Green Acres Manor

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Isabel Melanson arrived later, Administrator Certificate 7024381740 expires 2/8/27. At approximately 9:30am LPA toured the building and grounds. Facility currently has twelve (12) residents, two (2) of which are on hospice. LPA observed food stored in a safe manner with all open items covered. However, facility did not have at least a 2 day supply of perishable and 7 day supply of non-perishable food sufficient for 12 residents (deficiency cited, see 809D). Kitchen area is accessible only by half door. Kitchen drawer with sharp knives locked. Laundry room in long hall has cabinet that stores some cleaning solutions and toxins. Additionally, facility has cleaning supplies located in locked closet. Administrator joined LPA on tour of building and grounds after arriving. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperatures in sinks accessible to residents in care measured at 118.3 degrees F in room #11, 110.5 degrees F in room #10, 115.5 degrees F in room #8, 107.3 degrees F in long hall bathroom, 124.2 degrees F in bath next to room #2, and 124.7 in main shower room sink but 104.1 degrees F in main shower room shower head, 147.7 degrees F in room #3 and 149.5 degrees F in room #5. Water temperatures are therefore both over and under the allowable range of 105 to 120 degrees F (deficiency cited, see 809D). Fan switch in main shower room malfunctioning as it will not stay in the on position (deficiency cleared, see 809D). Continued on 809C... Continued from 809... Fire extinguishers were last inspected 12/9/26. Smoke/Carbon Monoxide detectors located throughout the facility are serviced by vendor, last serviced 3/13/26. Fire disaster drill conducted February 2026. Facility has a backup generator for use during a power outage. Facility has a back cottage that was previously utilized as an office and indicated as such on current facility sketch. Back cottage is now utilized as a live-in staff room. Area designated as RV parking/garage on current facility sketch is also being utilized as a live-in staff room in which two (2) staff members sleep and reside (deficiency cited, see 809D). Facility recently changed ownership; new owner is applying for licensure. Applicant present at facility during today's inspection. LPA and applicant discussed ensuring facility sketch is up to date and that no one occupies spaces not designated for living until fire clearance is granted. At approximately 12:30pm LPA conducted review of five [5] staff records. All required documentation present. Staff S1 and S2 did not have TB clearance on file (deficiency cited, see 809D). At approximately 1:30pm LPA conducted a review of six [6] resident records. Residents R1, R2, and R3 did not have current physician reports on file (deficiency cited, see 809D). At approximately 2:30pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in locked room. No deficiencies. LPA, Admin, and applicant discussed ensuring PRN MAR records resident outcomes. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report, LIC308- Designation of Responsibility, and Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Jun 29, 2026

Type of visit: POC

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced to conduct a POC visit. LPA met with caregiver. Administrator was not at facility but was available by phone. Licensee applicant Bana Solomon was present at facility and Admin gave applicant permission to sign report. Additionally, licensee applicant discussed many questions regarding regulations with LPA. On 8/12/25 LPA visited to facility to conduct a Plan of correction (POC) follow up visit. LPA tested water, water measured at 148.3 degrees F in long hall main bathroom, LPA measured temperature of water coming out of the shower head in the same bathroom and water measured at 100.8 degrees F. Additionally, water measured at 90.8 in jack and jill style bathroom for rooms #9/10, at 118.4 degrees F in long hall bath, and 123.6 degrees F in room #2. LPA and Admin discussed water temperatures. Admin was to work with licensee to get water temperature within regulation. Facility was to either repair or replace water heater(s); Admin will advise LPA of plan to replace or repair after discussing with licensee. As of today, the water heater has been repaired and LPA tested water temperatures in the same rooms as tested on 8/12/25. Water temperatures read:113.7 degrees F in long hall large showering bathroom, LPA measured temperature of water coming out of the shower head in the same bathroom and water measured at 98.5 degrees F. Additionally, water measured at 103.1 in jack and jill style bathroom in rooms #9/10, at 103.4 degrees F in long hall small bath, and 125.6 degrees F in room #2. All but one water temperature measured outside of the allowable range of 105 to 120 degrees F. Deficiency of regulation 87303(e )(2) is being recited today (deficiency cited, see 809D). Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Licensee Applicant and a copy of this report was given.the state’s words, verbatim · CDSS document, Mar 5, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(e)(2) · Plan of correction due date: Mar 19, 2026

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care...shall deliver hot water...of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). Based on LPA observation, the licensee did not comply with the section cited above in that water temperatures in sinks accessible to residents in care measured at 103.1 degrees F in room #9/#10, 125.6 degrees F in room #2 but measured at 98.5 degrees F in shower faucet in long hall bathroom next to kitchen, and 103.4 in smaller long hall bathroom, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 5, 2026

Plan of correction: Facility to submit 3 day water temperature log for sinks in facility showing temperature within 105-120 degrees F by plan of correction due date. Log to be accompanied by pictures of thermometer in running water with temperature reading visible in picture.

