • LIC 610 Emergency Disaster Plan (page 9, signed and dated) • Staff medication training policy (per H & S 1569.69) Deficiencies of the CA Code of Regulations, Title 22 are cited on following pages. See also Technical Advisory Notes--4 pages.the state’s words, verbatim · CDSS document, Sep 3, 2024

Allegation investigated: - Staff are denying POA visits to the facility - Residents must go to bed early

LPA Jeung met with staff and interviewed client and visiting family member. Based on investigation by the Community Care Licensing Division of the CA Department of Social Services--which included records review and interviews with staff, clients, and others--these allegations are determined to be unfounded, meaning that the allegations could not have happened and/or are without a reasonable basis. Prior to 9/14/23, POA for health care of client #1--referenced on LIC811 of 11/21/23--visited facility 5 days per week. Visits lasted a minimum of 30 minutes, up to 5 hours, and always included lunch and/or dinner service. She did not sign in on facility's visitation log. After 9/14/23, POAHC visits lasted up 30 minutes, only once or twice per week. She has never been forbidden to visit client #1. There have been no complaints about residents being forced to go to bed earlier than they would like to. Most of the residents tire easily and prefer to go to bed early. If someone does not want to go to sleep, staff will help them to get ready for bed, and s/he is free to go to sleep as s/he desires. Unfoundedthe state’s words, verbatim · CDSS document, Dec 21, 2023 · control 14-AS-20231114102411

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Annual Continuation

LPA Jeung reviewed client records to continue annual inspection of 7/17/23. No deficiencies related to client records are cited today.the state’s words, verbatim · CDSS document, Nov 21, 2023