Green Merrylands

Type of visit: Required - 1 Year

On 01/21/2026, Licensing Program Analysts (LPAs) Beena Singh and Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs met with staff/care giver Titus Irangus and was granted entry to the facility. At the time of the visit there were one (1) staff present, and three (3) residents present. LPA Singh explained the purpose of the visit to staff/care giver Titus Irangus. The facility is a five (5) bedroom, two (2) bathroom home with a kitchen/dining area, living room, laundry area and garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be non-ambulatory residents. The facility has two (2) Hospice Waiver. The current census is four (4) residents. LPA was accompanied by staff/care giver Titus Irangus 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). LPA observed no obstructions to indoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPAs inspected resident bedrooms; they are equipped with required furniture such as: mattresses, and storage space, lamps and chairs and sufficient lighting in the bedrooms. During the walk through, LPAs observed kitchen cabinet to be in despair. In addition, LPAs also observed no working lights in the laundry room. While inspecting facility garage LPAs observed a leakage coming from the water filter LPAs observed mold on the wall due to the leakage. LPAs will issue deficiency. Moreover, LPAs observed that bathrooms were clean, and appliances were operating appropriately. LPAs observed grab bars and non-skid mat in the resident bathrooms. ***Continuation in LIC809C *** LPAs observed night-lights maintained in hallways and passages to non private bathrooms. LPsA observed the outdoor passageways free of obstructions. LPAs observed sufficient furniture and lighting throughout the facility. LPAs measured and observed the water temperature in the bathroom to be at 110 degrees Fahrenheit. The facility is equipped and working with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster and the Emergency Disaster plan were posted in a common area. There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked in the medication cabinet. Food Service: Seven (7) days non-perishable and three (3) days perishable food supply observed at the facility. Care & Supervision: LPAs observed one staff sufficient number of staff to provide care and supervision to the residents in care. LPAs observed Emergency supplies in one of the cabinets. LPA observed first aid kit and first aid manual at the facility. Record Review: LPAs reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPAs reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings with tuberculosis (TB) test results. LPAs observed on-the-job training provided and documented Residential Care for the Elderly (RCFE) and Dementia, Postural Supports, Hospice Care training. LPAs observed no issues. LPAs audited Medication administration Record system (MARS) matched with medication administrated to the residents. LPAs observed there were activity program for the residents at the facility.Fire drill conducted on 12/1/2025.Liability Insurance valid through 03/28/2025 to 03/28/2026.License fee is current 1/21/2026. Deficiencies were cited during today's visit. An exit interview was conducted where this report, LIC809, LIC809C, 809D and Appeal Rights were discussed and provided via email to Licensee-Sandy Zhao due to technical issues during this visit..the state’s words, verbatim · CDSS document, Jan 21, 2026

Allegation investigated: Staff do not maintain the facility free of odors. Staff do not maintain facility floors free from slipping hazards.

On 12/11/2025 at 8:45 AM, Licensing Program Analyst (LPA) Beena Singh conducted an unannounced visit to the facility to deliver findings on a complaint alleging neglect/lack of supervision. LPA Singh met with Facility Administrator/Staff Brandon Marquez, facility representative, and was granted entry into the facility. The investigation conducted by LPA Singh consisted of interviews and review of pertinent records. Regarding the First Allegation: - Staff do not maintain the facility free of odors. Interviews with RP, Staff, resident and LPAs observation determined that Licensee/Staff do not maintain the facility free of odors. LPA Singh smelled the stench in the facility and from rooms when entered the facility on 11/20/2025 and 12/11/2025. Therefore, the allegation that Licensee/Staff do not maintain the facility free of odors has been Substantiated. Substantiated Third Allegation: - Staff do not maintain facility floors free from slipping hazards. The Licensed Program Analyst (LPA) Singh conducted interviews with the Responsible Person (RP), staff, a resident, and observed the facility, determining that staff did not maintain facility free from slipping hazards. LPA Singh specifically observed a trail of damp, streaky marks on the floor, which were presumed to have been left by a wet wipe/mop immediately before the LPA entered the facility. These marks extended from the bathroom, across the hallway, and into a bedroom. Further evidence of this hazard was noted by the presence of wet wipe marks on the bathroom floor during the facility tour. Therefore, the allegation that Licensee/Staff do not maintain facility floors free from slipping hazards has been Substantiated. Based on Investigation observations, interviews which were conducted and records review, the preponderance of evidence standard has not been met. Therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division & Chapter number) are being cited on the attached LIC 9099D). A civil penalty for a violation has been assessed in the amount of $2,200 in total. An exit interview was conducted, and this report (LIC809) LIC 809C, LIC809D, LIC 421BG(7/17) and Appeal Rights were discussed and copies were provided to Facility administrator /Staff Brandon Marquez. Fourth Allegation: - Staff do not ensure resident's incontinence care needs are met. Interviews with RP, Staff, resident and LPAs observation determined that Staff do not ensure resident's incontinence care needs are met. During the interviews with resident, resident stated their Staff ensures resident's incontinence care needs are met Therefore, the allegation that Staff do not ensure resident's incontinence care needs are met has been Unsubstantiated. In conclusion, based on all the evidence obtained during the investigation, it was determined that Staff do not maintain the facility free of odors. Interviews with RP, Staff, resident and LPAs observation determined that Staff do ensure resident's incontinence care needs are met. Therefore, the allegation that Staff do not maintain the facility kitchen clean and staff do not ensure resident's incontinence care needs are not met are Unsubstantiated. Based on the evidence found during the investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation 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, deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC809) LIC 809C were discussed and provided to Facility Administrator/Staff Brandon Marquez.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 56-AS-20251118093502

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a)(1) · Plan of correction due date: Dec 12, 2025

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.(1) Floor surfaces in bath, laundry and kitchen and facility areas shall be maintained in a clean, sanitary, and odorless condition. Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that floor surfaces in bath, and facility areas shall be maintained in a clean, sanitary, and odorless condition. which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 11, 2025

Plan of correction: Licensee will ensure facility is clean,sanitary and in odorless condition for residents in care by deep cleaning/sanitizing the facility done by POC due date and evidence to be sent to LPA Singh via email by the Plan of Correction(POC) due date 12/12/2025.

