Gracious Care Inc. #2

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Hernandez met with Staff Osvaldo Nunez. The capacity is (6) current census is (4). The facility is Residential Care Facility for the Elderly (RCFE). LPA Hernandez was accompanied by conduct a general an overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 72 degrees. Hot water temperature tested at 107 degress F. LPA Hernandez inspected resident bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA Hernandez observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Fire extinguishers were also observed at the facility. Posters such as personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. There is a Medicine cabinet with the resident’s medications locked. LPA observed bed located in common room. Deficiency will be issued. A previous licensing report was issued on 09/17/2025 giving notice of the same violation. Because you have been cited for repeating the same violation within 12 months, the following civil penalty shall be assessed until the violation is corrected. An immediate civil penalty of $250 is hereby assessed for the date of 08/26/2026. Food Service: More than seven (7) days’ supply of Non-perishable foods and more than two (2) days’ supply of perishable food supply were observed and sufficient for the number of residents in care. Care & Supervision: The facility has sufficient number of staff to provide care and supervision to the residents in care. **Continuation on LIC809-C** Record Review: LPA Hernandez reviewed four (4) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA observed Resident #2 (R2) and Resident #4 (R4) do not have an updated reappraisal or needs and services plan. Deficiencies will be issued. A previous licensing report was issued on 09/17/2025 giving notice of the same violation. Because you have been cited for repeating the same violation within 12 months, the following civil penalty shall be assessed until the violation is corrected. An immediate civil penalty of $250 is hereby assessed for the date of 08/26/2026. LPA observed four (4) residents medications. LPA observed no updated centrally stored medication log for Resident #1 (R1). Deficiency will be issued. Additionally, LPA observed R1's medication not properly labeled with prescription label. Deficiency will be issued. LPA observed for Resident #2 (R2) PRN medication is not properly documented. Deficiency will be issued. A previous licensing report was issued on 09/17/2025 giving notice of the same violation. Because you have been cited for repeating the same violation within 12 months, the following civil penalty shall be assessed until the violation is corrected. An immediate civil penalty of $250 is hereby assessed for the date of 08/26/2026. LPA Hernandez reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with Tuberculosis (TB) test result. LPA observed Staff #2 (S2) did not have First Aid/CPR certification. Deficiency will be issued. Based on the observations made during today’s visit, no deficiencies were' cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed and provided to Staff Osvaldo Nunez.the state’s words, verbatim · CDSS document, Aug 26, 2026

