Golden Legacy Elderly Care II

Allegation investigated: Staff did not provide a comfortable facility environment to residents in care

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Golden Legacy Elderly Care II RCFE on 7/17/26 at 9:00am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with staff, Dillon Williams and together discussed the investigation details. Based on the interviews and statements obtained during the investigation process, as well as LPA observations and recordings obtained by LPA the allegations are substantiated, LPA has Conducted interviews with multiple residents and Reporting Party. RP and one resident confirmed the loud music as being disruptive to peace and quite in shared facility. LPA conducted interview with resident who demonstrated volume on large stereo equipment in room. Report Continued on LIC 9099-C. Substantiated LPA also received a voicemail from a resident following a facility inspection where LPA could hear the stereo volume in the background that exceeds appropriate levels in a shared living environment. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Personal Rights is substantiated. The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.the state’s words, verbatim · CDSS document, Jul 17, 2026 · control 27-AS-20260224110236

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jul 20, 2026

Personal Rights of Residents in All Facilities: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by a resident playing music at a volume that disturbs other residents and poses an immediate personal rights risk to residents in carethe state’s words, verbatim · CDSS document, Jul 17, 2026

Plan of correction: Licensee shall review personal rights with all residents and obtain signatures from each resident acknowledging understanding of personal rights for all residents at the facility. Copies will be retained in each residents file and a copy will be sent to LPA by the POC due date.

Allegation investigated: ) The facility allowed excluded individuals to work in the facility. 2) Staff are forging resident documents.

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection at Golden Legacy Elderly Care II (RCFE) on 7/17/26 at 9:00am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with Staff, Dillon Williams and together discussed the investigation details. Based on files obtained and reviewed during the investigation process, LPA Gould was unable to corroborate the allegation. LPA reviewed 6 resident files. LPA requested and obtained physician reports (LIC 602) for all 6 residents in care (see confidential name list LIC-811 dated 7/17/26). LPA Gould reviewed reports for each resident. Upon review, the department has no concerns for five of the six physician reports are being altered or fraudulent. The files reviewed appear to be completed by the resident’s physician or an appropriately skilled professional that are able to complete the forms per department regulations. Report Continued on LIC 9099-C. Unsubstantiated Additionally, LPA conducted interviews with Three staff members and three residents, all individuals interviewed denied ever witnessing the identified excluded individuals present at the facility. LPA showed pictures of identified excluded individuals and all persons interviewed did not recognize them. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Other are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of other is substantiated. The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home.the state’s words, verbatim · CDSS document, Jul 17, 2026 · control 27-AS-20260211143110

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Jul 20, 2026

Administrator - Qualifications and Duties: All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement was not met as evidence by LPA observations and statements received while conducting 14 inspections since February 2026 to present, the administrator was present two of the 14 inspections which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jul 17, 2026

Plan of correction: licensee shall to provide an updated LIC 500 form indicating the dates and times the administrator are to be at the facility. Additionally, facility will keep a monthly log of administrator presence at the facility including signing in when the administrator arrives at the facility and time they depart the facility to ensure a record of administrator presence at the facility.

Type of visit: POC

On 5/21/26 Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Plan of Correction (POC) inspection to ensure previously identified deficiencies have been corrected per the agreed upon plan of correction. LPA observed the back ramp to the rear bedroom has been replaced and is sturdy to bear weight of residents and visitors. LPA observed facility has obtained a lock box for refrigerated medications and stored secure from residents. LPA also observed an adequate food supply that meets regulations and all items are of good quality and all food present has a future expiration date. Exit interview conducted and POC letters generated.the state’s words, verbatim · CDSS document, May 21, 2026

Type of visit: Required - 1 Year

On 5/8/26 at 1:00pm Licensing Program Analyst (LPA) Kevin Gould arrived at Golden Legacy Elderly Care II RCFE for the purpose of conducting a required 1 year annual inspection. LPA met with staff, Peni Vuidreketi and together conducted a tour of the home. LPA and staff evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor and clean. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA observed the ramp in the back of the facility from the back bedroom in in need of repair. The wood flooring is rotten and LPAs foot went through the flooring waking up the ramp. LPA also observed the sling door screen is broken and in need of repair/replacement. LPA measured the water temperature, temperature measured at 112 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, May 8, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