Allegation investigated: Staff neglect resulted in resident sustaining stage three pressure ulcer.

Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Caregiver Alexia Portillo and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records. First allegation: Staff neglect resulted in resident sustaining stage three pressure ulcer. Regarding the allegation stated above LPA conducted a review of records pertaining to Resident #1 during the review of records LPA discovered that on 7/14/2023 Resident #1 was admitted to Green Merrylands, during further review LPA discovered that on R#1 Physicians Report under physical status R#1 did not have any indication or history of skin condition or skin breaks. In addition, during further review LPA discovered that on R#1 Pre-Appraisal information it lists that R#1 did not have skin breakdown, wound or sores noted, Pre-Appraisal only indicated that R#1 only had redness on bottom due to pressure. Furthermore, weekly skin check documentation indicated that R#1 did not have any skin breakdown, wounds, or sores. During review LPA discovered that on 9/18/2023 R#1 was relocated and admitted to a new facility. Substantiated During review of record where R#1 was admitted demonstrated that R#1 arrived at the facility with pressure sores on legs and back. Local hospital listed Resident #1 pressure injury to be at a stage 3 injury appearance. Based on the evidence gathered during the investigation, the above allegation is Substantiated. Substantiated A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Personnel Requirements – General 87411 (a), from division 6, chapter, article 6, is being cited on the attached LIC 9099 D. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights to Facility Caregiver. ***In addition*** An immediate civil penalty is assessed for $500.00, per Health and Safety Code 1548 (c). In addition, an additional review is being conducted and additional civil penalty may be imposed per Health and Safety Code 1569.49 (f). Exit interview conducted and copy of report provided to Facility Caregiver Alexia Portillo Staff #1 informed LPA that staff is unaware if refund was given to R#1 responsible party. LPA attempted to contact R#1 reporting party, however, was unsuccessful. LPA observed that other attempts to contact R#1 responsible party were made however, no calls were answered or returned. Third allegation: Staff obstructed resident relocation by not permitting the removal of resident's belongings. Regarding the allegation stated above LPA conducted an interview with Staff #1 regarding the allegation S#1 informed LPA that belongings were not withheld and were given to R#1 responsible party. In addition, Staff #1 informed LPA that Resident #1 responsible party had arrived with Law Enforcement to the facility and not because the facility was refusing to release R#1 personal belongings. LPA attempted to contact Resident #1 reporting party however, calls were not answered or returned. Based on lack of evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated. Unsubstantiated: meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Caregiver Alexia Portillo at the end of the visit.the state’s words, verbatim · CDSS document, Aug 13, 2025 · control 56-AS-20240213155615

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Aug 14, 2025

Personnel Requirements – General.... (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement was not met as evidenced by: Facility staff failed to seek a higher level of care for R1’s pressure injurie[s] which multiplied while in care. The facility staff failed to inquire, assess the number, and seriousness of the pressure ulcers to determine if the level of care being provided to R1 was adequate, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 13, 2025

Plan of correction: The Licensee shall ensure that Personnel Requirements are met daily. Staff shall always ensure that residents are receiving care to meet their needs. If a resident need cannot be met, then a higher level of care may be needed. Hospice care shall not relieve staff of their duties. Proof of understanding shall be provided, and emailed to LPA by POC date 8/14/2025.

Type of visit: Required - 1 Year

On 03/25/25 at 08:43 AM, Licensing Program Analyst (LPA) Beena Singh made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Singh met with a staff and was granted entry to the facility. At the time of the visit there were two (2) staff present, and four (4) residents present. LPA Singh explained the purpose of the visit to staff/care giver Karim Ibarra Morales. Administrator Marquez has been contacted and arrived during the visit. The facility is a five (5) bedroom, two (2) bathroom home with a kitchen/dining area, living room, laundry area and garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be non-ambulatory residents. The facility has two (2) Hospice Waiver. The current census is four (4) residents. LPA was accompanied by Administrator Brandon Marquez-Gutierrez 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). LPA observed no obstructions to indoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, and storage space, lamps and chairs and sufficient lighting in the bedrooms. Moreover, LPA observed that bathrooms were clean, and appliances were operating appropriately. LPA observed grab bars and non-skid mat in the resident bathrooms. ***Continuation in LIC809C *** LPA observed night-lights maintained in hallways and passages to non private bathrooms. LPA observed the outdoor passageways free of obstructions. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperature in the bathroom to be at 110 degrees Fahrenheit. The facility is equipped and working with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster and the Emergency Disaster plan were posted in a common area. There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked in the medication cabinet. Food Service: Seven (7) days non-perishable and three (3) days perishable food supply observed at the facility. Care & Supervision: LPA observed sufficient number of staff to provide care and supervision to the residents in care and staff scheduled to work at night as required for facility with dementia residents. LPA observed Emergency supplies in one of the cabinets. LPA observed first aid kit and first aid manual at the facility. Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPA reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings with tuberculosis (TB) test results. LPA observed on-the-job training provided and documented Residential Care for the Elderly (RCFE) and Dementia, Postural Supports, Hospice Care training. LPA Singh observed no issues. LPA singh audited Medication administration Record system (MARS) matched with medication administrated to the residents. LPA observed there were activity program for the residents at the facility. No deficiencies were cited during today's visit. An exit interview was conducted where this report, LIC809, LIC809C were discussed and provided to Administrator Brandon Marquez.the state’s words, verbatim · CDSS document, Mar 25, 2025

