Heatherfield Inn

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Dieu-Qui Nguyen . LPA observed 3 residents and 3 staff in the facility. LPA toured the facility inside and out with ADM. License, Administrator Certificate, and personal rights posters were observed in the facility. LPA reviewed 2 resident file and 2 staff files. Family room, kitchen, dining area, 3 restrooms, 1 office area, 2 staff rooms, 4 resident rooms, and laundry room were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. The temperature of the refrigerator was observed at 40 degree F, and the temperature of the freezer was observed at -1 degree F. Medication closet was observed locked. Knives closet, and dish washing soap closet were observed locked. Room temperature was at 75 degree F, and hot water temperature was at 119 degree F in facility. Fire extinguisher was observed without date, staff went to buy new one and installed in the facility. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Carbon monoxide detectors were tested by ADM, and were working. First aid box, night lights, and flash lights were observed in the facility. continue on LIC809-C. Front yard and backyard were inspected. 2 storage room was observed locked at backyard. Some stuff were observed to block the walkway to the exit gates at the backyard. ADM removed them immediately. The last time the facility conducted the fire drill was on 7/8/2026. Deficiency noted today. See LIC809-D. 2 Out of 2 staff (S1, S2) are observed without continuous training records maintained at the facility. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Aug 7, 2026

Type of visit: POC

Licensing Program Analyst Steve Chang conducted a POC case management visit to clear deficiencies cited on August 28, 2025, during the annual inspection. LPA met with staff Jano Fonokalafi (S1). LPA explained the purpose of the visit to S1. The Facility was cited the following Type A deficiencies on August 28, 2025 87303(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 87355(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: LPA received the plan of correction by the POC due date. LPA observed 2 staff (S1, S2) and 5 residents in the facility. LPA toured the facility inside and out with S1. LPA observed all the window screen are fixed. LPA checked S1 and S2 are associated with the facility. LPA did not see any other staff in the facility. S1 stated the two volunteers LPA observed on 8/28/2025 do not appear at the facility since 8/29/2025. S1 stated ADM already processed the procedure of associating the 2 volunteers. Deficiencies cleared during todays visit. POC cleared letter provided to ADM. S1 read the report to ADM and signed the report on behalf of ADM. No Deficiencies was cited during todays visit. This report was reviewed by S1 . A copy of this report was provided to S1.the state’s words, verbatim · CDSS document, Sep 12, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Dieu-Qui Nguyen. LPA observed 4 residents (R1-R4). 2 staff (S1-S2) and two volunteer (V1, V2). S1 stated ADM comes to facility every day and usually stays 6 hours. ADM arrived the facility about one hour after LPA arrived at the facility. V1 and V2 are not associated with the facility. LPA toured the facility inside and out with S1 License, Administrator Certificate, and personal rights posters were observed in the facility. LPA reviewed 2 resident file and 2 staff files. 1 out of 2 staff file was observed missing staff training log, ADM stated he/she has that at home, ADM stated to send to LPA by end of today. Family room, kitchen, dining area, 3 restrooms, a office area, a staff room, 5 resident rooms, and laundry room were inspected. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet was observed locked. Knives closet, and dish washing soap closet were observed unlocked. S1 stated staff were just using it. S1 locked the knives closet and dish washing soap closet immediately. Room temperature was at 76 degree F, and hot water temperature was at 119 degree F in facility. Fire extinguisher was expired, ADM stated the facility will install new one today. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Carbon monoxide detectors were tested by S1, and were working. First aid box, night lights, and flash lights were observed in the facility. The screens in a resident room, and a bathroom. Page 1 of 2. Front yard and backyard were inspected. 2 storage room was observed at backyard. The last time the facility conducted the emergency and fire drill was on 7/15/2025. Deficiency noted today. See LIC809-D. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM. Page 2.the state’s words, verbatim · CDSS document, Aug 28, 2025

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Facility staff is violating personal rights by not allowing visitors inside facility Facility staff is not administering medication to residents according to physician orders. Facility staff is not addressing resident significant weight loss Residents do not have access to telephone in the facility