On 2/13/26 at 11:30am, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management -deficiencies inspection to address deficiencies observed while conducting a complaint investigation. LPA met with staff Mereisi Naisausau. LPA Gould inspected the food supply and observed approximately 20 canned goods that had expired in 2024 or 2025. LPA observed staff dispose of expired food items. LPA reviewed 5 resident files and observed one resident file with no signed admission agreement, ID and emergency information or pre-placement appraisal for R1 (see LIC-811 dated 2/13/26). Additionally, LPA inspected the medication supply and observed staff member disposing of used syringes in common medication containers that do not meet the safety requirements outlined in title 22 regulations. Per California Code of Regulations, Title 22, the following deficiencies are cited during today's inspection. Exit interview conducted and a copy of this report and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Feb 13, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(8) · Plan of correction due date: Feb 16, 2026

General Food Service Requirements: All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement was not met as evidenced by LPA observations of approximately 20 canned goods that had expired dates including 2024 and 2025 which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2026

Plan of correction: Licensee shall provide a written policy for reviewing food supplies and disposing of expired food items.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(f)(2) · Plan of correction due date: Feb 16, 2026

Maintenance and Operation: Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens. This requirement was not met as evidenced by LPA observations and staff statements that used syringes are disposed of in old medication containers that do not meet requirements specified in regulations which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2026

Plan of correction: Licensee shall obtain a container for used syringes that meets the requirements in regulations and provide a written statement that they have reviewed and understand the requirements in the regulations.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87506(a) · Plan of correction due date: Feb 16, 2026

Resident Records: Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This requirement was not met as evidenced by LPA review of resident records, R1 has an incomplete (blank) admissions agreement and no pre-placement appraisal which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 13, 2026

Plan of correction: Licensee shall ensure all resident files are complete, signed and dated. Licensee shall submit a written statement to the department stating they have reviewed and understand the regulations and requirements.

Type of visit: Case Management - Deficiencies

On 6/24/25 Licensing Program Analyst (LPA) Holly Williams conducted a case management inspection to ensure that the facility has stayed in substantial compliance since the informal meeting on 5/15/25 and to ensure that the compliance plan has been completed. LPA called the Licensee Diane Garcia and together discussed the report and Garcia gave permission for S2 to sign the report. According to Diana Garcia the facility designated administrator (FDA) Stacy Smith is on leave from 6/16/25 to 6/30/25. LPA conducted an inspection and upon entering the facility LPA observed a new caregiver S1. In an interview, R1 stated that they have met the administrator one time. LPA asked R2 if they had seen the administrator Stacy Smith and R2 stated they did not know that person. LPA found that S1's criminal record clearance was not cleared for this facility. LPA asked for S1's file and the health screening and the personnel record was not filled out except for S1's start date which was 5/28/25. LPA observed employee time sheets for S1 and the time sheets start on 6/10/25. LPA checked the LIC500 and it has not been updated to the new employee that in the facility. According to the licensee's compliance plan, they were supposed to hire additional staff by 6/15/25. According to S1 and S3 and the time sheets there has only been one caregiver at a time working at the facility. According to the compliance plan, the Licensee Diana Garcia was supposed to have training completed for the staff on chemical storage and safety, medication administration, storage, documentation, and special diets by 6/10/25. LPA has not received any proof of the a fore mentioned training's. [Continued on 809-C] The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal Rights and the report were left at the facility at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Jun 24, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(b) · Plan of correction due date: Jun 25, 2025

87355 Criminal Record Clearance (b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client.. This requirement was not met as evidenced by: Based on record review S1 did not have a criminal record clearance with the facility which poses an immediate health, safety and/or personnel rights risk.the state’s words, verbatim · CDSS document, Jun 24, 2025