Type of visit: Case Management - Other

On 08/08/2024 at 10:00AM, Licensing Program Analysts (LPAs) Melody Brown and Becky Mann met with Vicente PIcache Arambula to initiate a Case Management and issue additional Civil Penalty for the Annual Comprehensive Inspection conducted on 08/07/2024. Per records review, the facility were cited for the same regulations within 12-month period for California Code of Regulation (CCR) 87411(d), CCR 87470(c), civil penalty will be issued today, 08/08/2024 with the amount of $250.00 per repeat violation within 12 -month period. In addition, LPAs Brown and Mann amended the report issued on 08/07/2024 and issued new form Immediate Civil Penalty - Repeat Violation (LIC421IM) with the amount of $1,000.00 for HSC Section 1569.618(a), third offense within 12-month period. An exit an interview was conducted, where this report, LIC809, amended copy of LIC809C and LIC809D LIC421FC, LIC421IM and Appeal Rights were discussed and provided to Vicente Picache Arambula.the state’s words, verbatim · CDSS document, Aug 8, 2024

Type of visit: Required - 1 Year

On 08/07/2024 at 08:45 AM, 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. At the time of the visit there were two (2) staff present, and five (5) residents present. Vicente Picache Arambula reported to LPA Brown that Administrator Brandon Marquez was not at the facility. LPA Brown contacted Administrator Marquez and informed of the visit but call was not answered. LPA Brown explained the purpose of the visit to Vicente Picache Arambula. The facility is a five (5) bedroom, two (2) bathroom home with a kitchen/dining area, living room, laundry area and garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be non-ambulatory residents. The facility has two (2) Hospice Waiver. The current census is five (5) residents. LPA Brown was accompanied by Vicente Picache Arambula 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). LPA Brown observed no obstructions to indoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, and storage space. However, LPA Brown did not observed lamps and chairs. Technical Violation issued. Also, LPA Brown observed sufficient lightning. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms. Furthermore, during the tour of the facility, LPA Brown was denied access of the Administrator Office for spot inspection. Deficiency will be issued. LPA Brown observed movable bins used for storage of solid wastes outside the facility in disrepair. Deficiency will be issued.LPA Brown observed movable bins used for storing or transporting solid wastes from the premises does not have cover inside the facility. Deficiency will be issued. LPA Brown observed no chair and lamp on all resident bedrooms. Technical Violation will be issued. ***Continuation in LIC809C *** Incomplete Emergency Kit observed at the facility. Deficiency will be issued. LPA Brown observed no first aid manual approved by the American Red Cross, The American Medical Association or a state or federal health agency. Deficiency will be issued. Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPA Brown observed that Resident #2 (R2) and Resident #3 (R3) Admission Agreement do not have facility representative signature. Deficiency will be issued. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA Brown observed that no on-the-job training provided for Staff #2 (S2), Staff #3 (S3) and Staff #4 (S4), also, no documented Residential Care for the Elderly (RCFE) and Dementia, Postural Supports, Hospice Care trainings for S3 and S4. Deficiencies will be issued. During medication audit, LPA Brown observed that one (1) of R3's medication was given to R3 but per Medication Administration Records (MAR) review, it does not show that R3's medication was given per physician's direction. Also, LPA Brown observed one (1) of R3's medication was not given to R3 due to no refill available at the facility since 08/03/2024, two (2) of R3's medication were not given to R3 due to no refill at the facility since 08/04/2024 and one (1) medication was not given to R3 due to no refill at the facility since 08/06/2024. Deficiency will be issued. LPA Brown observed no activity program for the residents at the facility. Defiency will be issued. In addition, LPA Brown observed that no Administrator present at the facility during working hours as required and LPA Brown contacted Administrator Marquez and Licensee Zhao. Deficiency will be issued. Deficiency will be issued. Per records review, the facility were cited for the same regulations within 12-month period for CCR 87309(a)(1) and 87608(a)(5)(B) civil penalty will be issued today, 08/07/2024 with the amount of $250.00 per repeat violation. Also, the facility will be issued immediate civil penalty for repeat violation of $1000.00 for HSC Section 1569.618(a) for third offense within 12-month period. An exit interview was conducted where this report, LIC809, LIC809D, LIC421FC, LIC421IM, LIC9102TV, LIC9102, and Appeal Rights were discussed and provided to Vicente Picache Arambula. ***This is an amended copy of LIC809C issued on 08/07/2024*** LPA Brown observed no nightlight maintained in hallways and passages to nonprivate bathrooms. Deficiency will be issued. LPA Brown observed the outdoor passageways not free of obstructions. Deficiency will be issued. To add to that, LPA Brown observed Resident #1 (R1) with full bed rails and Vicente Picache Arambula reported to LPA Brown that R1 is not on Hospice Care and per records review, no written order from R1's physician was observed indicating the need for postural support/full bed rail. Also, LPA Brown observed,no exception letter submitted and approved by Community Care Licensing Division (CCLD) for R1's full bed rail. Deficiency will be issued. To add to that, LPA Brown observed Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4) have half bed rails. Vicente Picache Arambula reported to LPA Brown that R2, R3, and R4 don’t have written order from their physician indicating the need for half bed rail for mobility. Deficiency will be issued. Moreover, during the tour of the facility, LPA Brown observed one (1) screw driver, two gallons of laundry detergent in the laundry area not locked and accessible to resident in care. Deficiency will be issued. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperature in the bathroom to be at 116 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster and the Emergency Disaster plan were posted in a common area. Furthermore, during the tour of the facility, LPA Brown observed broken screens, metal wires, carpets, boxes in an unlocked kitchen drawer, accessible to residents in care. Deficiency will be issued. There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked in the medication cabinet. Food Service: Seven (7) days non-perishable and three (3) days perishable food supply observed at the facility. Care & Supervision: The facility does not have an administrator present in the facility. LPA Brown observed no sufficient number of staff to provide care and supervision to the residents in care as no staff scheduled to work at night as required for facility with dementia residents. Deficiency will be issued. ***Continuation in LIC809C ***the state’s words, verbatim · CDSS document, Aug 7, 2024

