Gines Residential Care Home III

Type of visit: Required - 1 Year

On 4/14/2026 at 9:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Licensee, Erlinda Gines and explained the purpose of the visit. The facility’s fire clearance was approved for all may be non-ambulatory. LPA toured facility including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. Temperature is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 110.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last purchased on March 2026. Emergency Disaster Plan last reviewed March 2026. Emergency Disaster Drill conducted March 24 2026. First aid kit was observed to be complete. LPA reviewed 4 residents records. LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility. Updated copies of the following documents were requested for facility file and are to be mailed to CCL by 4/20/2026: LIC 308 Designation of Administrative Responsibility Activities Calendar LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 14, 2026

Type of visit: Case Management - Incident

On 11/4/25 at 9:00 AM, Licensing Program Analyst (LPA) A. Gomez conducted a case management visit as a result of an self-reported incident report received 11/3/2025. LPA notified Licensee Erlinda Gines over the phone that they were at the facility and Licensee arrived at approximately 11:20 AM . It was reported that R1 was administered the incorrect medication for approximately four (4) days and had to be sent out to the emergency room. Licensee states that the oversight was made because the pharmacy sent out medications for an individual who does not reside at the facility and they did not notice. Licensee noticed the name on the medications belonged to someone else after R1 was sent out. Licensee states that R1 is still at the hospital but is expected to make a full recovery. LPA went over proper medication procedure and logging new medications with the Licensee. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Nov 4, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 7, 2025

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...for the provision of adequate services. This requirement was not met as evidence by: Based on interview with the Licensee R1 was administered the incorrect medication because the Licensee failed to verify the medications received by the pharmacy thereby requiring R1 to be hospitilized which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 4, 2025

Plan of correction: By POC Licensee agrees to review regulation and medication managment procedures, develop and implement a medication logging process and notify CCLD.

Allegation investigated: Staff are not meeting residents needs

On 10/30/2025, at 9:30 AM, Licensing Program Analysts (LPAs) A Gomez and Y Brown arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings concerning the allegations above. Upon entry, the LPAs informed staff 2 (S2) of the reason for the visit. Licensee/ Administrator Erlinda Gines was notified and arrived at 10:14 AM. LPAs conducted interviews, toured facility, reviewed camera footage, and reviewed documets. Report continues on LIC9099-C Substantiated LPAs observed that there is adequate food and snacks of good quality available to residents. LPAs also observed that at the time of the visit residents where served lunch at approximately 11:30am that consisted of homemade ground beef stew that included ground beef, tomato paste, peas, potatoes, and onions. LPAs also observed that residents with a puree diet were served a puree of bread, rice, ground beef, tomato paste, peas, potatoes, and onions. Therefore the allegation Staff are not providing adequate food service to resident's is Unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. exit interview conducted and a copy of this report provided. LPAs observed that on 10/30/2025 at around 3:30AM R2 was wandering the facility nude from the waist down and R3 was also wandering the facility at the same time. No staff responded to R2 or R3. LPA's also interviewed Administrator and S1 and found that there is not a set schedule for Staff and Staff checks of residents primarily in the evening. LPAs observed in R2 and R3's files that they both have documented wandering behavior. LPA's also found through interview and review of camera footage that residents requiring incontinence care are having as much as a 12 hour gap between having their incontinence changed (6pm-6am). Therefore the allegation of Staff are not meeting residents needs is Substantiated. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Oct 30, 2025 · control 15-AS-20251022124253

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Nov 6, 2025

(a) Facility personnel shall at all times be sufficient in numbers...to meet resident needs...of adequate services. This requirement is not met as evidence by Based on observations of facility cameras LPAs observed R2 wandering the facility nude from the waist down at approximately 3:30am on 10/30/2025 as well as R3 wandering around at the same time frame. Both residents have wandering behaviors noted in their files. No staff responded to the residents movments which poses a potential personal rights and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 30, 2025

Plan of correction: By POC facility agrees to update their staff schedules and notify CCLD

Allegation investigated: Facility does not have staff on duty at night Staff does not ensure resident is provided drinking water