Plan of correction: Licensee agrees to send in a statement of understanding of the regulation to the LPA by the POC due date. Licensee agrees to include in the statement that the facility will not have any employees working on the premises that do not have a background clearance. Holly.williams@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR87412(e) · Plan of correction due date: Jun 25, 2025

87412 Personnel Records (e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked. This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above because there is only 1 person scheduled 24 hours a day 7 days aweek which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 24, 2025

Plan of correction: Licensee agrees update the LIC500 and hire additional staff to make sure there is 24 hour 7 days a week coverage at all times by POC due.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(2) · Plan of correction due date: Jun 25, 2025

87405(d)(2 If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform...This requirement was not met as evidenced by: Based on record review and interview, the licensee did not abide by the compliance plan and regulations which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 24, 2025

Plan of correction: Licensee agrees to send a statement of understanding of the regulation cited to the LPA by the POC due date. Licensee agrees to send proof of completion of the compliance plan that was written by the licensee by July 1, 2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(f) · Plan of correction due date: Jun 25, 2025

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks... This requirement was not met as evidenced by: Based on record review the facility did n ot have a health screening for S1 which poses an immediate health, safety and/or personnel rights risk.the state’s words, verbatim · CDSS document, Jun 24, 2025

Plan of correction: Licensee agrees to complete S1's file and send to LPA by 7/1/25. Licensee agrees to send a statement of understanding of the regulation cited to LPA by POC due date.

Type of visit: Office

A virtual Informal conference was conducted today on 05/15/2025 at 1:00 PM via Microsoft Teams. The purpose of the meeting is to discuss complaint allegations and non-compliance concerns. Present in the meeting are Licensing Program Manager Czarrina Camilon-Lee, and Licensing Program Analyst Holly Williams, and Licensee Diana Garcia. The informal conference process was explained during this meeting to include the administrative processes. Discussed Concerns: The following concerns were discussed: back house and shed and permitting for these structures, staff associations, Inadequate administrator hours, staffing, special diets, medication storage, medication administration. storage of cleaning supplies, and activities for residents. The facility agreed to provide a plan by 5/30/2025 for the list below and to ensure the facility stays in substantial compliance · Have activities available and offer outings. · Shed in backyard available for inspection and if someone moves in to have the structures permitted by the city and obtain fingerprint clearances. · Employ more staff. · Ensure all staff are associated and to utilize Guardian. · Ensure and train staff on medication administration, medication storage and documentation, and special diets. Continued LIC-809 · Provide LIC500 and ensure it is always updated. · Ensure cleaning supplies are locked up. Community Care Licensing Department (CCLD) will do the following: · Increase Monitoring Licensee agrees to receive Technical Support Program (TSP) referral. The licensee was advised failure to follow agreed plan could result in a Non-Compliance Conference. No deficiencies were cited during today's meeting. An exit interview was conducted with facility representatives Diana Garcia, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.the state’s words, verbatim · CDSS document, May 16, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Holly Williams and LPA Charlie Yang arrived unannounced to conduct an annual inspection. LPA Williams called and spoke with facility licensee on the phone Diana Garcia and explained the purpose of the visit. LPA Williams asked Diana Garcia to come to the facility or to have the new administrator Stacy Smith be present. Garcia stated that Smith could not come because Smith is at the other facility and if Smith did not show up then Aisake Jemesa the caregiver can sign the report. 2 hours into the inspection the licensee Diana Garcia arrived at the facility. LPA Williams reviewed 6 resident files (R1-R6) and six staff files (S1-S6). LPA Williams toured the facility with Aisake Jemesa and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 82 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 109.8 degrees Fahrenheit, which is within the required range of 105 and 120 degrees. LPA Williams observed bathroom did not have a bath mat. LPA Williams observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Williams observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Williams observed a locked cabinet for the storage of medication. LPA Williams observed unlocked cabinets for the storage of cleaning solutions. The garage was unlocked and the cleaning supplies and poisons were accessible to residents. LPA Williams observed the knives locked and inaccessible to residents. LPA Williams observed in R1's room a bag of candy, the smell of urine was strong, and medication was out and accessible. [Continue on 809-C] LPA Williams reviewed R1's LIC 602 and it stated that R1 is on a special diet and R1 cannot store R1's own medication. LPA observed LIC500 dated 3/20/25 states 1 staff member scheduled Tuesday through Saturday. LPA Williams observed a LIC500 that had the administrator working Saturday, Sunday, and Monday. LPA Williams while conducting record review found S1 did not have a health screening or a TB Test. LPA Williams interviewed 1 staff member (S7) and 1 resident (R1). The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal Rights were printed and a copy was given to the facility licensee at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Apr 14, 2025