The state marks this report as 61 pages; the online copy we transcribed has 15. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

On 07/24/2024 at 09:00 AM, 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 Administrator Brandon Marquez and was granted entry to the facility. At the time of the visit there were two (2) staff present, and five (5) residents present. During the visit, Administrator Brandon Marquez reported to LPA Brown that there are two (2) residents that tested positive for Covid-19 and are isolated. Also, one (1) resident who's out with family for the weekend tested positive as well for Covid-19. Therefore, total of three (3) resident tested positive for Covid-19 at the facility. LPA Brown informed Administrator Brandon Marquez that the required comprehensive annual inspection will be completed in a later time. An Exit interview was conducted where this report, LIC809 was discussed and provided to Administrator Brandon Marquez.the state’s words, verbatim · CDSS document, Jul 24, 2024

Type of visit: POC

On 03/13/2024 at 11:45 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility in order to verify clearance of plans of correction created with Licensee Sandy Zhao, from visit on 02/15/2024, 02/29/2024 and 03/06/2024. LPA Brown met with Administrator Brandon Marquez. Licensee Sandy Zhao was contacted and informed of the visit. The following Plan of Correction (POC)s were cleared at the time of the visit: The Licensee was cited on 02/29/2024 for 87355(e)(1) Criminal Record Clearance for allowing Staff #5 to work at the facility without criminal background clearance. Licensee continued to allow S5 to work at the facility without criminal background clearance. Based on observation on 02/29/2024 and 03/06/2024, Licensee continued to allow S5 to work at the facility without criminal background clearance. The plan of correction was to obtain S5 Criminal Record Clearance. On 03/08/2024, Licensee Sandy Zhao submitted Staff #5 (S5) Criminal Record Clearance granted on 03/07/2024. LPA Brown provided a clearance letter for this deficiency during the visit. The Licensee was cited on 02/15/2024 for 87309 Storage Space (a)(1). On 03/06/2024, Licensee Sandy Zhao submitted staff training on CCR 87309 Storage Space (a)(1). LPA Brown provided a clearance letter for this deficiency during the visit. The Licensee was cited on 02/15/2024 for 87506 Resident Records (e). On 03/06/2024, Licensee Sandy Zhao submitted staff training on CCR 87506 Resident Records (e). LPA Brown provided a clearance letter for this deficiency during the visit. The Licensee was cited on 02/15/2024 for 87608 Postural Supports (a)(5)(B). On 03/06/2024, Licensee Sandy Zhao submitted staff training on CCR 87608 Postural Support (a)(5)(B). LPA Brown provided a clearance letter for this deficiency during the visit. ***Continuation in LIC809C*** The Licensee was cited on 02/15/2024 for CCR 87224 Eviction Procedures (a). On 03/06/2024, Licensee Sandy Zhao submitted staff training on CCR 87224 Eviction Procedures (a). LPA Brown provided a clearance letter for this deficiency during the visit. The Licensee was cited on 02/29/2024 for HSC 1569.618 (a). On 03/06/2024, Licensee Sandy Zhao submitted signed Statement of Understanding on HSC 1569.618 (a). LPA Brown provided a clearance letter for this deficiency during the visit. An exit interview was conducted and this report, LIC809 was discussed and provided to Administrator Brandon Marquez.the state’s words, verbatim · CDSS document, Mar 13, 2024

