Gracious Living

Type of visit: Office

On 6/29/2026 an in office meeting was held to discuss a revised updated Plan of Correction with Facility Administrator Jesus Correra. Individuals present at the meeting included Regional Manager (RM) Leslie Mendiveles, Licensing Program Manager (LPM) Efren Malagon and Licensing Program Analyst (LPA) Paola Guerrero. During this office meeting, the following issue was addressed and discussed: Plan of Correction related to Complaint # 56-AS-20250408075332. Administrator Jesus Correa will revise the Plan of Correction and provide complete details of the process of repayment plan to Resident #1. In addition, the Administrator Jesus Correa will also revoke the loan agreement dated on 4/25/2025, and the lifetime service contract with Resident #1. Administrator Jesus Correa will list the dates and signatures from Licensee, Resident #1, and Administrator in the Plan of Correction. The Jesus Correa will provide an updated Plan of Correction with all the information discussed during the meeting by 7/15/2026.the state’s words, verbatim · CDSS document, Jun 29, 2026

Allegation investigated: Licensee is financially abusing Resident

Licensing Program Analyst (LPA) Paola Guerrero arrived at the facility to deliver investigative findings. LPA met with Jesus Correa and explained the purpose of the visit. On April 8, 2025, the Department received a complaint with allegation of personal rights violation of R1. The Department investigation consisted of review of facility and other records, observations, and interviews with pertinent individuals. Investigation revealed that on or around February 23, 2024, Licensee ABJC Gracious Living Inc. received money from R1 in the form of a check for $100,000. Subsequent checks were received by Licensee from R1 on or around March 5, 2024, for $200,000, and on or around June 21, 2024, for $300,000. Records show that Licensee representative Angel Kao and Administrator Jesus Correa are co-joint owners of the facility business accounts. In addition, Investigation revealed that on or around February 2024, R1 gave $40,000 to Jesus Correa in form of a loan. Records show that Jesus Correa obtained two notary agreements one for $600,000 ‘lifetime’ service and the second for $40,000 ‘lifetime supply’ of the supplies R1 would need at facility. However, the $40,000 loan to Jesus Correa was dated after the fact, on April 25, 2025. Substantiated During further review the Department discovered that the loan agreement Jesus Correa initiated indicated that there was no collateral, no interest, along with no penalty if Jesus Correa does not repay R1. Both Angel Kao and Jesus Correa acknowledged receipt of monies from R1. Purpose of $40,000 to Jesus Correa was to renovate a property. Other monies received were for lifetime service “for the basic care and board that the Gracious Living could offer” and lifetime supply service while R1 was at facility. However, facility is not licensed to offer “lifetime” services as described. In obtaining monies from R1, Angel Kao and Jesus Correa violated R1 personal rights and financially abused R1. Allegation above is substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Health and Safety Code (HSC) is being cited on the attached LIC 9099D. An exit interview was conducted where this report was discussed and provided to Facility Administrator Jesus Correa.the state’s words, verbatim · CDSS document, Jun 12, 2026 · control 56-AS-20250408075332

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.269(a)(29)(E) · Plan of correction due date: Jun 15, 2026

Enumerated rights; severability... (a) Residents of residential care facilities for the elderly shall have all of the following rights:... (29) To manage their financial affairs. A licensee shall not require residents to deposit their personal funds with the licensee. Except as provided in approved continuing care agreements, a licensee, or a spouse, domestic partner, relative, or employee of a licensee, shall not do any of the following:...(E) Enter into a loan or promissory agreement or otherwise borrow money from a resident This requirement was not met as evidenced by: Based on interviews, record review, the Licensee received personal funds from R1 for lifetime services and supplies that facility is not licensed to provide. Licensee also entered into a loan agreement with R1. This posed an immediate Health, Safety, or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Jun 12, 2026

Plan of correction: The Licensee has agreed to read over regulation 1569.269(a)(29)(E) and provide LPA with a signed acknowledgement acknowledging and understanding the regulation. The Licensee will also provide LPA with the revoking process of the loan agreement dated 4/25/2025, along with the lifetime service contract. Furthermore, the Licensee will provide LPA with a repayment plan or the process of repaying back R1 by POC date: 6/15/2026.