On 04/01/2025 at 9:45 AM Licensing Program Analyst (LPA) Marcela Yanez subsequent conducted an unannounced complaint investigation visit to deliver findings on the above allegations. LPA met with Lead Staff Fonokalafi Jano and stated the purpose of the visit. On 12/23/2024 the Department received a complaint with allegations that the facility is not addressing significant weight loss of the resident, the staff is not allowing visitors inside the facility, the staff is not administering medication according to doctor’s order, and the residents not having access to the telephone. During the course of investigation, LPA interviewed 3 staff (S1-S3). LPAs obtained records for 3 Residents (R1-R3) which consisted of Physicians Report, Medication Administration Record, facility menu, and residents weight log. Page 1 of 2. Unsubstantiated LPA interviewed ADM to address the allegation of significant weight of weight loss of resident. ADM stated that the residents weight fluctuates, and it is documented on the weight record log and any significant weight loss is immediately reported to their Physician. ADM stated that some residents have dietary restrictions that are documented in the residents file in the Physicians Report. LPAs reviewed monthly weight log of residents and there was no significant weight loss. LPAs interviewed Staff S1-S2 both stated visitors are allowed in the facility and can visit in the front room where there is a loveseat or the common area or patio in backyard and in the resident’s bedrooms. S1 and S2 stated that during the pandemic Covid-19 the facility had restrictions before entering the facility such as Covid-19 rapid tests and body temperature check. During LPAs visit LPAs observed a resident’s visitors in resident bedrooms. During visit LPA observed three phone receivers accessible to residents in care located in the kitchen common area and the front office/sitting area. ADM stated the facility is equipped with audio enhancing devices for the residents who are hearing impaired. ADM showed LPAs the device. During investigation LPA reviewed centrally stored medication record and reviewed medication with staff and based on record review the medication count was accurate and medication was administered as prescribed by physicians. Based on observations, interviews and document review the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. No citations noted at today’s compliant investigation visit. Exit interview conducted with Lead Staff. This report was provided to review and for signature. A copy of this report was provided to Fonokalafi Jano, Lead Staff. Page 2 of 2. END OF REPORT.the state’s words, verbatim · CDSS document, Apr 1, 2025 · control 26-AS-20241223170818

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit to follow up on the deficiencies cited on 12/30/2024. LPA Rai met with Administrator, Dieu-Qui H Nguyen and stated the purpose of today's visit. During visit, LPA observed 3 staff and 5 residents at the facility. 2 Out of the 3 staff were associated to the facility and obtained a Criminal Record Clearance. Staff (S2) is working at the facility as a caregiver, providing care and supervision and does not have a Criminal Record Clearance and associated to the facility. During visit, LPA observed S2 assisting R1 with walking from R1's bedroom to the living room. S2 stated he/she provides care and supervision to the residents in care. LPA Rai observed S2's medication bottles with medications in staff room. During visit, LPA Rai did observe S3's staff file to be complete and present in the facility for LPA Rai to review. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC 809-D. A civil penalty is being assessed for the amount of $500 for S2 working in the facility for more than 5 days without receiving criminal record exemption transfer approval. The civil penalty will be for $500 ($100 per day x 5 days = $500). See LIC421BG. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. LPA Rai provided Letter of Deficiency Citations Cleared. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC 809-D. This report was reviewed with Administrator Dieu-Qui H Nguyen and a copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jan 30, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Jan 31, 2025

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review ... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department... This requirement is not met as evidenced by: Based on record review and interview, the Licensee did not ensure S2 obtained a Criminal Background Clearance prior to working at a licensed facility which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 30, 2025

Plan of correction: Licensee/Administrator stated to submit a written plan of action understanding regulation and will ensure to obtain a Criminal Background Clearance for S2 prior to working in the facility by POC due date. Licensee/Administrator agreed and understood.

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Simi Rai and Marcela Yanez conducted an unannounced visit to conduct an investigation visit for a complaint received on 12/23/2024. During the complaint investigation, a case management was conducted due to deficiencies observed during the investigation process. LPAs met with Administrator Dieu-Qui H Nguyen. During today's visit, LPAs observed 2 staff at the facility and providing care and supervision to the residents in care. S1 was preparing snacks for the residents and S2 was providing incontinence care to residents. LPAs reviewed LIS 536 Facility Personnel Report Summary for the facility dated 12/30/2024. Administrator stated both staff had Criminal Record Clearance and provided the names of the 2 staff. LPAs were able to verify S1's name on the LIS 536 but the name S2 provided was not on the LIC 536. Administrator provided a different name for S2 than S2 stated to LPAs. Administrator stated S2 has obtained a Criminal Record Clearance. LPAs requested staff file for S2. Administrator was not able to provide a complete staff file for S2 which would include S2's letter of Criminal Record Clearance. The only document from S2's staff file Administrator was able to provide for LPAs to review was the training completed for 2024. Administrator stated S2's file is maintained out of the facility in a separate location. Administrator did not maintain S2's staff file at the facility and was not available for licensing agency to review. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC 809-D. This report was reviewed with Administrator Dieu-Qui H Nguyen and a copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Dec 30, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(g) · Plan of correction due date: Jan 6, 2025

87412 Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This requirement is not met as evidenced by: Based on record review and interview, Licensee did not maintain staff file for S2 at the facility and was not available to the licensing agency for review which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 30, 2024

Plan of correction: Administrator stated to submit a written plan of action understanding regulation and will ensure staff files are maintained at the facility and be available to the licensing agency for review by POC due date. Administrator agreed and understood.