On 9/18/2025, at 8:50 AM, Licensing Program Analysts (LPAs) A Gomez and J Sampair arrived unannounced to conduct an initial 10-day complaint investigation and deliver findings concerning the allegations above. Upon entry, the LPAs informed staff 2 (S2) of the reason for the visit. Licensee/ Administrator Erlinda Gines was notified and arrived at 9:20 AM. LPAs conducted interviews, toured facility, reviewed camera footage, and reviewed documets. Report continues on LIC9099-C Unsubstantiated On the allegations Facility does not have staff on duty at night and Staff does not ensure resident is provided drinking water the following was found: LPAs reviewed camera footage available at the facility for the month of September focusing on the night hours. LPAs observed staff on camera providing care/supervision at night. LPAs reviewed the staff roster along with their schedule and observed that there is at least one staff available on call at night for each night of the week. Therefore the allegation of Facility does not have staff on duty at night is UNSUBSTANTIATED. LPAs also toured the kitchen and observed water bottles available in the pantry as well as cold water from a Britta pitcher available in the refrigerator. Facility states that they primarily utilize the pitcher water offered to residents in a glass. LPAs interviewed S2, Administrator, and Backup Administrator who all confirmed that water is available for all residents. S2 and Administrator states that R1 declines the facilities water and insists on drinking the water that they purchased for themselves. Therefore the allegation of Staff does not ensure resident is provided drinking water is UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 18, 2025 · control 15-AS-20250910140047

Allegation investigated: Staff illegally evicted a resident in care Staff is not competent to provide care Staff is mismanaging residents medication Staff is not assisting with incidental medical care Administrator is not qualified to carry out their necessary duties

On 9/10/2025, at 8:25 AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to deliver investigation findings concerning the allegations above. Upon entry, the LPA informed Licensee/ Administrator Erlinda Gines of the reason for the visit. During the investigation, LPA reviewed the files for R1 and requested copies of R1's full file, staff roster, and all staff trainings. LPA also received additional documentation from W1. On the allegations Staff illegally evicted a resident in care, Staff is not competent to provide care, Staff is mismanaging residents medication, Staff is not assisting with incidental medical care, and Administrator is not qualified to carry out their necessary duties the following was found: Report continues on LIC9099-C Unsubstantiated On 6/22/2025 an eviction notice was issued to R1 for repeated violation of the facilities house rules. An additional eviction notice was issued on 9/2/2025 for non-payment of August 2025 rent and partial payment of July 2025. LPA reviewed incident reports for R1 and found multiple incidents documented from 6/4/2025 – Present alleging that R1 had in some way violated the house rules and/or other residents personal rights. LPA observed that R1’s care plan dated 4/22/2025 and physicians report dated 5/23/2025 noted R1 as being angry with outbursts however the facility alleged that R1's behaviors were escalating. On 8/16/2025 the facility notified residents that they would be installing cameras in common areas. On 8/26/2025 LPA visited the facility for a case management because it was alleged that R1 assaulted a staff member. During the visit LPA observed R1 yelling and cursing in common areas without provocation. LPA also reviewed camera footage and observed R1 going into another residents room while they were having their incontinence changed and also blocking the caregivers from allowing police into the facility by pressing their feet against the door. LPA requested that a new appraisal and physicians report be done for R1 to assess their change in condition. On 8/26/2025 LPA observed that the facility helped to facilitate the required incidental medical assistance for R1 to receive possible medication assistance and a new physicians assessment. R1 later refused to go to the appointments and update their care plan according to Administrator and W1. LPA observed that the administrator holds a valid administrator certificate and that their backup administrator was knowledgeable of procedures. All staff are also current on their required training's. Facility does not have a MAR but LPA reviewed the medication and was unable to locate where the facility did not provide medications to R1 as prescribed. Throughout the investigations LPA received correspondences from W1 who corroborated that R1's behaviors are escalating and R1 is refusing assistance for their change in condition. Therefore, the above allegations are unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Sep 10, 2025 · control 15-AS-20250701150452

Allegation investigated: Staff do not provide resident with a diet according to resident’s health needs.