Type of visit: POC

On 03/06/2024 at 12:45 PM, Licensing Program Analysts (LPAs) Melody Brown and Paola Guerrero conducted an unannounced visit to the home in order to verify clearance of plans of correction created with Licensee Sandy Zhao, from visit on 02/15/2024 and 02/29/2024. LPA Brown met with staff Jonathan Israel Guzman Pineda. Licensee Sandy Zhao was contacted and informed of the visit. The following deficiency were not cleared during the time of the visit: The Licensee was cited on 02/29/2024 for 87355(e)(1) Criminal Record Clearance for allowing Staff #5 to work at the facility without criminal background clearance. Licensee continued to allow S5 to work at the facility without criminal background clearance. Therefore Plan of Correction (POC) was not cleared at the time of the visit. Civil penalty will be assessed in the amount of $100 per day for six (6) days. The Licensee was cited on 02/15/2024 for 87309 Storage Space (a)(1). During today's visit and based on record review and interview, LPAs Brown and Guerrero observed that the licensee did not have staff training on site. Plan of Correction was to train all staff on CCR 87309(a)(1). Therefore, the POC was not cleared at the time of the visit. Civil penalty will be assessed in the amount of $100 per day for six (6) days. The Licensee was cited on 02/15/2024 for 87506 Resident Records (e). During today's visit and based on record review and interview, LPAs Brown and Guerrero observed that the licensee did not have staff training on site. Plan of Correction was to train all staff on CCR 87506(e). Therefore, the POC was not cleared at the time of the visit. Civil penalty will be assessed in the amount of $100 per day for six (6) days. The Licensee was cited on 02/15/2024 for 87608 Postural Supports (a)(5)(B). During today's visit and based on record review and interview, LPAs Brown and Guerrero observed that the licensee did not have staff training on site. Plan of Correction was to train all staff on CCR 87608(a)(5)(B). Therefore, the POC was not cleared at the time of the visit. Civil penalty will be assessed in the amount of $100 per day for six (6) days. ***Continuation on LIC809C *** The Licensee was cited on 02/15/2024 for 87224 Eviction Procedures (a). During today's visit and based on record review and interview, LPAs Brown and Guerrero observed that the licensee did not submit a self-certification letter that the regulation has been read and is understood. Therefore, the POC was not cleared at the time of the visit. Civil penalty will be assessed in the amount of $100 per day for six (6) days. An exit interview was conducted with staff Jonathan Israel Guzman Pineda 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 6, 2024

Type of visit: Case Management - Deficiencies

On 03/06/2024 at 12:45 PM, Licensing Program Analysts (LPAs) Melody Brown and Paola Guerrero, met with Staff Jonathan Israel Guzman Pineda to initiate Case Management Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation. LPAs Brown and GUerrero observed no Administrator present at the facility. S5 reported to LPAs Brown and GUerrero that the facility's Administrator's in Mexico for a family emergency. Deficiency will be issued. Per records review, the facility were cited for the same regulations within 12-month period and this would be the fouth (4th) offense for HSC 1569.618(a) and CCR 87355(e)(1), an immediate civil penalty will be issued today, 03/06/2024 with the amount of $1000.00 for third offense repeat violation within 12-month period for not having administrator present at the facility during working hours and $1000.00 for staff working at the facility without criminal background clearance, third offense. An exit interview was conducted where this report, LIC809, LIC809D, LIC421IM and Appeal Rights were discussed and provided to staff Jonathan Israel Guzman Pineda.the state’s words, verbatim · CDSS document, Mar 6, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.68(a) · Plan of correction due date: Mar 13, 2024

HSC 1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having an Administrator present during working hours at the facility which pose potential health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Mar 6, 2024

Plan of correction: Licensee stated to make sure there's an Administrator present at the facility during normal working hours and submit proof of staff schedule showing Administrator present at the facility during working hours to LPA Brown at Plan of Correction (POC) due date.

Type of visit: POC

On 02/29/2024 at 09:40 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the home in order to verify clearance of plans of correction created with Administrator Brandon Marquez, from visit on 02/15/2024. LPA Brown met with staff Jonathan Israel Guzman Pineda. Licensee Sandy Zhao was contacted and informed of the visit. The following Plan of Correction (POC)s were cleared at the time of the visit: The licensee was cited on 02/15/2024 for 87465 (a)(6) Incidental Medical and Dental Care. During today's visit and based on record review and interview, LPA Brown observed that the licensee did not have staff training on site. Plan of Correction was to train all staff on CCR 87465(a)(6) and submit proof of All Staff Training Log to LPA Brown at Plan of Correction (POC) due date on 02/16/2024. Therefore, the POC was not cleared until today's visit where Licensee Zhao submitted proof of staff Training to LPA Brown. Civil penalties will be assessed in the amount of $100 per day for thirteen (13) days. The LPA provided a clearance letter for this deficiency during the visit. The following deficiency were not cleared during the time of the visit: The Licensee was cited on 02/15/2024 for 87309 Storage Space (a)(1). During today's visit and based on record review and interview, LPA Brown observed that the licensee did not have staff training on site. Plan of Correction was to train all staff on CCR 87309(a)(1). 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 fourteen (14) days. The Licensee was cited on 02/15/2024 for 87506 Resident Records (e). During today's visit and based on record review and interview, LPA Brown observed that the licensee did not have staff training on site. Plan of Correction was to train all staff on CCR 87506(e). 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 seven (7) days. ***Continuation on LIC809C *** The Licensee was cited on 02/15/2024 for 87608 Postural Supports (a)(5)(B). During today's visit and based on record review and interview, LPA Brown observed that the licensee did not have staff training on site. Plan of Correction was to train all staff on CCR 87608(a)(5)(B). 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 seven (7) days. The Licensee was cited on 02/15/2024 for 87224 Eviction Procedures (a). During today's visit and based on record review and interview, LPA Brown observed that the licensee did not submit a self-certification letter that the regulation has been read and is understood. 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 seven (7) days. Moreover, the Licensee was cited on 01/22/2024 for HSC 1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (a) Based on observation, interview and records review, the Licensee did not have Administrator present during working hours at the facility. Licensee did not submit the required plan of correction on the due date on 01/29/2024. Deficiency will be issued with new due date during this visit on 02/29/2024 in form LIC809 - Deficiency as durimg today's visit, LPA Brown observed no Administrator present at the facility during working hours. An exit interview was conducted with staff Jonathan Israel Guzman Pineda where this report, LIC809 along with Civil Penalty Assessment pages, and Appeal Rights were reviewed and provided.the state’s words, verbatim · CDSS document, Feb 29, 2024