Allegation investigated: Staff does not ensure resident is engaging in physical activities. Staff did not ensure resident was transported to medical appointments. Staff did not provide a comfortable environment for a resident in care. Staff are not monitoring resident's health condition Staff are not administering medication as prescribed Facility did not ensure that staff are trained. Staff did not ensure resident is provided with appropriate food and beverages.

Licensing Program Analysts (LPAs) Holly Williams and Vincent Moleski made an unannounced visit to conclude the investigation of the above allegations and to deliver the findings. LPAs Holly Williams and Vincent Moleski met with Josevata Turaga and together discussed the investigation details. Diane Garcia the administrator through text gave permission for Turaga to sign the report. This investigation consisted of interviews, observations, and record review. LPA Williams interviewed administrator Diane Garcia. LPA Williams interviewed staff (S1-S2), 5 residents (R1-R5), case manager (CM), responsible party for R5 (RP) and home health nurses (HHN1-HHN2). When LPA Williams visited the facility on 9/19/24 LPA Williams heard very loud music coming from R4’s room. LPA Williams asked S1 if he could ask R4 could turn the music down and S1 did. In an interview, R5’s RP when helping R5 move out there was loud music playing and 5 minutes after they arrived S1 turned it down. In an interview with R5 they stated that the loud music was distressing to R5. In an interview, CM said that they had heard the loud music, and it was distressing to R5. [Continued on 9099-C] Substantiated In an interview, on 10/01/24, CM and HHN1 said they arrived at the facility on 9/6/24 to see R5 decompensating. In an interview, HHN1 said R5 was wheezing but R5’s lungs were clear. In an interview, HHN1 said it was anxiety. In an interview, HHN1 and CM said they asked S1 if S1 was administering R5’s inhaler and S1 said it was on the bed. In an interview, CM said they did not find an inhaler on the bed. In an interview CM and HHN1 said they looked for R5’s sensor on R5’s arm and it wasn’t there. In an interview, CM said S1 pulled out 2 bins with medication for R5 and HHN1 pulled out the inhaler and S1 said they had not seen that inhaler before. In an interview, both HHN1 and CM said that S1 had the Medication Administration Record (MAR) filled out to date but did not know what the medication looked like. In an interview, HHN1 said they asked if S1 is the one who gives all the medications to R5 and S1 said yes. In an interview, HHN1 said they asked where R5's diabetic monitor is and S1 said they did not know. In an interview, CM said on 9/25/24, S1 pulled out 2 bins with medication for R5 and the HHN1 pulled out the inhaler and S1 said S1 had not seen that inhaler before. In an interview, CM said that not all required medications were in the bin. LPA Williams asked who gives the injections of insulin and HHN2 said the staff members do. In an interview, HHN2 said that HHN2 educated S1 on how to give the injection and to apply the diabetic monitors. In an interview, HHN1 said that nursing only goes there once a week. In an interview, HHN2 said that R5 could inject themselves when R5 is feeling good but there are times when R5 cannot inject themselves. In an interview, on 9/6/24 CM said they took a picture of the food served to R5 and it was fried potatoes, hot-dogs with barbecue sauce and sent it to LPA Williams. In an interview with the administrator Garcia, Garcia told LPA Williams that Garcia has pictures of the meals that S1 is feeding to R5, When LPA Williams received pictures from Garcia, they were pictures of the diabetic meals that were sent to R5 by CM after they saw what R5 was eating. LPA Williams and Licensing Program Manager (LPM) Czarrina Camilon-Lee visited Golden Legacy II on 11/06/24 and went into R3’s room LPA Williams and LPM Camilon-Lee observed candy in a bag on the night stand and a bucket halfway filled with candy on the floor. When LPA Williams questioned S1 about the candy S1 said,” oh yeah R3’s family brought that.” LPA Williams reviewed R3’’s medical assessment (LIC602) that states R3 is pre diabetic and tests his blood sugar. LPA Williams reviewed the pre appraisal for R3 states that R3 should be on a diabetic diet and that R3 is taking Metformin which is a diabetic medication. In an interview, R5’s RP said that R5 would tell them that the food is not healthy, and the food was cold. In an interview, R5’s RP said R5 was served dinner while they were there, and RP had a chance to see the food the facility was serving. In an interview, R5’s RP said the food R5 was being served [Continued on 9099-C] was all starch and they would call it, “Junk Food.” According to the medical assessment (LIC602) R2 is supposed to have a soft diet and while LPA Williams and LPM Czarrina Camilon Lee were there R2 was served a sandwich with chips and grapes. In an interview, R5 stated that there was not planned activities. In an interview, R2, R5, and the CM all stated there are no planned activities. S4 said that there are not planned activities. Through record review, LPA Williams found that S1 only had 36.5 hours of training done when starting work at the facility when 40 is required. As a result of this investigation, LPA Williams finds the allegation(s) to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. The following deficiencies were cited per CCR Title section 87465(a)(4), 87628(b)(4), 87219(a)(4), 87468.1(a)(2), 87465(a)(2), 87411(c), and 87628(a). An exit interview was conducted with Josevata Turanga. A copy of this report was provided to Josevata Turanga.the state’s words, verbatim · CDSS document, Dec 23, 2024 · control 27-AS-20240912224643