Type of visit: Case Management - Deficiencies

On 10/07/2025 Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced case management visit regarding deficiencies that were cited during annual visit on 09/17/2025. LPA was granted entry to facility by Staff Ricardo Rojas Garcia. LPA observed plan of corrections for annual report dated 09/17/2025 are now cleared.the state’s words, verbatim · CDSS document, Oct 7, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Staff Ricardo Rojas Garcia and was granted entry to the facility. Licensed capacity is (6) current census (3). LPA was accompanied by Staff Ricardo Rojas Garcia to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. Hot water temperature tested at 74 degrees Fahrenheit. Deficiency will be issued. A previous licensing report was issued on 10/18/2024 giving notice of the same violation. Because you have been cited for repeating the same violation within 12 months, the following civil penalty shall be assessed until the violation is corrected. An immediate civil penalty of $250 is hereby assessed for the date of 09/17/2025. There was a designated office for resident/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA was unable to enter room that is locked. Deficiency will be issued. A previous licensing report was issued on 10/18/2024 giving notice of the same violation. Because you have been cited for repeating the same violation within 12 months, the following civil penalty shall be assessed until the violation is corrected. An immediate civil penalty of $250 is hereby assessed for the date of 09/17/2025. There was a designated office for resident/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. LPA Hernandez observed common room upstairs with bed. Deficiency will be issued. Additionally, LPA observed no activity calendar for residents in care. Deficiency will be issued. A previous licensing report was issued on 10/18/2024 giving notice of the same violation. Because you have been cited for repeating the same violation within 12 months, the following civil penalty shall be assessed until the violation is corrected. An immediate civil penalty of $250 is hereby assessed for the date of 09/17/2025. There was a designated office for resident/staff files. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Facility has a variety of food available for residents. Dishes, cups, and utensils were also stored properly. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. Record Review: LPA reviewed (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA observed for Resident #1 (R1) and Resident #2 (R2) no updated physician report. Deficiency will be issued. A previous licensing report was issued on 10/18/2024 giving notice of the same violation. Because you have been cited for repeating the same violation within 12 months, the following civil penalty shall be assessed until the violation is corrected. An immediate civil penalty of $250 is hereby assessed for the date of 09/17/2025. Additionally, LPA observed no pre-placement appraisal for R1. Deficiency will be issued. A previous licensing report was issued on 10/18/2024 giving notice of the same violation. Because you have been cited for repeating the same violation within 12 months, the following civil penalty shall be assessed until the violation is corrected. An immediate civil penalty of $250 is hereby assessed for the date of 09/17/2025. LPA observed no reappraisal made for R1. Deficiency will be issued. LPA observed no needs and services plan for R1. Deficiency will be issued. LPA reviewed (3) residents medications. LPA observed incorrect documentation of PRN medications for Resident #3 (R3). R3's medication is labeled as PRN but being given as a daily medication. Deficiency will be issued. Furthermore, LPA observed no updated centrally stored medication log for R3. Deficiency will be issued. Additionally, LPA also reviewed (3) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings. LPA observed no required staff training for Staff #1 (S1) in file. Deficiency will be issued. LPA observed no plan of operation for facility. Deficiency will be issued. A previous licensing report was issued on 10/18/2024 giving notice of the same violation. Because you have been cited for repeating the same violation within 12 months, the following civil penalty shall be assessed until the violation is corrected. An immediate civil penalty of $250 is hereby assessed for the date of 09/17/2025. Additionally, LPA observed no fire/earthquake drills being done. Last drill was dated May 2025. Deficiency will be issued. Based on the observations made during today’s visit, deficiencies and civil penalties were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) and (LIC809D) (LIC421FC) was discussed and provided to Staff Ricardo Rojas Garciathe state’s words, verbatim · CDSS document, Sep 17, 2025

Allegation investigated: Licensee failed to immediately notify responsible party of resident death.

Licensing Program Analyst (LPA) Raquel Hernandez conducted an unannounced visit to deliver findings on the allegation listed above. LPA met with Staff Ricardo Rojas Garcia and explained the purpose of the visit. The investigation consisted of staff and resident interviews along with obtaining documentation pertaining to allegation. For the allegation, Licensee failed to immediately notify responsible party of resident death. Based on interviews, LPA Hernandez observed no copy of death report was provided to former Resident #1 (R1) responsible party. In addition, based on record review, LPA Hernandez observed facility did not provide death report of R1 to Community Care Licensing. Substantiated Based on the evidence gathered during the investigation, the allegation listed above is deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence the standard has been met. An exit interview was conducted and the forms LIC9099 and LIC9099D were discussed and left with Ricardo Rojas Garcia along with a copy of the appeal rights. For the allegation, Caregiver unable to communicate with residents family. LPA Hernandez observed facility staff able to communicate with residents in care. Additionally, it was indicated by Staff #2 (S2) that facility staff have no issues communicating with resident's families. For the allegation, Licensee failed to provide an admission agreement within 7 days. LPA Hernandez spoke with Administrator Sandy Zhao where it was stated responsible party was provided with an admission agreement copy. Administrator stated responsible party did sign admission agreement within seven days following resident's admission. LPA Hernandez observed signature from R1's responsible party. Based on record review, there was not enough evidence to corroborate admission agreement was not provided. For the allegation, Licensee altered the admission agreement after responsible party signed the agreement. LPA Hernandez observed admission agreement for R1 where signatures from R1's responsible party were obtained. Administrator Sandy Zhao stated admission agreement has remained the same. Based on record review, there was not enough evidence to corroborate admission agreement was altered. Based on the evidence gathered during today’s investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and this form LIC9099-A was discussed and left with Staff Ricardo Rojas Garciathe state’s words, verbatim · CDSS document, Jun 17, 2025 · control 56-AS-20221031141433

