Good Samaritan II

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) made an unannounced visit to conduct the required annual inspection. LPAs were greeted and granted entry. LPAs met with Administrators, Leonardo Cambio and Susan Cambio explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, no bed-ridden. Facility is a 2 level home with 5 bedrooms, 2 bathrooms, kitchen, great room with a dining room table and a living room with a screened fireplace. The second level is a loft. Residents are not allowed in loft. Administrator Leonardo Cambio certificate expires August 9, 2027. LPAs and administrator toured facility. LPAs toured resident rooms 1 resident room is private and two rooms are shared. All resident rooms had the required furnishings and bed linens. Extra linens and towels are stored in the hall closet. Smoke detectors/ carbon monoxide tested operational. Fire extinguisher in hallway is fully charged. The last emergency drill was conducted on March 7, 2026. LPAs and administrator toured garage, which is locked and used for storage. LPAs observed extra food, supplies and furniture stored in garage. LPAs observed both bathrooms are clean and operational. Hot water measured 112.2 degrees Fahrenheit. LPAs and administrator toured backyard, there were no bodies of water. LPAs observed shaded seating areas for clients to sit outside. No obstacles or hazards observed in the backyard. Both exit gates are operational. LPAs and administrator inspected the kitchen. LPAs observed knives and sharp objects are kept locked in kitchen cabinet. LPAs observed medications are kept locked in the kitchen drawer. The stove has knobs removed for residents safety. LPAs observed two days perishable and 7 days non perishable food supply on hand. LPAs observed three day emergency supply of food and water. LPAs inspected the first aid kit. First aid kit did not have a first aid manual. LPAs inspected the loft, the loft is used for staff only. LPAs observed the light fixture on the ceiling in the loft did not have a cover. LPAs did not observe an emergency evacuation chair. LPAs reviewed two staff files, no discrepancies observed. All staff had required training and CPR/ First Aid training. All staff members are background cleared and associated to facility. LPAs reviewed six resident files and two resident medications, no discrepancies observed. Facility does not have a dedicated internet device for resident use. No deficiencies are being cited as a result of this visit. Technical violations are being issued. Please see LIC9102s dated June 29, 2026. An exit interview was conducted with the facility administrator and a copy of the report was provided.the state’s words, verbatim · CDSS document, Jun 29, 2026

The state marks this report as 7 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

During a complaint investigation visit conducted on July 17, 2025, Licensing Program Analyst (LPA) determined that after resident R1 was discharged from the facility on or around April 12, 2025, facility staff became unable to account for the whereabouts of R1's records maintained at the facility after they had been requested by legal representation for R1 on May 21, 2025 and a subsequent visit from a copy service that took place on June 9, 2025. After the complaint investigation visit, licensee requested additional time to continue searching for the files. On August 14, 2025, facility administrators confirmed via email that they had misplaced the records after the abrupt request from R1's spouse to have R1 discharged from the facility after over two years of admission. As a result, one type A deficiency is being cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights were provided to a facility representative.the state’s words, verbatim · CDSS document, Sep 22, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87506(e) · Plan of correction due date: Sep 23, 2025

Per CCR 87506(e) on Resident Records, "Original records (...) shall be retained for a minimum of three (3) years following termination of service to the resident". This requirement is not met as evidenced by: Based on interviews and records reviewed, resident records for R1 have been lost (...) following the resident's discharge from the facility in April 2025. Facility staff is unable to locate the recors at this time in order to provide them to the resident's responsible party upon request. This constitutes an immedicate risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Sep 22, 2025

Plan of correction: Licensee stated their awareness of the applicable regulations and would submit a statement in writing by the plan of corrections due date.

Allegation investigated: Licensee is not providing resident's records to their responsible party as required.

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of initiating the investigation into the allegation listed above. LPA was greeted and granted entry by facility administrator Susan Cambio after stating the purpose of the visit. LPA conducted an interview via telephone with administrator Leo Cambio who stated that a copy service had come in person to the facility to obtain duplicates of the available records for resident R1. R1 moved out of the facility without notice on or around April 12, 2025, and the records were relocated to a central administrative location at the time. At the time of the visit from the copy service, the only files available that could be located by facility staff were the hospice records and not the resident records. At the time of the present visit, administrator is still unable to account for the location of the requested records. CONTINUED ON FORM LIC9099-C Substantiated CONTINUED FROM LIC9099 Regarding the allegation that Licensee is not providing resident's records to their responsible party as required, the following has been concluded: After an initial request dated May 21, 2025 and after a visit from a copy service was scheduled on June 9, 2025, the facility was only able to provide hospice records for resident R1 to their responsible party. Other records such as the resident's admission agreement, physician report and individual needs assessments could not be located and/or provided at that time. They have not been located or provided since. As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A type B deficiency is cited on an attached form LIC9099-D. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 22-AS-20250716093842

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(19) · Plan of correction due date: Aug 15, 2025

Per CCR 87468.2(a)(19): "residents in (...) shall have all of the following personal rights: To have prompt access to review all of their records and to purchase photocopies of their records. (...) records shall be provided within two (2) business days". This requirement is not met as evidenced by: The initial request for request was made on May 21, 2025. As of the present visit, records have not been provided to R1's responsible party in full, which constitutes a potential risk to the health, safety and personal rights of individuals in care.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: Licensee will continue efforts to locate the records and ensure that they are provided to the responsible party as soon as possible. Proof of submission to be submitted to LPA before the plan of corrections due date.