On 9/8/2025, at 3:30 PM, Licensing Program Analyst (LPA) James Sampair arrived unannounced at the facility to complete the investigation of the allegation above. Upon entry into the facility, the LPA identified himself and stated the purpose of the visit to Administrator / Licensee (ADM 1) Linda Gines and Administrator (ADM 2) Elizabeth Boehmer. Over the course of the investigation, the LPA interviewed Resident R1, Witness W1, ADM 1, and ADM 2. The LPA reviewed R1's Physician's Report, Preplacement Appraisal, Care Plan, personalized diabetic menu for R1, Caregiver Notes, and photos of R1's food refusals. Continued on LIC 9099-C . . . Unsubstantiated . . . Continued from LIC 9099 The complaint alleges that staff do not provide R1 with a diet according to resident’s health needs. R1 stated that they do not feed him the food he wants. ADM 1 and ADM 2 stated and the LPA observed that they are serving R1 a diabetic diet but he often refuses to eat it in favor of personally bought food or demands that he be fed non-diabetic foods such as peanut butter and jelly sandwiches. The data collected does not support the allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED. Exit interview conducted with ADM 1 and ADM 2 and a copy of this report was provided.the state’s words, verbatim · CDSS document, Sep 8, 2025 · control 15-AS-20250619100905

Type of visit: Case Management - Incident

On 8/26/25 at 8:30 AM, Licensing Program Analyst (LPA) A. Gomez conducted a case management visit as a result of an self-reported incident report received 8/19/2025. LPA met with Assistant Administrator Elizabeth Boehmer. It was reported that R1 assaulted S1. LPA reviewed R1's care plan and spoke with staff. LPA requested that R1 get an updated care plan and appointment for a new physicians report by 8/29/2025. While at the facility LPA observed the facility blocking the passageway into the kitchen with a round table. LPA had the facility remove the table. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 26, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: Aug 26, 2025

(d) The following...shall apply to all facilities(6)All... passageways...shall be kept free of obstruction. This requirement was not met as evidence by: Based on observation the facility was not in compliance with the above regulation by having a table blocking the passage way into the kitchen which poses a potential safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 26, 2025

Plan of correction: Facility removed table POC clear.

Type of visit: Required - 1 Year

On 3/07/2025 at 8:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Licensee, Erlinda Gines and explained the purpose of the visit. The facility’s fire clearance was approved for all may be non-ambulatory. LPA toured facility with Licensee including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. Heater is currently out of service since 3/6/2025 and is scheduled for repair 3/7/2025 temperature is maintained at 58 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 109.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last purchased on 04/13/2024. Emergency Disaster Plan not available. First aid kit was observed to be complete. At 10am, LPA reviewed 6 residents records. At 10:40 am, LPA reviewed 2 staff records and 2 of 2 have current first aid training and associated to the facility. Report Continues on LIC809-C THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: LPA observed kitchen drawer unlocked with butcher Knife and kitchen scissors LPA observed the medication cabinet unlocked and over the counter medication unlocked in kitchen cabinet used by staff. LPA observed staff working at facility that is listed as excluded in Guardian. $500 civil penalty Facility does not have an updated/current emergency disaster plan Facility does not have records of emergency disaster drills ***Civil Penalties in the amount of $500 are being assessed on todays date*** Administrator had to leave the visit early and Licensee approved caregiver to sign report. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 7, 2025

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff did not report incident(s) regarding resident(s) in care. Staff did not prevent resident from being financially abused while in care. Staff did not adequately address resident's change in condition.