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(1)(A) · Plan of correction due date: Jun 18, 2025

87211 Reporting Requirements (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... (A) Death of any resident from any cause. Based on record review, licensee did not comply with section cited above by not ensuring death report of former Resident #1 (R1) was provided to R1's responsible party, which poses an immediate health, safety, and personal rights risk to those in care.the state’s words, verbatim · CDSS document, Jun 17, 2025

Plan of correction: Licensee stated to notify all resident's responsible parties as well as licensing department for future deaths and severe occurences.

Type of visit: Case Management - Deficiencies

On 04/02/2025 Licensing Program Analyst (LPA) Raquel Hernandez conducted an announced visit to the facility in regards to Complaint 56-AS-20221031141433. Upon visit, LPA observed Administrator Sandy Zhao failed to report to the department death of former Resident #1 (R1) within 7 seven days of the occurrence. Based on the observations made during today’s visit, a deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) (LIC809D) was discussed and provided Administrator Sandy Zhao. Along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Apr 2, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A) · Plan of correction due date: Apr 7, 2025

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency..(1) A written report shall be submitted to the licensing agency..(A) Death of any resident from any cause regardless of where the death occurred.. Based on record review, licensee failed to meet this requirement by not ensuring Resident #1 (R1) death was reported to licensing within seven days of occurence, which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 2, 2025

Plan of correction: Licensee stated to submit staff training on reporting requirements regulation 87211 by Plan of Correction (POC) due date to LPA Hernandez.

Type of visit: Case Management - Deficiencies

On 04/02/2025 Licensing Program Analyst (LPA) Raquel Hernandez conducted an unnanounced visit pertaining to complaint 56-AS-20221031141433. During visit, LPA Hernandez observed Resident #2 (R2) facility file to not be located at the facility. LPA advised Administrator all resident's files must be at facility and presented to licensing upon request. Based on the observations made during today’s visit, a deficiency was cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) (LIC809D) was discussed and provided to Assistant Administrator Sandy Zhao. Along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Apr 2, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Apr 9, 2025

87506 Resident Records: (a) the licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. Based on record review, licensee failed to meet this requirement by not ensuring Resident #2 (R2) file was completed and located at the facility upon request, which poses a potential health, saftey, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Apr 2, 2025

Plan of correction: Licensee stated to submit to LPA Hernandez Resident #2 (R2) completed facility file by Plan of Correction due date as well as have hard copy availabile at facility.