Type of visit: Case Management - Deficiencies

On 02/29/2024 at 09:40 AM, Licensing Program Analyst (LPA) Melody Brown, met with Staff Jonathan Israel Guzman Pineda to initiate Case Management Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation. Per documents review during the facility visit today, 02/29/2024, LPA Brown reviewed documents and interview staffs and observed that Staff #5 (S5) had been working at the facility since 02/20/2024 and per documents review, LPA Brown observed that S5 does not have criminal background clearance and S5 reported to LPA Brown that S5 started working at the facility on 02/20/2024. LPA Brown informed Licensee Zhao that deficiency will be issued and Civil Penalties were assessed during the facility visit today, 02/29/2024 with the amount of $1000.00 will be assessed for allowing S5 to work at the facility without criminal background clearance and will continue to be assessed of $100.00 per day per citation until corrected. Also, during today's visit, LPA Brown observed no Administrator present at the facility. S5 reported to LPA Brown that the facility's Administrator's out for vacation then later informed LPA Brown that Administrator was out for family emergency. Deficiency will be issued. Per records review, the facility were cited for the same regulations within 12-month period and this would be the third offense for HSC 1569.618(a) and CCR 87355(e)(1), an immediate civil penalty will be issued today, 02/29/2024 with the amount of $1000.00 for third offense repeat violation within 12-month period for not having administrator present at the facility during working hours and $1000.00 for staff working at the facility without criminal background clearance, third offense. An exit interview was conducted where this report, LIC809, LIC809D, 421BG, 421FC, LIC421IM and Appeal Rights were discussed and provided to staff Jonathan Israel Guzman Pineda.the state’s words, verbatim · CDSS document, Feb 29, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.618 · Plan of correction due date: Mar 8, 2024

HSC 1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having an Administrator present during working hours at the facility which pose potential health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: Licensee stated to submit Signed Statement of Understanding on HSC 1569.618 and submit to LPA Brown at POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Mar 1, 2024

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance... This requirement is not met as evidenced by: Based on observation and interview, the Licensee did not comply with the section cited above by not obtaining Staff #5 (S5) criminal record clearance before allowing S5 to work at the facility on 02/20/2024 which pose immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 29, 2024

Plan of correction: Licensee stated to not allow S5 to work at the facility without obtaining the required Criminal background clearance and submit copy of Staff Schedule and Personnel Summary Report (LIC500) to LPA Brown at Plan of Correction due date.

Type of visit: POC

On 02/15/2024, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the home in order to verify clearance of plans of correction created with Licensee, Sandy Zhao from visit on 01/22/2024. LPA Brown met with staff . The following Plan of Correction (POC)s were not cleared at the time of the visit: The Licensee was cited on 01/22/20224 for 87224 Eviction Procedures (a). Based on observation and interview, the Licensee refused to accept R1 back to the facility upon hospital discharge. Licensee did not submit the required plan of correction on the due date on 01/29/2024. Deficiency will be issued with new due date during this visit on 02/15/2024. The Licensee was cited on 01/22/2024 for 87465 Incidental Medical and Dental Care (a)(6). Based on observation, interviews and records review, Licensee did not update R3, R4 and R5 Medication Administration Record (MAR) after dispensing R3, R4 and R5 medications per their physician's order. Licensee did not submit the required plan of correction on the due date on 01/23/2024. Deficiency will be issued with new due date during this visit on 02/15/2024. The Licensee was cited on 01/22/2024 for 87309 Storage Space (a)(1). Based on observation, interview and records review, LIcensee did not lock the one (1) knife at the kitchen cabinet making it accessible to residents in care. Licensee did not submit the required plan of correction on the due date on 01/23/2024. Deficiency will be issued with new due date during this visit on 02/15/2024. The Licensee was cited on 01/22/2024 for 87303 Maintenance and Operation (a). Based on observation and interview, Licensee did not have the kitchen cabinet and laundry cabinet in good repair. Licensee did not submit the required plan of correction on the due date on 01/29/2024. Deficiency will be issued with new due date during this visit on 02/15/2024. *** Continuation on LIC809C *** The Licensee was cited on 01/22/2024 for HSC 1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (a) Based on observation, interview and records review, the Licensee did not have Administrator present during working hours at the facility. Licensee did not submit the required plan of correction on the due date on 01/29/2024. Deficiency will be issued with new due date during this visit on 02/15/2024. An exit interview was conducted where this report was discussed and provided to Administrator Brandon Marquez.the state’s words, verbatim · CDSS document, Feb 15, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(6) · Plan of correction due date: Feb 16, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care...(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observation, interviews and records review, the Licensee did not comply with the section cited above by not updating R3, R4 and R5 Medication Adminisitration Record (MAR) after dispensing R3, R4 and R5 medications per their physician's order which pose immediate health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Feb 15, 2024

Plan of correction: Licensee stated to train all staff on CCR 87465(a)(6) and submit proof of All Staff Training Log to LPA Brown at Plan of Correction (POC) due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a)(1) · Plan of correction due date: Feb 16, 2024

87309 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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. Based on observation, interview and records review, the LIcensee did not comply with the section cited above by not locking the one (1) knife at the kitchen cabinet making it accessible to residents in care which pose immediate health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Feb 15, 2024