Type of visit: POC

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the plan of corrections for the deficiencies issued during the annual visit conducted on June 9, 2025. The certificate of liability insurance for the facility was provided by the licensee with an effective expiration date of 05/28/2026 as well as adequate coverage amounts corresponding to Title 22 requirements. One of the two pending admission agreements was also provided and reviewed. The second one is still pending the return of the resident's responsible party who was out of the country for approximately two months and is scheduled to return in the coming weeks. The second admission agreement will be provided by the licensee at the earliest convenience. The deficiency will therefore be cleared once the second document is provided. An exit interview was conducted and a copy of this report was provided to a facility representative.the state’s words, verbatim · CDSS document, Jul 2, 2025

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility administrator Susan Cambio after stating the purpose of the visit. There are currently three residents in care, none of which are receiving hospice care at this time. LPA observed residents relaxing in the facility's common living areas with visitors or in their respective bedrooms. LPA accompanied by facility staff toured the physical plant. The facility is a two-story house with a loft used exclusively for staff accommodation, along with an attached garage. The facility has two shared and two private bedrooms along with one staff room on the ground level and two shared bathrooms, one of which is en-suite from one of the rooms. Bedrooms appear clean and sanitary. No residents are observed using postural supports at the time of the visit. All resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary and are equipped with grab bars and slip mats. Hot water temperature measured at 108F and 110F in two separate bathrooms equipped with faucets used for personal grooming. LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items, cleaning supplies and the medication central storage are verified to be secured. The wall-mounted fire extinguisher is charged. LPA tested the smoke and carbon monoxide detectors which were found to be operational. The garage is inaccessible to residents and used for laundry as well as additional storage of food and supplies. CONTINUED ON FORM LIC809-C CONTINUED FROM LIC809 LPA and facility staff toured the outside of the facility. LPA observed a shaded outdoor seating area with furniture for resident use. There is one self-latching gate on one side of the property and a double-wide gate on the other side of the property. The routes of egress are free of clutter and obstructions. There are no bodies of water on the premises. Facility does not utilize locked perimeters or delayed egress. LPA reviewed three resident records. Two resident records are found to be incomplete for two recently admitted residents. Admission agreements, pre-admission appraisals and individual needs assessments are found to be missing. Type B deficiency cited. LPA reviewed resident medication records and prescription orders for all residents with no discrepancies observed. Oxygen is not currently in use on the premises. There is one resident currently assessed as being bedridden at the time of the visit per their physician report. Resident is however able to reposition independently and is regularly placed in a wheelchair. Facility staff instructed to request an updated form LIC602 accurately reflecting the resident's condition. LPA reviewed staff records for two caregivers present during the visit. Present staff members have current CPR certificates on file. Incomplete initial and annual training observed on file. Type B deficiencies cited. Disaster drills are conducted however no proof of attendance is currently being generated. Type B deficiency cited. Both staff members present are background cleared. Both staff members are however not associated to the present licensed location. Type A deficiency cited. Based on the observations made during today’s visit, one type A and seven type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.the state’s words, verbatim · CDSS document, Jun 9, 2025

The state marks this report as 9 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility administrators Leo and Susan Cambio. During the inspection, LPA and facility staff conducted a tour of the physical plant and observed the following: The facility is a one-story home with a loft, two private bedrooms, two shared bedrooms and one staff room in addition to the facility's common living areas and two bathrooms, including one en-suite. All resident bedrooms have the required furnishing, bathrooms are equipped with grab bars and slip mats. LPA observed all beds have linens and blankets. The backyard has a shaded area and the routes of egress are free of clutter and obstructions. There are currently three residents admitted to the facility with no resident receiving hospice care at the time of the visit. The current hospice waiver allows for one resident. Residents are observed to be clean and appear well taken care of. Bathrooms faucets and toilets were operational. Water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Fire drills are conducted quarterly. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required. Smoke and carbon monoxide detectors tested operational. One fire extinguisher present is observed to be fully charged. LPA advised licensee to ensure annual maintenance or replacement of the fire safety equipment. Sharp items and cleaning supplies were confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure, however the daily prepared medication were located in a separate drawer without a lock. Medication was reviewed for accuracy during the visit. LPA reviewed three resident files along with one staff file. One staff member on the roster was found to be background cleared but not associated to this specific licensed location. Based on the observations made during today’s inspection, two type A deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report along with appeal rights was left at the facility.the state’s words, verbatim · CDSS document, Jul 26, 2024