Type of visit: POC

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to the facility to verify clearance of Plan of Correction from visit on 10/18/2024. LPA Rico met with staff Juan M. Estrada Barajas and was granted entry to the facility. During today's visit, Licensee Sandy Zhao and House Manager Brandon Marquez as contacted and informed of the visit. The following deficiencies were not cleared during the time of the visit: The Licensee was cited on 10/18/2024 for 87208(a) Plan of Operation. During today's visit and based on record review and interview, LPA Rico observed that the Licensee did not have Plan of Operation located in facility file. The Plan of Correction was sending proof to LPA Rico the facility has Plan of Operation maintain in facility file. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days. The Licensee was cited on 10/18/2024 for 87303(e)(2) Maintenance and Operation. During today’s visit and based on interview and observation. LPA Rico observed that the Licensee did not fix the water temperature. The Plan of Correction was for the licensee to send LPA Rico proof the water temperature has been fixed. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days The Licensee was cited on 10/18/2024 for 87307(a)(3)(B) Personal Accommodations and Services. During today’s visit, LPA Rico observed bedroom number one had broken dresser. The Plan of Correction was for the Licensee to replace the drawer and send proof to LPA Rico. Therefore, the POC was no not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days. The Licensee was cited on 10/18/2024 for 87311 Telephones. During today’s visit, LPA Rico verify no staff training was conducted the regulation cited. The Plan of Correction was for the Licensee to send proof that all staff members were train all staff on the regulation 87311 Telephones. Therefore, the POC was no not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days. The Licensee was cited on 10/18/2024 for 87412(a)(13)(B)1 Personnel Records. During today’s visit, LPA Rico did not receive copies of Administrator requirements/training's. The Plan of Correction was for the Licensee to send LPA copies of Administrator requirements/training's. Therefore, the POC was no not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days. The Licensee was cited on 10/18/2024 for 87219(a) Planned Activities. During today’s visit, LPA Rico verify no staff training was conducted the regulation cited. The Plan of Correction was for the Licensee to send proof all staff members were train on the regulation 87219(a) Planned Activities. Therefore, the POC was no not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days. The Licensee was cited on 10/18/2024 for 87555(b)(26) General Food Service Requirements. During today’s visit, LPA Rico did not observe perishable foods for a minimum of two days shall be maintained on the premises. The Plan of Correction was for the Licensee to go grocery shopping and send proof to LPA Rico. Therefore, the POC was no not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days. The Licensee was cited on 10/18/2024 for 87457(c) Pre-Admission Appraisal. During today’s visit, based on record review, LPA Rico observed the facility was unable to obtain R1 Pre-admission Appraisal. The Plan of Correction was for the Licensee to send LPA Rico a copy of R1 Pre-admission. Therefore, the POC was no not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for five (5) days. The Licensee was cited on 10/18/2024 for 87458(a) Medical Assessment. During today’s visit, based on record review, LPA Rico observed the facility was unable to obtain R2 and R3 LIC602. The Plan of Correction was for the Licensee to send LPA Rico a copy of R2 and R3 LIC602. Therefore, the POC was no not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days. The Licensee was cited on 10/18/2024 for 87412(g). During today’s visit, based on record review, LPA Rico observed the facility did not have all personnel records at the facility. The Plan of Correction was for the Licensee to send LPA Rico proof all personnel records are maintain at the facility. Therefore, the POC was no not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days. The Licensee was cited on 10/18/2024 for 80044(a) Inspection Authority of the Licensing Agency. During today’s visit, LPA Rico was unable to enter the upstairs bedroom. The Plan of Correction was to submit Statement of Understanding to California Code of Regulations (CCR) 8044(a) to LPA Rico and will provide access to Community Care Licensing Department. Therefore, the POC was no not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for four (4) days. Furthermore, a repeated violation of Health and Safety Code Section 1569.618(b). A pervious licensing report was issued on 02/29/2024 giving notice of the same violation. Because you have been cited for repeating the same violation within 12months, the following civil penalty shall be assessed until the violation is corrected. An immediate civil penalty of $250 is hereby assessed for the of 10/25/2024. An exit interview was conducted with staff Juan M. Estrada Barajas where this report, LIC809 along with Civil Penalty Assessment pages, and Appeal Rights were reviewed and provided.the state’s words, verbatim · CDSS document, Oct 25, 2024