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2) · Plan of correction due date: Dec 31, 2024

87465 Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility... This requirement was not met as evidenced by: Based on observation, record review, and interview the facility did not take R5 to R5's doctor appointments which poses an immediate health, safety and/or personnel rights risk.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: Licensee agree's to write a statement of stating that the licensee will take the residents to and from their doctors appointments by the POC due date. Holly Williams@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Dec 31, 2024

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health... This requirement was not met as evidenced by: Based on observation, record review, and interview S1 did not have 40 hours total of training before starting employment with the facility which poses an potential health, safety and/or personnel rights risk.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: Licensee agrees to write a statement committing to having all initial training which is 40 hours completed before an employee starts working at the facility by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 24, 2024

87465 Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self-administered medications as needed... This requirement was not met as evidenced by: Based on observation, record review, and interview S1 did not administer R5's inhaler which poses an immediate health, safety and/or personnel rights risk.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: Licensee agrees to retrain all staff members on how to store medication and how to administer medication. Licensee agrees to provide a written plan on when training will be and will send to LPA Williams by POC due date. When training is finished licensee agrees to send the sign in sheet and training materials to LPA Williams on date of statement of training.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(b)(4) · Plan of correction due date: Dec 24, 2024

87628 Diabetes (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (4) Providing modified diets as prescribed by a resident's physician as specified in Section 87555(b)(7). This requirement was not met as evidenced by: Based on observation, record review, and interview S1 did not prepare meals for residents that according to the Physicians report need a diabetic diet and allowed R3 who is on a diabetic diet to have candy in their room which poses an immediate health, safety and/or personnel rights risk.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: Licensee agrees to retrain all staff members on specialized diets. Licensee agrees to provide a written plan on when training will be by POC due date and will send LPA Williams the sign in sheet and training material by date on statement of training. date.Holly.williams@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87219(a)(4) · Plan of correction due date: Dec 31, 2024