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 Administrator Jesus Correa. The capacity is (6) current census is (4). The facility is a six (6) bedroom, two and a half (2 1/2) bathroom home with a kitchen/dining area, living room and attached garage. The facility is Residential Care Facility for the Elderly (RCFE). LPA Hernandez was accompanied by Administrator Jesus Correa 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. 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. Posters such as personal rights, the CCL complaint poster, labor laws, and the disaster plan were posted in a common area. There was a designated storage space for resident/staff files. There is a Medicine cabinet with the resident’s medications locked. LPA observed scissors, knives, and chemicals kept unlocked accessible to residents in care. Deficiency will be issued. 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 two (2) resident files for admission agreements, updated physician reports, pre-placement appraisals and needs and services plans. LPA observed two (2) residents medications. LPA observed no updated centrally stored medication log for Resident #1 (R1) and Resident #2 (R2). Deficiency will be issued. LPA observed no reapprasial's for Resident #1 (R1) and Resident #2 (R2). Deficiency will be issued. Additionally, LPA observed no needs and services plan for R1 and R2. Deficiency will be issued. LPA Hernandez reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with Tuberculosis (TB) test result. No issues were observed. Based on the observations made during today’s visit, 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 Administrator Jesus Correa.the state’s words, verbatim · CDSS document, May 8, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Administrator Jesus Correa and was granted entry to the facility. At the time of the visit there was two (2) staff present, and four (4) residents present. The facility is a six (6) bedroom, two and half (2.5), bathroom home, with a kitchen/dining area, living room, with open driveway. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (6) current census (4). LPA was accompanied by Facility Administrator, 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. LPA inspected resident’s 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 observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms to be 114.9 degrees F 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. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. LPA observed an in-ground pool in the backyard, the perimeter of pool is gated and locked. There was a designated storage space for resident/staff files. Medications are kept inside medication closet inaccessible to residents in care. 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. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed four (4) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. 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 Facility Administrator Jesus Correa.the state’s words, verbatim · CDSS document, Apr 7, 2025

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.

Allegation investigated: Facility did not provide resident's records to resident's authorized representative. Facility did not ensure that resident's had a TB test Facility recommended hospice services for resident Facility has cameras in common areas that is being monitored Facility is not providing cable

Licensing Program Analyst, (LPA) Yolanda Delgado arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Leofel Capulong and explained the purpose of the visit. On March 8, 2024, Community Care Licensing received a complaint alleging facility did not provide resident's records to resident's authorized representative, facility does not provide well balanced meals, facility did not ensure that residents had a TB test, facility has cameras in common areas that are being monitored, and facility is not providing cable. LPA conducted interviews with Administrator, staff, residents, and additional witnesses. LPA also conducted a review of pertinent documentation. LPA was unable to interview Resident #1 (R1) in order to obtain pertinent information due to R1 passing away on March 17, 2024. (Continued on Page 2) Unfounded (Continued on from Page 1) In regards to the allegation that facility did not provide resident’s records to resident’s authorized representative, it was reported that on March 7, 2024, R1’s authorized representative provided a handwritten request to obtain R1’s records and staff refused. Interview with resident’s authorized representative stated that records were received March 9, 2024. Information obtained by Administrator stated that records were sent on June 4, 2024. LPA conducted a review of pertinent documentation that corroborated the request for records, records sent and received. Regarding the allegation facility did not ensure that residents had a Tuberculosis (TB) test, it was reported that R1’s TB test was read on May 4, 2023, by R1’s primary doctor; however, the visitor log did not include a sign-in visit from the primary doctor. Information obtained from Administrator, staff, and residents, indicated that a TB test is required prior to being placed at the facility. It was advised that R1 had their TB test conducted on May 2, 2023, and read on May 4, 2023. LPA reviewed pertinent documents in resident’s files that included documentation of a TB test for all clients in care prior to placement. Interview with additional witness indicated that TB test was done on May 13, 2022 and read on May 16, 2022 and another TB test was done on March 1, 2024 and read on March 4, 2024. In regards to the allegation facility recommended hospice services for resident, it was reported that Licensee and Administrator pushed for R1 to be placed on hospice. Information obtained from R1’s representative indicated that R1 was not on hospice when R1 moved into the facility on May 17, 2022. LPA conducted interviews with Administrator, staff and residents. Information obtained stated that R1’s start of care for hospice was on April 28, 2022. LPA conducted a review of R1’s hospice documents indicated that R1 was on hospice prior to moving into the facility. It was also alleged that the facility has cameras in common areas that are being monitored by Administrator. Information obtained from Administrator, staff, and residents, stated that cameras are in the common area and are being monitored. It was further advised that the cameras do not record audio which is in accordance to the reference material provided by the department. Cameras were observed by the LPA in the common areas only. LPA reviewed the facility’s plan of operation/program statement in which cameras are not part of the program. (Continued on Page 3) (Continued from Page 2) Regarding the allegation facility is not providing cable, it was reported that the cable in the living room was turned off, prohibiting residents from being able to watch. Information obtained from Administrator, staff, residents and witness indicate that residents are provided streaming services in each of their room and the living room. LPA observed the living room television and resident’s room with streaming channels. Review of the facility’s plan of operation, program statement, and or placement agreement indicates that cable is available in the living room of the facility, Residents can pay an extra charge to have it available in their bedrooms. Based on staff interviews, resident interviews, facility records, the allegations facility did not provide resident’s records to resident’s authorized representative, facility did not ensure that residents had a TB test, facility recommended hospice services for resident, facility has cameras in common areas that is being monitored, facility is not providing cable, we have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. An exit interview was conducted, and a copy of this report was provided along with LIC811- Confidential Names list.the state’s words, verbatim · CDSS document, Nov 13, 2024 · control 56-AS-20240308082752