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Mary Rico and Raquel Hernandez made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with caregiver Richardo Rojas Garcia and was granted entry to the facility. The facility is a two-story home (8) bedroom (4), bathroom home and, with a kitchen/dining area, living room and attache garage. Licensed capacity is (6) current census (3). LPAs were accompanied by House Manager Brandon Marquez to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). The facility is maintained at a comfortable temperature. The facility is equipped with operating carbon monoxide alarms and fire alarms. Posters such as personal rights, the CCL complaint poster, Infection Control Plan, and Disaster Plan were posted in the common area. Dishes, cups, and utensils were also stored properly. LPA inspected resident’s bedroom they’re equipped with required furniture: such mattresses night stands, and storage space. Deficiencies that were found during facility tour: LPAs inspected residents’ bedrooms; bedroom number one had a broken dresser. Residents’ bathroom shower did not have non-skid mats. LPAs tested residents’ hot water; the temperature tested at 78 F. In addition, one of the hallways lights did not turn on, the bathroom located by bedroom number four and three had the light switched broken and did not have appropriate lighting for the residents. Furthermore, LPAs requested House Manager Brandon Marquez to test the kitchen stove. LPAs observed House Manager turning the stove on with a lighter. LPAs observed facility phone line to be off. LPAs observred the facility did not have two days of perishable supplies for the number of residents in care. Lastly, LPAs were unable to enter one of the bedrooms on the second floor. House Manager Brandon Chavez stated they are unable to open the bedroom because the Administrator Na Zhao "Sandy" has the keys to enter the bedroom. Activities were not being provided, as listed on their calendar. Delicacies that were found during record review: LPAs observed the facility did not have their Plan of Operation in their facility file. In addition, R1 did not have a pre-placement, R2 and R3 did not have a Physician Report in file. During medication audit, LPA observed staff did not provide R3 with their medication, 2 out of the 10 medications were not provided. Medications were documented as given but were still in the bubble wrap. Furthermore, during medication audit, R3 requires a blood glucose to be check twice a day. LPAs observed the glucose needle kit. Based on R3 care plan, R3 is unable to administrator his own medications. The facility does not have a skilled professional on duty to provide R3 services. During staff record review, LPA observed S1 did not have a valid CPR and the facility did not have the Administrator's personnel record along with their Administrator training's at the facility. Records must be maintain at the facility. Care & Supervision: The facility had one Care Giver and House Manager Brandon Marquez present during inspection. The House Manager took over 25 minutes to arrive at the facility. At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The facility did not have House Manager or Administrator present 24 hours. Furthermore, the House Manager Brandon Marquez is a Administrator for three other facilities. Based on observations today, the facility will be issued (5) Type A deficiencies and (9) Type B deficiencies per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) was discussed to Licensee Sandy Zhao on the phone and was provided to House Manager Brandon Marquez along with a copy of LIC809,LIC809D , and the appeal rights.the state’s words, verbatim · CDSS document, Oct 18, 2024

The state marks this report as 10 pages; the online copy we transcribed has 9. You can request the full file from the county licensing office.

Type of visit: POC

Licensing Program Analysts (LPAs) Mary Rico and Bianca Wolcott conducted an unannounced visit to the facility to verify clearance of Plan of Correction from visit on 02/29/2024. LPA Rico and Wolcott met with caregiver Kevin Galvan Bastidas. During today's visit, Licensee Sandy Zhao was contacted and informed of the visit. The following deficiencies were not cleared during the time of the visit: The Licensee was cited on 02/29/2024 for 87309(a) Storage Space. During today's visit and based on record review and interview, LPA Rico observed that the licensee did not have staff training on site. The Plan of Correction was to train all staff on 87309(a) Storage Space. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for six (6) days. The Licensee was cited on 02/29/2024 for 87413(a)(1) Personnel – Operations. During today's visit and based on record review and interview, LPA Rico observed that the licensee did not submit the updated LIC500 and signed statement of understanding on the cited regulation. The Plan of Correction was to update LIC 500 and send a copy to LPA Rico. In addition, the Licensee was to submit Signed Statement of Understanding on the cited regulation to LPA Rico. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for six (6) days. The Licensee was cited on 02/29/2024 for 1569.618(b) Administration and management of residential care facilities; substituted qualifications; employee scheduling. During today’s visit and based on interview, LPA Rico observed that the licensee did not have a designated substitute present. The Plan of Correction was for the licensee to have a designated substitute when the Administrator is not present and send proof to LPA Rico. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for six (6) days. The licensee was cited on 02/29/2024 for 1569.618(a) Administration and management of residential care facilities; substituted qualifications; employee scheduling. During today’s visit and based on an interview, LPA Rico observed that the licensee did not have an Administrator present during working hours. The Plan of Correction was for the licensee to send proof of when the Administrator will return to the facility and a copy of the schedule. Along with a signed statement of understanding on the cited regulation to LPA Rico. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for six (6) days. The licensee was cited on 2/29/2024 for 87211(a)(1) Reporting Requirements. During today’s visit and based on an interview, LPA Rico observed that the licensee did not have staff training on site. The Plan of Correction was for the licensee to train all staff 87211(a)(1) Reporting Requirements and submit proof of Staff Training Log to LPA Rico, along with a signed statement of understanding on the cited regulation to LPA Rico. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for six (6) days. An exit interview was conducted with caregiver Kevin Galvan Bastidas where this report, LIC809 along with Civil Penalty Assessment pages, and Appeal Rights were reviewed and provided.the state’s words, verbatim · CDSS document, Mar 7, 2024