On 10/25/2024 at 9:30 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a complaint visit and deliver findings. LPA explained the purpose of the visit to Licensee, Erlinda Gines. During visit LPA interviewed Erlinda as no prior staff works at the facility. On the allegation of "Staff did not report incident(s) regarding resident(s) in care" The investigation found that staff at the facility did not properly report critical incidents concerning Resident 1 (R1). Specifically, the staff failed to report that R1’s designated Power of Attorney (POA) was missing and unresponsive, a situation that left R1 vulnerable to financial and decision-making exploitation. The administrator acknowledged, they knew the POA was not paying and wasn’t reachable, but did not file a formal report about the missing POA. Report continues on LIC9099-C Substantiated Additionally, despite noticing changes in R1’s health condition, the staff failed to notify R1’s physician, as required. The administrator admitted, “I did not contact the physician because I was told that the niece was the main point of contact,” which directly contributed to gaps in R1’s medical care and oversight. Therefore the allegation is SUBSTANTIATED On the allegation "Staff did not prevent resident from being financially abused while in care" it was found that staff were aware of financial issues involving R1 as early as November 2023 but did not act promptly to prevent further financial abuse. The administrator admitted, “We knew the POA was not paying, and the niece would sometimes pay R1’s rent,” but a financial abuse report was not filed until March 22, 2024. Additionally, despite being advised to contact Adult Protective Services (APS), staff did not make an immediate report. The administrator further acknowledged that “we waited too long to do anything because we were trying to be nice and help R1,” which resulted in prolonged financial vulnerability for R1. Therefore the allegation is SUBSTANTIATED. On the allegation "Staff did not adequately address resident's change in condition" it was found that Staff failed to respond adequately to changes in R1’s health condition. The administrator disclosed that R1’s niece, who was not the designated Power of Attorney (POA), was making significant healthcare decisions on R1’s behalf. When asked about this, the administrator stated, “We listened to the niece and let her make decisions for R1, even when R1 had a change in condition.” This deference to an unauthorized individual led to a delay in medical intervention. Staff was unable to adequately provide care to the resident because of the condition change. The administrator admitted that she did not notify R1’s physician, explaining, “I was told that the niece was the main point of contact.” However, there was no POA documentation stating that the niece could make decisions for R1. Therefore the allegation is SUBSTANTIATED. LPA also obtained POA documentation along with other documents for R1. LPA was unable to make contact with R1 or any responsible parties for R1. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.the state’s words, verbatim · CDSS document, Oct 25, 2024 · control 15-AS-20240328084808

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211a(1) · Plan of correction due date: Oct 25, 2024

a)Each licensee shall furnish...the following:(1)A written report shall be submitted...within seven days of the occurrence of any of the events ... This requirement was not met as evidence by: Based on file review and interview the Licensee did not report incidents regarding R1 in a timely manner which posed a potential health and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 25, 2024

Plan of correction: R1 no longer resides at the facility. Administrator has reviewed the regulations and has started documenting according to regulations. POC cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Oct 25, 2024

The licensee shall ensure that residents are regularly observed... When changes ... are observed, the licensee shall ensure that such changes are ... brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidence by: Based on file review and interview the Licensee did not report changes in R1's condition to the appropiate persons which posed a potential safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 25, 2024

Plan of correction: R1 no longer resides at the facility. Administrator has reviewed the regulations and has started documenting according to regulations. POC cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(8) · Plan of correction due date: Oct 25, 2024

(a) In addition to the rights listed in Section 87468.1,...Residents... privately operated ... shall have...(8)To be free from...financial exploitation...abuse. This requirement was not met as evidence by: Based on interview with Administrator they did not stop R1 from being financialy abused which posed an imediate personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Oct 25, 2024

Plan of correction: R1 no longer resides at the facility. Administrator reviewed the regulations and confirmed to LPA that they now understand what is expected. POC cleared

Type of visit: Case Management - Health Checks

On 04/08/2024 at 11:39 AM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of CCLD receiving notification of a Resident being relocated to facility due to a fire at another facility. LPA met with Administrator, Erlinda Gines and explained the purpose of the visit. LPAs toured facility including but not limited to the bedrooms, bathrooms, common area, kitchen, and outdoor area. Hot water temperature was measured at 114.2 degrees F in the hallway bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Resident's medications were kept locked. Smoke detectors are interconnected with the sprinkler system. A comfortable temperature was maintained at 71 degrees F. Carbon monoxide detector observe. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 04/18/2023. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. LPA spoke with R1 to see how they are adjusting to the facility. R1 has dementia and was unable to give coherent answers . R1 is currently on Hospice. R1 was seen by the doctors this morning and sustained no injuries due to fire. Administrator is still awaiting residents file. No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Apr 8, 2024