Allegation investigated: Facility failed to report a resident went to the hospital

Licensing Program Analyst, (LPA) Yolanda Delgado arrived unannounced at the facility to conclude an investigation for the above allegation. LPA Delgado met with Leofel Capulong and explained the purpose of the visit. On March 8, 2024, Community Care Licensing received a complaint alleging that facility failed to report a resident went to the hospital. It was reported that a resident was choking and ended up at the hospital about a month ago. LPA conducted interviews with Administrator, staff, and additional witnesses. LPA also conducted a review of pertinent documentation. LPA was unable to interview Resident #1 (R1) in order to obtain pertinent information due to R1 passing away on March 17, 2024. It was alleged that on January 29, 2024, Resident #2 (R2) was choking at the facility and was transported to the hospital. Information obtained from Administrator indicated that R2 was being visited by family (Continued on Page 2) Substantiated (Continued from Page 1) member when R2 began choking on a small piece of cantaloupe. It was advised that Staff #1 (S1) performed Heimlich maneuver and Staff #2 (S2) contacted emergency personnel services. Emergency personal arrived and transported R1 to the local hospital. Administrator indicated that the facility did send a serious incident report to Community Care Licensing (CCL). Administrator provided a serious incident report of an incident that occurred on January 29, 2024, involving R2. LPA requested confirmation of the incident being reported to CCL. Administrator provided an email sent to another LPA on March 13, 2024. Administrator was unable to provide proof of the incident report being sent abiding by Title 22 regulations. LPA was unable to locate any information pertaining to an incident on January 29, 2024, or pertaining to R2 in the Regional Office internal database. Title 22 Regulations, Section 87211 (1) indicates that a written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified. Therefore, based on observations and interviews, the allegation that facility failed to report a resident went to the hospital is SUBSTANTIATED. The facility will be cited for Title 22, Division 6, Chapter 8, Article 04, Section 87211 (1)(D). This poses a health and safety and or personal rights risk to clients in care. An exit interview was conducted where this report, 9099-D, and appeal rights were discussed. Copies of the documents were provided to House Manager.the state’s words, verbatim · CDSS document, Nov 13, 2024 · control 56-AS-20240308082752

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(1)(D) · Plan of correction due date: Nov 20, 2024

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 of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not being met as evidenced by: Facility did not report to CCLD that 911 was called for R2 and was taken to the hospital. This poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Nov 13, 2024

Plan of correction: Licensee will report any incidents involving residents within the time frame as required, document and maintain records of confirmation of incidents sent to CCLD. Licensee will review regulation and conduct training and submit copy by email to LPA by POC due date.