Allegation investigated: Staff does not properly report incidents involving residents

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver findings on the allegation listed above. LPA met with staff member Kevin Galvan Bastidas and explained the purpose of the visit. The investigation consisted of staff interviews, document reviews, and a facility tour. For the allegation, Staff does not properly report incidents involving residents. During interviews with staff, S1 and Administrator informed LPA that R1 had passed away at facility on 2/8/2024. Administrator admitted they did not submit the Death Report to Community Care Licensing. In addition, during resident event log it was documented that R1 had passed away on 2/8/2024. Furthermore, on resident event log review LPA discovered that R2 had a fall on 11/14/2023 and was also not reported to Community Care Licensing. In addition, Administrator admitted that R3 passed away at her facility and did not submit the Death Report. Substantiated Based on the evidence gathered during today’s investigation, the one (1) allegations listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence the standard has been met. During today’s visit, one (1) Type A deficiency were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) and (LIC9099D) was discussed and provided staff member Kevin Galvan Bastidas along with a copy of the appeal rights.the state’s words, verbatim · CDSS document, Feb 29, 2024 · control 18-AS-20210520160259

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

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require... (1) A written report shall be submitted to the licensing agency... This requirement is not met as evidenced by: Based on interview and records review, the Licensee did not comply with the section cited above by not submitting Special Incident Report (SIR) to CCL for R2 fall and R1 and R3 Death Report. This pose potential health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: Licensee stated to train all staff on CCR 87211(a)(1) and submit proof of Staff Training Log to LPA Rico by POC due date. Licensee will submit Signed Statement of Understanding on CCR 87211(a)(1) to LPA Rico by POC due date. POC due date 3/1/2024

Allegation investigated: Staff does not seek timely medical attention for residents

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to investigate and deliver findings on the allegation listed above. LPA met with staff member Kevin Galvan Bastidas and explained the purpose of the visit. The investigation consisted of staff interviews, document reviews, and a facility tour. For the allegation, Staff does not seek timely medical attention for residents. During interview with staff, the Administrator informed LPA Rico that facility staff will seek medical attention for the residents in a timely manner. During a record review, LPA discovered the facility has resident event log as proof of documentation they are providing medical attention to residents. LPA Rico did not find evidence to corroborate the allegation. Unsubstantiated Based on the evidence found during the investigation, the one (1) allegation listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means 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. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to along with a copy of the staff member Kevin Galvan Bastidas appeal rights.the state’s words, verbatim · CDSS document, Feb 29, 2024 · control 18-AS-20210520160259

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to the facility for a complaint. During the complaint visit, LPA Rico completed a case management visit to cite for three (3) deficiencies found during facility tour. During facility tour, LPA observed the cleaning solutions in the laundry room without a lock. LPA requested for S1 to lock the cleaning solutions. During interviews with staff, S1 admitted they work 24 hours for 5 days Monday -Friday and are the only staff working at the facility. S1 stated that S2 will be working 24hours for 2 days Saturday – Sunday and are the only staff working at the facility. S1 also admitted the facility staff are in vacation. Furthermore, during an interview with the Administrator they admitted they not present during working hours because they are in Northern California.In addition, the Administrator also admitted the facility does not have a designated substitute who has the adequate qualifications to adequate to be responsible and accountable for the facility and is on premises 24 hours per day. During today’s visit, four (4) Type A deficiencies to the facility were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report, LIC809, LIC809D, Appeal Rights were discussed and provided to staff member Kevin Galvan Bastidasthe state’s words, verbatim · CDSS document, Feb 29, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Mar 1, 2024