Type of visit: Required - 1 Year

On 3/12/2024 at 10:00AM Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a 1-Year Annual Required visit and met with Administrator, Erlinda Gines . The facility is cleared for all may be non-ambulatory. LPA toured and inspected the facility inside and outside with administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of seven (7) total bedrooms which four (4) bedrooms are currently occupied by the residents and one (1) bedroom is occupied by staff. The facility has auditory signals on each sliding door in the resident's room. All outdoor and indoor passageways are kept free of obstruction. There were no bodies of water present at this facility. LPA observed medication located in Kitchen and were observed to be locked. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. A comfortable temperature is maintained at 70 degrees Fahrenheit. Hot water temperature in the residents’ shared bathroom was measured at 113.3 degrees F. Resident's bathrooms have grab bars inside the shower. The showers have non-skid mat. Hygiene items, extra linens and toiletry supplies were checked and sufficient. Fire extinguisher in kitchen was last serviced on 4/18/2023, smoke detectors and carbon monoxide were operational. First aid kit was inspected and was complete. Food supplies were sufficient to meet 2-day perishable and 7-day non-perishable requirements. 4 of 4 Resident records were reviewed at approximately 10:15AM. 3 of 3 Staff records were reviewed at approximately 10:36 AM. All staff were fingerprinted and associated to the facility. All staff have current CPR First aid certifications. First Aid kit was observed complete. Emergency disaster plan last reviewed 3/11/2024. report continues on LIC809-C The Following Deficiencies were Observed At 10:50 during file review LPA observed and found out through conversation with administrator that there is not adequate staffing for the needs of residents as R4 can require a 2 person assist Updated copies of the following documents were requested for facility file and are to be submitted to CCLD by 03/31/2024: LIC 500 Personnel Report LIC 308 Designation of Administrative Responsibility LIC 610E Emergency Disaster Plan The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Mar 12, 2024

Type of visit: Required - 1 Year

At 10:35AM Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a 1-Year Annual Required visit and met with caregiver, Emelia Domingo. Administrator, Erlinda Gines arrived at approximately 11:00AM. The facility staffs all had criminal record clearances to work at the facility. LPA toured and inspected the facility inside and outside with administrator including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of seven (7) total bedrooms which five (5) bedrooms are occupied by the residents and one (1) bedroom is occupied by staff. The facility has auditory signals on each sliding door in the resident's room. All outdoor and indoor passageways are kept free of obstruction. There were no bodies of water present at this facility. LPA observed medication located in Kitchen and were observed to be locked. LPA observed lighting in all rooms are adequate for the comfort and safety of the clients. Hot water temperature in the residents’ shared bathroom was measured at 118.1 degrees F. Resident's bathrooms have grab bars inside the shower. The showers have non-skid mat. Hygiene items, extra linens and toiletry supplies were checked and sufficient. Fire extinguisher in kitchen was last serviced on 4/18/2023, smoke detectors and carbon monoxide were operational. First aid kit was inspected and was complete. Food supplies were sufficient to meet 2-day perishable and 7-day non-perishable requirements. Resident records were reviewed at approximately 11:15AM. Staff records were reviewed at approximately 12:00 PM. The following deficiencies were observed; · At approximately 12:10pm during staff file review LPA observed S1, S2, S3, S4 did not have current First Aid certification. · At approximately 12:20pm during staff file review LPA observed S5 is not associated to facility. ·At approximately 12:30pm during staff file review LPA observed Administrator file incomplete missing Physicians report, TB screen, and Criminal record statement. Continued from LIC809 The following forms are to be updated and submitted to CCLD by 12/11/2023. LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan (9 pages) Liability Insurance Updated Facility floor plan/ Sketch The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct these deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted, a copy of this report provided and appeal rights providedthe state’s words, verbatim · CDSS document, Nov 30, 2023