Type of visit: POC

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced to conduct a Case Management. LPA met with Administrator (Admin) Isabel Melanson. On Wednesday 7/30/25 Admin provided LPA detailed updates outlining the current status of plans of corrections issued for deficiencies identified 7/10/25 at Annual Inspection, all plans of corrections were due 7/31/25. Administrator advised LPA pertaining to: Deficiency 87303(a) Our range/stove has been repaired. The hinges were replaced on the oven door and it now seals correctly. The ignitors and wiring connected to the ignitors were replaced on both the burners requiring repairs and both burners and now fully functional. Today, LPA tested range stove during visit and found it to be operational and functioning. LPA observed oven door to close properly. Also, portion of carpet in long main hall that was a potential tripping hazard has been removed and replaced with wood-like flooring. Flooring does not appear to present as a tripping hazard. Administrator advised LPA pertaining to: Deficiency 87303(e)(2). Plumbing vendor came out to address our water temperature issues. They found that there had been a timer set that had been controlling the output of Continued on 809C... Continued from 809... hot and cold water flow throughout the house. The plumber turned off the timer and that seemed to correct the issue. Water temps seem to be staying in the required levels following the timer being turned off. The plumber said he did not find anything "wrong" or "broken" with any of the 4 water heaters. He did recommend replacing our main water heater with a commercial sized one due to the amount of use our hot water gets. Today, LPA tested water, water measured at 148.3 degrees F in long hall main bathroom, LPA measured temperature of water coming out of the shower head in the same bathroom and water measured at 100.8 degrees F. Additionally, water measured at 90.8 in jack and jill style bathroom for rooms #9/10, at 118.4 degrees F in long hall bath, and 123.6 degrees F in room #2. LPA and Admin discussed water temperatures. Admin will work with licensee to get water temperature within regulation. Admin agreed to post caution signs above facility sinks accessible to residents indicating that water may be hotter than 125 degrees F. Facility will either repair or replace water heater(s); Admin will advise LPA of plan to replace or repair after discussing with licensee. LPA will return once repairs/replacement is complete to test water. Administrator advised LPA pertaining to: Deficiency 87555(b)(20). We have ordered a vent for the kitchen as well as scheduled the installation for the vent for Wednesday August 6th at 8AM. Today, LPA observed presence of kitchen vent. Vent is operational and functioning. Administrator advised LPA pertaining to: Deficiency 87309(a). Our handyman was able to repair the cabinet in the laundry room so that the door locks correctly. He will also be repairing our carpet in the long hall way Continued on 809C(2)... Continued form 809c... tomorrow. Once that is completed, I will forward the invoice to you as well as some pics of the repaired carpet. Today, LPA inspected laundry room cabinet and found its locking feature to be operational and functioning. LPA confirms that all plans of correction have been satisfied, except 87303(e)(2) for the water temperature. Upon LPA return to SRRO, deficiency clearance letters will be issued to facility. LPA will return at later date to test the water temperature(s). No deficiencies cited. Exit interview conducted with Admin and a copy of this report was given.the state’s words, verbatim · CDSS document, Aug 12, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Isabel Melanson arrived later, Administrator Certificate 7024381740 expires 2/8/27. At approximately 9:45am LPA toured the building and grounds. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Kitchen area is accessible only by half door. Kitchen drawer with sharp knives locked. Kitchen range/stove has a broken oven door such that it does not close properly and range burners are clogged such that the burners do not operate properly (deficiency cited, see 809D). Kitchen range does not have overhead vent or ventilation system. Kitchen does have cathedral style window with vent on the side, but vent does not have functional operation switch (deficiency cited, see 809D). Carpet just outside of kitchen at entrance to the long hall is heavily soiled and has a wearing hole that has grown in size and presents as a tripping hazard (deficiency cited, see 809D). Laundry room in long hall has cabinet that stores cleaning solutions and toxins; however, cabinet framing is heavily worn down such that the locking feature does not always securely lock, leaving toxins accessible to residents (deficiency cited, see 809D) All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperatures in sinks accessible to residents in care measured at 128.4 degrees F in room #12 and 124.7 degrees F in room #15 but measured 94.3 degrees F in jack and jill style bath in room #9/#10 and 87.8 degrees F in main bathroom next to kitchen. Water temperatures are therefore both over and under the allowable range of 105 to 120 degrees F (deficiency cited, see 809D). Continued on 809C... Continued from 809... At approximately 12:00pm LPA conducted a review of six [6] resident records. All required documentation present. Resident (R1) had bedridden status on their physician's report however Admin assessed R1 in wheelchair and questions bedridden status. LPA advised of regulation for bedridden residents and advised to notify local fire department of bedridden status, but that they can also contact the physician to correct the physician's report. Admin agreed to both and will report back to LPA the findings of the doctor and fire department. Admin will also provide LPA with proof of notification to fire department. LPA advised Admin if fire clearance is granted for bedridden residents, staff will need to receive training per regulation 87606 and facility must meet all other requirements of regulation 87606 as well as Health and Safety Code 1569.72, respectively. At approximately 1:30pm LPA conducted review of five [5] staff records. All required documentation present. At approximately 2:30pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in locked cabinets. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Jul 10, 2025