87309(a) Storage Space (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. Based on observation and interview the licensee did not comply with the section cited above evidenced by not having cleaning solutions locked which poses an immediate Health, Safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: Licensee has agreed to send proof they have read and understood the regulation and will send proof they have trained all staff on the regulation cited above. POC due date 03/01/2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR87413(a)(1) · Plan of correction due date: Mar 1, 2024

87413(a)(1) Personnel - Operations (a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.This requirement is not met as evidenced by: Based on observation, interview and record review the licensee did not comply with the section cited above evidenced by not providing staff coverage when regular staff are on vacationthe state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: The licensee has agreed to provide an updated LIC 500 and provide the following documents of which staff members provide coverage while other staff are on vacation. Licensee will submit Signed Statement of Understanding on the cited regulation to LPA Rico by POC due date. POC due date 03/01/2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.618(b) · Plan of correction due date: Mar 1, 2024

1569.618(b)Administration and management of residential care facilities; substituted qualifications; employee scheduling.(b).one ..manager..designated substitute qualifications.. responsible designated substitute shall meet..This requirement is not met as evidenced by: Based on observation and interview the licensee did not comply with the section cited above evidenced by Licensee admitting not having a designated substitute which poses an immediate Health, Safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: Licensee has agreed to have a designated susbstitue when the Administrator is not present. Licensee will send proof to LPA. Licensee will submit Signed Statement of Understanding on the cited regulation to LPA Rico by POC due date. POC due date 3/1/2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC1569.618(a) · Plan of correction due date: Mar 1, 2024

1569.618(a)Administration and management of residential care facilities; substituted qualifications; employee scheduling.(a)... operation of the facility when the administrator is temporarily absent from the facility. Based on observation and interview the licensee did not comply with the section cited above evidenced by Administractor admitting they not present during working hours which poses an immediate Health, Safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: The licensee has agreed to send proof of when the Administrator will be return to the facility and copy of the schedule. Licensee will submit Signed Statement of Understanding on the cited regulation to LPA Rico by POC due date. POC due date 3/1/2024

Type of visit: Required - 1 Year

0900: Licensing Program Analyst (LPA) Amy Goldenberg arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card. LPA spoke telephonically with the Licensee. LPA noted upon arrival one caregiver (E1), non- english speaking and five residents present. 0935: LPA Goldenberg reviewed Guardian Roster report and noted that E1 and E2 are Unknown/Volunteer status in Guardian. E1 and E2 are scheduled to work in this home today. 0955: Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. LPAs observe the facility to be clean and in good repair. The home is maintained at a comfortable temperature for the residents. Lighting is sufficient for safety and comfort. Water temperature measured 111 degrees F. Grab bars, non-slip mats are present in the restrooms. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the garage. All outdoor and indoor passageways are free of obstruction. Night lights and emergency lighting is present. A locked area is provided for medications and sharp objects. There is a telephone working at this location. The LIC 610E, emergency disaster plan is maintained. The facility has a current written definitive plan of operation. The facility does not handle resident money. 1022: Personnel Records/Training/and Staffing- LPA reviewed (3) employee records. CPR requirements have been met. The facility does not employ enough staff. Upon arrival LPA observed E1 on duty alone. Review of finger print clearance revealed that E1 is cleared as a volunteer only. E2 is also only cleared as a volunteer. E1 and E2 are the scheduled staff for this facility. The facility administrator is not present a sufficient number of hours to maintain the facility as evidenced by lack of maintenance of training records, improper staffing and expired fire extinguisher dated 02/01/2019. Administrator certification is present for administrator on file, Na Zhao expired 03/26/2021. 1118: Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medial and Dental- LPA reviewed five (5) resident records. 1230: Food Service- LPA was present during the lunch time meal. The meal is adequate to meet the nutritional needs of the residents. Food prep areas are clean and organized. Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually, however the last time was on 02/01/2019. The facility is not documenting disaster drills. 1244: LPA began preparation of report for delivery. Based on the information received during this visit today, the following deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with and a copy provided to the facility representative. Appeal Rights were also provided at the time of the exit interview.the state’s words, verbatim · CDSS document, Oct 25, 2023