Plan of correction: Licensee stated to train all staff on CCR 87309(a)(1) and submit proof of Staff Training Log to LPA Brown at POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e) · Plan of correction due date: Feb 23, 2024

87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having Resident #1 (R1) record at the facility which poses potential health, safety and personal rights risks to resident in care.the state’s words, verbatim · CDSS document, Feb 15, 2024

Plan of correction: Licensee stated to train all staff on CCR 87506(e) and submit proof of Staff Training Log to LPA Brown at Plan of Correction (POC) due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(5)(B) · Plan of correction due date: Feb 23, 2024

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by allowing Resident #2 (R2) to have full bed rail at the facility which pose potential health, safety and personal rights risks to resident in care.the state’s words, verbatim · CDSS document, Feb 15, 2024

Plan of correction: Licensee stated to train all staff on CCR 87608(a)(5)(B) and submit proof of training log to LPA Brown at POC due date. Administrator will remove R2 full bed rail and submit proof to LPA Brown at POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Feb 23, 2024

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required … Licensee did not meet this requirement as evidenced by: Based on interviews, record review and observations, the Licensee refused to accept R1 back to the facility upon hospital discharge. This posed a potential Health, Safety or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 15, 2024

Plan of correction: Licensee stated to review Title 22, Section 87224(a) and write a self-certification that the regulation has been read and is understood. and submit to LPA Brown by Plan of Correction (POC) due date.

Allegation investigated: Facility staff refused to accept a resident back after hospitalization.

On 01/22/2024 at 11:04 AM, Licensing Program Analysts (LPAs) Melody Brown, Michelle Echeveria and Bianca Wolcott arrived at the facility to investigate a complaint and deliver the findings for the above complaint allegation. Upon arrival, LPAs Brown, Echeverria and Wolcott met with a Staff #3 (S3). Administrator Brandon Marquez was contacted and informed of the visit. LPAs Brown, Echeverria and Wolcott informed S3 of the purpose of the visit. The investigation consisted of file review and interviews with relevant parties. LPAs Brown, Echeverria and Wolcott conducted interviews, and reviewed facility files. The allegation indicates Facility staff refused to accept a resident back after hospitalization. S1 reported that they did not pick-up Resident #1 (R1) from the hospital because they do not have staff at the facility to provide care and supervision for R1 as Staff #4 (S4) had an injury and unable to work. Staff #2 (S2) reported to LPAs Brown, Echeverria and Wolcott that the hospital did not call S2 that R1’s ready for discharged but they called S1. *** Continuation in LIC9099C *** Substantiated Per interviews and file review, LPAs Brown, Echeverria and Wolcott observed that the facility did not accept R1 back from the hospital even after S1 was notified of R1's discharged on 01/12/2024. LPAs Brown, Echeverria and Wolcott will be issuing a citation. In addition, LPA Brown contacted hospital social worker in Fontana and Riverside and both social worker's reported that the facility refused to accept R1 back at the facility after informing S1 that R1's ready for discharged. Per investigation conducted today, 01/22/2024, R1's now living at a residential care facility for the elderly (RCFE) in the city of Hemet, California with move in date of 01/20/2024. Based on LPA Brown, Echeverria and Wolcott observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore, the allegation of Facility staff refused to accept a resident back after hospitalization is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is cited on the attached LIC9099D. An exit interview was conducted where this report (LIC 9099), LIC9099D, and Appeal Rights were discussed and provided to Administrator Brandon Marquez.the state’s words, verbatim · CDSS document, Jan 22, 2024 · control 56-AS-20240116115558

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(a) · Plan of correction due date: Jan 29, 2024

87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required … Licensee did not meet this requirement as evidenced by: Based on interviews, record review and observations, the Licensee refused to accept R1 back to the facility upon hospital discharge. This posed a potential Health, Safety or Personal Rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 22, 2024

Plan of correction: Licensee stated to review Title 22, Section 87224(a) and write a self-certification that the regulation has been read and is understood. and submit to LPA Brown by Plan of Correction (POC) due date.