Allegation investigated: Facility neglecting residents in care Facility does not provide well balanced meals Facility did not inform resident's POA a change iin condition Facility did not change resident's adult brief Facility requesting resident to be medicated

Licensing Program Analyst, (LPA) Yolanda Delgado arrived unannounced to the facility to conclude an investigation pertaining to the allegations listed above. LPA met with Leofel Capulong and explained the purpose of the visit. On March 8, 2024, Community Care Licensing received a complaint alleging facility neglecting residents in care, facility does not provide well balanced meals, facility did not inform resident’s POA a change in condition, facility did not change resident’s adult brief, and facility requesting resident to be medicated. LPA conducted interviews with Administrator, staff, and additional witnesses. LPA also conducted a review of pertinent documentation. LPA was unable to interview Resident #1 (R1) in order to obtain pertinent information due to R1 passing away on March 17, 2024. (Continued on Page 1) Unsubstantiated (Continued from Page 1) In regards to the allegation that facility neglecting residents in care, it was reported that residents are not getting the care that they need. LPA conducted interviews with Administrator, staff, residents and witness and information obtained from the interviews did not corroborate the allegation of residents not getting the care they need. LPA conducted review of resident’s physician reports, preplacement appraisal information, documentation of visits from hospice agencies did not corroborate neglect in resident’s care. Regarding the allegation facility does not provide well balanced meals, it was reported that Resident #1 (R1) was served a tuna sandwich with a donut and or frozen meals only. Information obtained from Administrator, staff, residents, and witness indicated that residents are provided well balanced meals. It was also reported that each resident is able to request their own meals. LPA observed lunch being cooked for two residents and they chose what foods they wanted to eat. LPA was unable to obtain additional pertinent information regarding the allegation due to inability to interview R1. In regards to the allegation facility did not inform resident’s POA a change in condition, it was reported that R1’s authorized representative was not informed of the resident beginning to wander at night and R1’s physician possibly changing medication. LPA conducted interviews with Administrator, staff, residents and witness and information obtained from the interviews did not corroborate the allegation that a meeting took place between the Administrator, social worker and R1’s PCP and R1’s POA was not informed. LPA conducted review of R1’s physician report, R1’s medication record, hospice records, visitor sign in sheets did not corroborate a change of condition that R1’s POA would not have been informed of. In regards to the allegation that facility did not change resident’s adult brief, it was reported that R1’s adult brief was not changed by caregiver. Information obtained from interviews with staff indicated that residents are changed every 4 hours or more if needed, residents that use adult brief’s are clean and dry at all times. LPA conducted a review of residents hospice of visits from hospice agencies did not contain at any time that a residents were left in soiled briefs did not corroborate the allegation. In regards to the allegation facility requesting resident to be medicated. It was reported the Administrator called R1’s authorized representative inquiring if R1 can be placed on medication due to wandering at night. Information obtained from Administrator denied that the facility requested R1 to be placed on medication. (Continued on Page 3) (Continued from Page 2) Information obtained from staff indicated that R1 would be anxious at night and sometimes combative and R1’s PCP would make changes to R1’s medication. LPA conducted a review of R1’s hospice medication records that R1’s PCP would issue a prescription for a change in medication did not corroborate the allegation. Based on staff interviews, resident interviews, facility records, resident files, the allegations that facility neglecting residents in care, facility does not provide well balanced meals, facility did not inform resident’s POA a change in condition, facility did not change resident’s adult brief, facility requesting resident to be medicated is unsubstantiated. Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted with Leofel Capulong and a copy of this report along with LIC811- Confidential Names list was provided.the state’s words, verbatim · CDSS document, Nov 13, 2024 · control 56-AS-20240308082752

Allegation investigated: Facility provided information to an unauthorized representative

Licensing Program Analyst, (LPA) Yolanda Delgado arrived unannounced at the facility to conclude an investigation for the above allegation. LPA Delgado met with Leofel Capulong and explained the purpose of the visit. During the course of the investigation, LPA conducted interviews with Administrator, staff, and additional witnesses. LPA also conducted a review of pertinent documentation. LPA was unable to interview Resident #1 (R1) due to R1 passing away on March 17, 2024. On October 8, 2024, Community Care Licensing received a complaint alleging that facility provided information to an unauthorized representative. It was reported that documentation pertaining to R1 was requested and R1’s and additional residents’ medical history was provided. It was alleged that Resident’s Power of Attorney, (POA) provided a written request to the facility in order to obtain R1’s (Continued on Page 2) Substantiated (Continued from Page 1) records on March 7, and March 10, 2024. Information obtained from Administrator indicated the request for records was sent on June 4, and June 6, 2024. LPA observed documentation that indicated records were sent to the requestor on May 30, 2024 and included information for Residents #2 (R2), Resident #3 (R3) and Resident #4 (R4), which the requestor was not authorized to receive. Administrator admitted that R2, R3, and R4’s confidential information was sent to the requestor and also corroborated that the requestor was not an authorized party to receive the documentation. Title 22 regulations state personal information shall remain confidential and to approve their release, except as authorized by law. This is a violation to the health and safety and or personal rights of clients in care. Therefore, based on observations and interviews, the allegation that facility provided information to an unauthorized representative is SUBSTANTIATED. The facility will be cited for Title 22, Division 6, Chapter 8, Article 08, Section 87468.2 (a)(2). An exit interview was conducted where this report, 9099-D, and appeal rights were discussed. Copies of the documents were provided to House Manager.the state’s words, verbatim · CDSS document, Nov 13, 2024 · control 56-AS-20241008134008