87219 Planned Activities a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: (4) Physical activities such as games, sports and exercise which develop and maintain strength, coordination and range of motion. This requirement was not met as evidenced by: Based on observation and interview Licensee does not provide planned activities or physical activities which poses an potential health, safety and/or personnel rights risk.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: Licensee agrees to retrain all staff members on planned activities and send LPA Williams a calendar with scheduled planned physical activities by POC due date. Licensee agrees to provide a written plan on when training will be and will send LPA Williams the sign in sheet and training materials by statement of planned training due date. Holly.williams@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Dec 30, 2024

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidenced by: Based on observation, record review, and interviews S1 and licensee did provide a comfortable living enviroment which poses an potential health, safety and/or personnel rights risk.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: Licensee agrees to write a statement of understanding that all residents have the right to live in a comfortable enviroment. and explaining what the licensee will do in the future to meet that requirement by POC due date. Holly.williams@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87628(a) · Plan of correction due date: Dec 24, 2024

"(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional." This requirement was not met as evidenced by: Based on observation and interviews, a resident was not able to perform their own blood glucose testing or injections, and staff were not monitoring their ability to do so, which poses an immediate health, safety and/or personnel rights risk.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: Licensee agrees to send a plan for training of all staff on change of conditions and reporting to administrator of change of conditions.Send this plan to LPA Williams by POC due date. Holly.williams@dss.ca.gov

Type of visit: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to deliver finding on a complaint and discovered unrelated deficiencies. LPA Williams texted Diana Garcia to inform her of deficiencies found and Garcia stated Josevata Turaga could sign the reports. LPA Moleski toured a resident's (R1's) room and observed a folding pocketknife with the blade extended alongside antacid tablets and numerous packages of nicotine gum on a small table next to the resident's bed. This facility is hereby cited per 22 CCR Sections 87465(h)(2) and 87309(a). This facility was previously cited on 11/6/24 for having medications unlocked, including the same kind of antacid tablets. As this is a repeat violation, a civil penalty in the amount of $250 is hereby assessed. An exit interview was held with Turaga. Appeal rights and a copy of this report were left with Turaga.the state’s words, verbatim · CDSS document, Dec 23, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Dec 24, 2024

"(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients." This requirement was not met as evidenced by: Based on observation, a resident was in posession of a knife, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: Licensee agrees to remove the knife from the resident's room by the POC due date. Failure to do so will result in additional civil penalties. Licensee shall provide LPA Williams with a photograph of the resident's room showing that all unsafe or hazardous items have been removed. holly.williams@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Dec 24, 2024

"(2) 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 was not met as evidenced by: Based on observation, a resident was allowed access to medication, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Dec 23, 2024

Plan of correction: Licensee agrees to remove the medication from the resident's room by the POC due date. Failure to do so will result in additional civil penalties. Licensee shall provide LPA Williams with a photograph of the resident's room showing that all unsafe or hazardous items have been removed. holly.williams@dss.ca.gov

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management visit on 11/21/2024. This visit is to confirm ORDERS TO INDIVIDUAL FOR IMMEDIATE EXCLUSION FROM ALL FACILITIES. LPA met with caregiver Misivono Qadroka and stated the purpose of visit. Facility understands this is an Immediate Exclusion effective 11/21/2024 and S1 is excluded and cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with clients and not allow this employee to be physically present in the facility. Exit interview conducted, a copy of this report provided on this date. A signature on these forms acknowledges receipt of these forms.the state’s words, verbatim · CDSS document, Nov 22, 2024