The state marks this report as 9 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Allegation investigated: Staff did not keep the facility free of ants

Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to open an investigation into the above allegation. Administrator was not available to come to the facility but was available by phone and allowed for caregiver to sign reports. Complaint alleges facility not free of ants. LPA observed ants present in resident bathroom in facility. The ants were observed to be coming out of the sink itself and crawling up toward the light switch. Per staff interview, facility is aware of ants, has ant baits in place and they are changed out every two weeks and Terminix comes every 4-6 months. Per Title 22, regualtion 87303(a) The facility shall be clean, safe, sanitary and in good repair at all times. Based on LPA's observations, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D. Substantiatedthe state’s words, verbatim · CDSS document, Aug 9, 2024 · control 21-AS-20240802083205

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 23, 2024

87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met by licensee as evidenced by: Based on LPA observation ants present in resident room in facility, which poses a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 9, 2024

Plan of correction: Facility to submit service work order from pest control company along with paid invoice by plan of correction due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by caregiver. Administrator Isabel Melanson arrived later at approximately 10:00am. Facility contact information was reviewed. At approximately 9:30am LPA and caregiver toured the building and grounds. Admin joined tour at approximately 10:00am. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. The following observations were made of food stored in pantry: tomatoes in bin had black spots, white film, and bluish greenish fuzzy film surrounded by white substance. Storage bin containing canned good had sticky brown film and brown substance with orange film on some cans. Open ziploc bag of lentils, lentils spiling out into bin. Macaroni and cheese box with best when used by date of 3/20/2023 (deficiency cited, see 809D). Kitchen had block of knives open and accessible when half door to kitchen is left open. LPA observed on three occasions during inspection that half door to kitchen was left unlocked, making knives accessible to residents in care (deficiency cited, see 809D). Per LPA conversation with Admin, Admin to move sharp knives to locked drawer. LPA and caregiver observed broken cabinet lock in long hall laundry room, cabinet contained toxins and cleaning supplies. Admin advised LPA that the broken lock is scheduled to be replaced by repairman and laundry room door remains locked at all times. All bedrooms were equipped with lighting, night stand, and chest of drawers. However, R1 in room #10 did not have bed present. R1's pre-appraisal, care plan, and physician's report did not note a preference or an approval for not having a bed (deficiency cited, see 809D). All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mat and grab bars. Water temperature in sinks accessible to residents in care measured at 121.3 degrees F in long hall bathroom (next to room #6), 119.3 degrees F in room #12, 118.7 degrees F in room #11, 118.5 degrees F in room #10, 114.7 degrees F in room #3, and 117.4 in the main bathroom, degrees F all which are within the allowable range of 105 to 120 degrees F except for in the bathroom next to room #6. Admin turned down water heater slightly to bring temperature down to below 120 degrees F. Continued on 809C... Continued from 809... Four [4] out of [4] fire extinguishers were last inspected 12/7/2023. Smoke/Carbon Monoxide detectors located throughout the facility are serviced by vendor, last serviced 2/19/2024. Per Admin, fire disaster drill conducted last month. However, no documentation of drill conducted was available. LPA confirmed with staff that fire drill was conducted. Admin will keep record of drill documentation going forward. Facility has a backup generator for use during a power outage. At approximately 11:30am LPA conducted review of 5 staff records. S1, S2, and S3 do not have current 1st Aid/CPR certifications on file (deficiency cited, see 809D). S4 did not have TB clearance on file (deficiency cited, see 809D). S2, S3, and S5 did not have current annual training (deficiency cited, see 809D). At approximately 1:30pm LPA conducted a review of 5 resident records. All required documentation present. At approximately 2:30pm LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies Isabel Melanson Administrator Certificate 7024381740 expires 2/8/2025. LPA and Administrator discussed facility's Infection Control Plan and Emergency Disaster plan. No new updates. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report Liability Insurance Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Admin. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was giventhe state’s words, verbatim · CDSS document, Jun 20, 2024

The state marks this report as 11 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.