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(2) · Plan of correction due date: Nov 20, 2024

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law. This requirement was not being met as evidenced by: R2, R3, R4's information was given to R1's representative whom is not a legal repesentative of R2, R3, and R4. This poses a potential health and safety risk.the state’s words, verbatim · CDSS document, Nov 13, 2024

Plan of correction: Licensee will ensure each document for a resident that is requested that it will be sent to the legal representative and conduct a secondary check prior to sending requests with management. Licensee will review regulation and email LPA a self-certifying statement of understanding and compliance of the regulation by POC due date.

Type of visit: Required - 1 Year

On 04/15/2024 at 01:15 PM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with a staff and was granted entry to the facility. Administrator Paul Krause was contacted and arrived during the visit. At the time of the visit there were two (2) staff present, and five (five) residents present. The facility is a five (5) bedroom, two (2) bathroom home with a kitchen/dining area, living room, garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) non-ambulatory residents, of which one (1) may be bedridden and approved for two (2) hospice waiver. The current census is five (5) residents. LPA Brown was accompanied by Staff #2 (S2) 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 Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA Brown 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 Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperatures in the bathroom to be at 130 degrees Fahrenheit. Deficiencies will be issued. Administrator regulated the hot water to 119 degrees Fahrenheit during the visit. 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 CCLD complaint poster, Ombudsman poster, were posted in a common area. ***Continuation in LIC809C *** 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. However, LPA Brown observed two (2) residents with half bedrail but per documents review, no written order from physician indicating the need for postural support - bedrail for mobility in the two (2) residents facility file. Deficiency will be issued. Also, LPA Brown observed one (1) resident with full bed rail but not on hospice and per documents review, no approved exception on file. Deficiency will be issued. LPA Brown observed no Emergency Disaster Plan at the facility. Deficiency will be issued. LPA Brown did not observed Fire Drill or Earthquake Drill conducted at the facility. Deficiency will be issued.There is a Medicine Cabinet for the residents with the resident’s medications locked. LPA Brown observed the complete first aid kit and first aid book at the facility. 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 an Administrator present in the facility with appropriate and enough hours to appropriately manage the facility. The facility has sufficient number of staff to provide care and supervision to the residents in care. Record Review: LPA Brown reviewed four (4) resident files for admission agreements, updated physician reports, pre-placement appraisals. LPA Brown observed one (1) resident Admission Agreement was not signed by the Licensee. Deficiency will be issued. LPA Brown observed no Personnel Records available during the visit. Deficiency will be issued. In addition, Administrator Krause reported to LPA Brown that staff records were maintained at the other facility. Deficiency will be issued. Moreover, LPA Brown observed Staff #3 (S3) working at the facility without criminal background clearance and S3 reported to LPA Brown that S3 has been working at the faciity since 12/2023. Deficiency will be issued. Also, LPA Brown observed Staff #1 (S1) working at the facility with criminal background clearance but criminal background clearance was not transferred to the facility. Deficiency will be issued and Civil Penalties were assessed during the facility visit with the amount of $500.00 and will continue to be assessed of $100.00 per day per citation until corrected for failure to obtain criminal record clearance for S3 and for not transferring S1 criminal background clearance to the facility. ***Continuation in LIC809C *** LPA Brown interviewed Staff #2 (S2) and S2 reported no Dementia training was provided to staffs at the facility. Deficiency will be issued. Medications/electronic Medication Administration Record (MAR) were audited, and LPA Brown observed no issue. Based on the observations made during today’s visit, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809), LIC809D, LIC9102 forms, LIC421BG and Appeal Rights were discussed and provided to Administrator Paul Krause.the state’s words, verbatim · CDSS document, Apr 15, 2024

The state marks this report as 98 pages; the online copy we transcribed has 10. You can request the full file from the county licensing office.