Type of visit: POC

This report is being amended due to LPA error. Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to amend this report on 11/19/2024. LPAs Moleski and Williams met with Misivono Qadroka and explained the purpose of the visit. LPA Williams previously cited this facility per 22 CCR Section 87465(h)(2) on 11/6/24. LPA Williams had set the due date for the plan of correction for 11/8/24. LPA Williams received a request for an extension of this due date on 11/08/24. LPA Williams approved this extension on 11/08/24. On 11/18/24, LPA Williams arrived to conduct a plan of correction visit. LPA Williams erroneously assessed $1,000 worth of daily civil penalties for a failure to correct, despite having previously granted an extension to licensee Diana Garcia, as described above. All civil penalties assessed on 11/18/24 are hereby waived, as they were assessed in error. LPA Williams received a plan of corrections from Garcia on 11/18/24. LPA Williams cleared the plan of correction during this visit on 11/19/24, and provided Misivono Qadroka with a clearance letter. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Misivono Qadroka .the state’s words, verbatim · CDSS document, Nov 18, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Holly Williams and Licensing Program Manager Czarrina Camilon-Lee arrived unannounced for this complaint investigation. LPA Williams and LPM Camilon-Lee met with caregiver Misivono Qadroka and explained the purpose of the visit. The administrator Diane Garcia was asked to come to the facility but declined and asked if Garcia could call. During an interview with R3 LPA Williams found unlocked medications In resident night stand drawer accessible to anyone: Robitussin cough medicine and acid rescue. The following deficiencies cited. See LIC809-D. Appeal rights provided. This investigation consisted of record review and interviews with staff and residents. LPA Williams interviewed (R1-R4) and did record review for R3, R4, R2.the state’s words, verbatim · CDSS document, Nov 6, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Nov 8, 2024

87465Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible ... This requirement was not met as evidenced by: Based on observation of LPA Williams and LPM Camilon-Lee medications were observed unlocked in night stand drawer which poses an immediate health, safety and/or personnel rights risk.the state’s words, verbatim · CDSS document, Nov 6, 2024

Plan of correction: Staff agreed to lock up the medicines today. Administrator Diane Garcia will send a statement of understanding stating that the regulations have been reviewed and staff has been retrained on medication storage by POC due date. Holly.williams@dss.ca.gov

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPAs) Vincent Moleski and Holly Williams arrived unannounced to open a complaint investigation and observed unrelated deficiencies. LPAs Moleski and Williams spoke with facility administrator Diana Garcia on the telephone and explained the purpose of the visit. Garcia said staff member Misivono Qadroka could sign this report in her absence. Upon arrival, LPAs Moleski and Williams observed a caregiver present in the facility (S1). LPA Williams reviewed Guardian records and observed S1 was not associated to this facility. S1 told LPA Moleski that they had been working at this facility since 9/1/24, and works five days per week. LPAs Moleski and Williams reviewed S1's file and observed that it was not complete. S1's personnel record (LIC 501) was not completed, did not include S1's educational history or past work experience, and was not signed by S1. This facility is hereby cited per 22 CCR Sections 87355(e)(2) and 87412(a). An exit interview was held with Garcia. Appeal rights and a copy of this report were left with Qadroka.the state’s words, verbatim · CDSS document, Sep 19, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Sep 19, 2024

"(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility... (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)..." This requirement was not met as evidenced by: Based on observation, record review, and interview S1 was not associated with the facility which poses an immediate health, safety and/or personnel rights risk.the state’s words, verbatim · CDSS document, Sep 19, 2024

Plan of correction: Licensee agrees to associate S1 by POC due date. Holly.williams@dss.ca.gov

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: Sep 23, 2024

"87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information..." This requirement was not met as evidenced by: Based on record review, S1 did not have a completed personnel record which poses a potential health, safety, and/or personnel rights risk.the state’s words, verbatim · CDSS document, Sep 19, 2024

Plan of correction: Licensee agrees to have personnel record completed by POC due date. Holly.williams@dss.ca.gov

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct a case management visit. LPAs Moleski and Williams spoke with licensee Diana Garcia over the phone and explained the purpose of the visit. During a prior visit, LPAs Moleski and Williams observed two backyard sheds, which have not been permitted for habitation and which have not been cleared by the fire department. During the visit, one of the sheds had an air conditioning unit running, but the windows were blocked. LPAs Moleski and Williams observed through the windows of the second shed personal affects, including food and medications, along with a pet cat. LPAs Moleski and Williams knocked on both sheds but received no answer. In an interview, Garcia said she and her mother had used and were still using the sheds for habitation on occasion. During this visit, LPAs Moleski and Williams observed a sewer outflow pipe which had spewed out toilet paper and feces at some previous time. The toilet paper and feces were dried up and caked onto the cement patio. A staff member (S1) said that the toilet paper and feces had been there for at least two weeks. This facility is being cited per 22 CCR Sections 87303(a) and 87204(a). An exit interview was held with Garcia. Appeal rights and a copy of this report were left with staff member Mareta Teku.the state’s words, verbatim · CDSS document, Aug 5, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Aug 6, 2024