Type of visit: Case Management - Deficiencies

On 01/22/2024 at 11:04 AM, Licensing Program Analysts (LPAs) Melody Brown, Michelle Echeverria and Bianca Wolcott met with Administrator Brandon Marquez to initiate Case Management Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation. Per documents review during the facility visit today, 01/22/2024, LPAs Brown, Echeverria and Wolcott reviewed documents and interview staffs and observed that Staff #3 (S3) has criminal background clearance but the Licensee/Administrator did not transfer S3's criminal background clearance to the facility. S3 reported to LPAs Brown, Echeverria and Wolcott that S3 started working at the facility on 01/09/2024. Interviews with Staff #1 (S1) and Staff #2 (S2) confirmed that Staff #4 (S4) had been working at the facility since 01/06/2024 and per documents review, LPAs Brown, Echeverria and Wolcott observed that S4 does not have criminal background clearance and S2 reported to LPAs Brown, Echeverria and Wolcott that S4 started working at the facility on 01/06/2024. LPAs Brown, Echeverria and Wolcott informed Administrator Marquez that deficiency will be issued and Civil Penalties were assessed during the facility visit today, 01/22/2024 with the amount of $200.00 will be assessed for allowing S4 to work at the facility without criminal background clearance and $500.00 for S3 working at the facility without criminal background clearance transfer and will continue to be assessed of $100.00 per day per citation until corrected for for not transferring S3 criminal background clearance to the facility. Moreover, documents review also indicated that the facility does not have the records for Resident #1 (R1) and S2 reported to LPAs Brown, Echeverria and Wolcott that S1 admitted R1 to the facility without any documentation. Deficiency will be issued. During the tour of the facility, LPAs Brown, Echeverria and Wolcott observed that Resident #2 (R2) has full bedrails and per documents review, R2 was not on hospice and no written documentation from R2's physician indicating the need for full bed rail and no full bed rail exemption was submitted to Community Care Licensing Division (CCLD). Deficiency will be issued. *** Continuation in LIC809C *** Also, during the tour of the facility on 01/22/2024 at 11:20 AM, LPAs Brown, Echeverria and Wolcott observed one (1) knife in the kitchen cabinet, not locked and accessible to clients in care. Deficiency will be issued as this pose immediate health, safety and personal rights risks to residents in care. Furthermore, LPAs Brown, Echeverria and Wolcott observed no first aid book available at the facility. Deficiency will be issued. Moreover, LPAs Brown, Echeverria and Wolcott observed broken drawers in the kitchen cabinet and laundry room. Deficiencies will be issued. Moreover, LPAs Brown, Echeverria and Wolcott observed that Resident #3 (R3), Resident #4 (R4) and Resident #5 (R5) medications were dispensed but staff at the facility did not update R3, R4 and R5 Medication Administration Record (MAR). Deficiency will be issued. Lastly, during the visit on 01/22/2024, LPAs Brown, Echeverria and Wolcott observed that no Administrator present at the facility during working hours and LPAs Brown, Echeverria and Wolcott had to contact Administrator to go to the facility. Deficiency will be issued. Also, LPAs observed no Administrator present at the facility during working hours. Deficiency will be issued. Per records review, the facility were cited for the same regulations within 12-month period for CCR 87303(a) and HSC 1569.618(a), civil penalty will be issued today, 01/22/2024 with the amount of $250.00 per repeat violation within 12-month period. An exit interview was conducted where this report, LIC809, LIC809D, 421BG, 421FC and Appeal Rights were discussed and provided to Administrator Brandon Marquez.the state’s words, verbatim · CDSS document, Jan 22, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Jan 23, 2024

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance... This requirement is not met as evidenced by: Based on observation and interview, the Licensee did not comply with the section cited above by not obtaining Staff #4 (S4) criminal record clearance before allowing S4 to work at the facility on 01/06/2024 which pose immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 22, 2024

Plan of correction: Licensee stated to not allow S4 to work at the facility without obtaining the required Criminal background clearance and submit copy of Staff Schedule and Personnel Summary Report (LIC500) to LPA Brown at Plan of Correction due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87355(e)(2) · Plan of correction due date: Jan 29, 2024

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance... This requirement is not met as evidenced by: Based on observation and interview, the Licensee did not comply with the section cited above by not transferring Staff #3 (S3) criminal record clearance to the facility before allowing S3 to work at the facility on 01/09/2024 which poses potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 22, 2024

Plan of correction: Licensee stated to transfer S3 criminal record clearance to the facility and submit proof to LPA Brown at POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(6) · Plan of correction due date: Jan 23, 2024

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care...(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observation, interviews and records review, the Licensee did not comply with the section cited above by not updating R3, R4 and R5 Medication Adminisitration Record (MAR) after dispensing R3, R4 and R5 medications per their physician's order which pose immediate health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Jan 22, 2024

Plan of correction: Licensee stated to train all staff on CCR 87465(a)(6) and submit proof of All Staff Training Log to LPA Brown at Plan of Correction (POC) due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87309(a)(1) · Plan of correction due date: Jan 23, 2024

87309 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. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked. Based on observation, interview and records review, the LIcensee did not comply with the section cited above by not locking the one (1) knife at the kitchen cabinet making it accessible to residents in care which pose immediate health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Jan 22, 2024

Plan of correction: Licensee stated to train all staff on CCR 87309(a)(1) and submit proof of Staff Training Log to LPA Brown at POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jan 29, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety...This requirement is not met as evidenced by: Based on observation and interview, the Licensee did not comply with the section cited above by not having the kitchen cabinet and laundry cabinet in good repair which pose potential health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Jan 22, 2024

Plan of correction: Licensee stated to repair the broken cabinet in the kitchen and in the laundry room and submit proof to LPA Brown at Plan of Correction (POC) due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.618(a) · Plan of correction due date: Jan 29, 2024

HSC 1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having an Administrator present during working hours at the facility which pose potential health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Jan 22, 2024

Plan of correction: Licensee stated to submit Signed Statement of Understanding on HSC 1569.618 and submit to LPA Brown at POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(e) · Plan of correction due date: Jan 29, 2024

87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having Resident #1 (R1) record at the facility which poses potential health, safety and personal rights risks to resident in care.the state’s words, verbatim · CDSS document, Jan 22, 2024

Plan of correction: Licensee stated to train all staff on CCR 87506(e) and submit proof of Staff Training Log to LPA Brown at Plan of Correction (POC) due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87608(a)(5)(B) · Plan of correction due date: Jan 29, 2024

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Based on observation, interview and records review, the Licensee did not comply with the section cited above by allowing Resident #2 (R2) to have full bed rail at the facility which pose potential health, safety and personal rights risks to resident in care.the state’s words, verbatim · CDSS document, Jan 22, 2024

Plan of correction: Licensee stated to train all staff on CCR 87608(a)(5)(B) and submit proof of training log to LPA Brown at POC due date. Administrator will remove R2 full bed rail and submit proof to LPA Brown at POC due date.