"(a) The facility shall be clean, safe, sanitary and in good repair at all times..." This requirement was not met as evidenced by: Based on observation, dried feces and toilet paper were left on a backyard patio, which poses an immediate health and safety risk.the state’s words, verbatim · CDSS document, Aug 5, 2024

Plan of correction: Licensee agrees to have the area cleaned by POC due date. Licensee shall send a photograph of the cleaned area by POC due date. vincent.moleski@dss.ca.gov

From the deficiency page — Deficiency type: Type A · Section cited: CCR87204(a) · Plan of correction due date: Aug 6, 2024

"A licensee shall not operate a facility beyond the conditions and limitations specified on the license..." This requirement was not met as evidenced by: Based on interview and observation, two backyard studios were being used for habitation, despite not being approved for use by the fire department, code enforcement, and this facility's license.the state’s words, verbatim · CDSS document, Aug 5, 2024

Plan of correction: Licensee agrees to send LPA Moleski a written plan to address this deficiency by POC due date. vincent.moleski@dss.ca.gov

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Vincent Moleski and Holly Williams arrived unannounced to conduct a case management visit. LPAs Moleski and Williams met with staff member Mareta Teku and explained the purpose of the visit. LPA Moleski attempted to reach the licensee and the administrator of this facility but could not reach either of them. LPA Moleski printed out an updated license reflecting an updated fire clearance and collected this facility's previous license. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Teku.the state’s words, verbatim · CDSS document, Aug 1, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required 1 year annual inspection. LPA met with direct care staff and explained purpose of visit. Administrator's Certification 1/3/2025. LPA and direct care staff toured the interior and exterior of the facility including common areas, resident bedrooms, resident bathrooms, staff room, kitchen, dining room, laundry area, and garage. LPA observed the facility to be clean and in good repair and to have sufficient furniture and lighting throughout. LPA observed sufficient seven day non-perishable and two day perishable food supplies. LPA observed locked sharps locked cabinet designated for medications. Chemicals (2 bottles of bleach and 1 gallon of bug spray) are not locked up in back area of property. LPA observed grab bars and non-skid flooring in all bathrooms. LPA observed locked toxins in the laundry room and a supply of linens/towels/blankets on hand. Fire extinguishers was last inspected 2/28/2024. The facility conducts fire/disaster drills with residents on 2/9/2024. Smoke/monoxide alarms are working order. LPA observed a complete First Aid kit on site and measured the hot water at 113.2 *F in the bathroom. LPA observed all doors to have alarms. LPA observed seating on patio, a locked shed, and two gates that were unlocked and accessible. There were tree branches and debris in back of property. Workshop was locked with a cat looking out. Facility sketch shows workshop, but licensee stated mom stays there occasionally. Two old refrigerators, two washers, and two dryers which need to be removed. LPA reviewed five resident files and three staff files, including criminal record clearances. A review of staff records indicates not all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews. LPA requested the following updated documents for community care licensing to be submitted via email by April 16, 2024: Updated Facility Sketch, New Fire Clearance, LIC 308 Designation of Administrator, LIC 500 - Personnel Report, LIC 610E Emergency Disaster Plan, Copy of Administrator's Certificate, and Copy of Liability Insurance. ruth.wallace@dss.ca.gov Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiencies are being cited. See 809-D's for citations. Immediate civil penalty of $500.00 was issued to facility. Failure to correct the deficiencies by the noted due date may result in an additional penalty being assessed. Exit interview conducted with direct care staff. Copy of reports and (LIC 811 Confidential Names) left at facility.the state’s words, verbatim · CDSS document, Apr 11, 2024