Allegation investigated: Staff do not keep the facility free from pests. Staff do not properly maintain the facility grounds. Staff are not providing adequate laundry service. Staff residing in the facility do not have a Criminal Record Clearance. Staff providing care and supervision have not completed required training.

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced investigation visit to deliver the investigation findings and met with Staff Head Fonokalafi Jano (SH) On 3/5/2024, the Department received a complaint with the above allegations. On 3/12/2024, the Department conducted an initial investigation visit. LPA toured the facility inside and out. LPA interviewed 2 staff and 2 residents. LPA requested staff training documents. Continue on LIC9099-C. Page 1 of 3. Unfounded Staff do not keep the facility free from pests: Staff do not properly maintain the facility grounds: On 3/12/2024, LPA interviewed staff S1. S1 stated the facility staff are required to sweep the floor three times a day. S1 stated resident R1's dog cannot be in the dining room when the residents are eating their food in the dining room. S1 stated the staff sweep the floor before the residents eat for breakfast, lunch and dinner. S1 stated there is maintenance services for the front yard and backyard. During the visit, LPA observed the front area clean and had no obstruction which poses a health or safety hazard. LPA did not observe items that poses health or safety concern. LPA observed the kitchen, dining room area, and sitting area were kept clean and free of litter, rodents, vermin and insects. LPA observed the 4 resident rooms, 2 resident bathrooms, laundry room, outside and staff room were clean and free of litter, rodents, vermin and insects. LPA observed two staff cleaning bathrooms and resident bedrooms during LPA's visit. Staff are not providing adequate laundry service: On 3/12/2024, LPA interviewed staff S2. S2 stated residents have shower every other day, and there is a schedule for resident showers. S2 stated facility staff strip residents' bed and change the linens on the day that residents have showers. S2 stated residents have schedule for showers posted on the whiteboard. LPA observed the resident's shower schedule on the whiteboard. LPA observed a note from ADM which stated "All bedding will be changed and laundered on shower days" and "All client laundry will be washed on Thursdays". LPA observed the 4 resident rooms, 2 resident bathrooms clean and free of litter. LPA observed the laundry machines not broken. LPA observed resident rooms and laundry hampers were not overflowing. There is no evidence to indicate staff are not providing adequate laundry service. Continue on LIC9099-C. Page 2 of 3. Staff residing in the facility do not have a Criminal Record Clearance: On 3/12/2024, LPA interviewed staff S1 and checked S1 with the facility personnel report summary. S1 is Criminal Record Clearance and is associated to the facility. LPA interviewed staff S2 and checked S2 with the facility personnel report summary, S2 is Criminal Record Clearance and is associated to the facility. S2 stated there are staff members that come earlier than their shift and sleep at the facility. S2 provided the names of staff S3, S4 and S5. LPA checked S3, S4 and S5 with the facility personnel report summary, and they are Criminal Background Clearance and are associated to the facility. LPA observed 3 staff (S4, S6, S7) in the facility and checked staff S6, S7 with the facility personnel report summary. Both staff are Criminal Background Clearance and are associated to the facility. Staff providing care and supervision have not completed required training: On 3/12/2024, staff S1 showed LPA the staff training documents on the cell phone. LPA obtained a copy of 4 caregivers training documents. Based on the review of the training log, 4 Out of 4 caregivers completed the required training. No evidence to indicate staff have not completed required training. The Department has investigated the above allegations. Based on the investigation, records reviewed, observation, and interviews conducted, the Department found that the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. No citations noted at today’s compliant investigation visit. Exit interview conducted with ADM. This report was provided to review and for signature. A copy of this report was provided to ADM. Page 3 of 3.the state’s words, verbatim · CDSS document, Nov 15, 2024 · control 26-AS-20240305131931

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator (ADM) Qui Nguyen. During the visit, LPA observed 5 residents, 1 staff and 1 volunteer. LPA explained the purpose of the visit. LPA toured the facility inside out with ADM which included the Living room, kitchen, dining room, 3 restrooms and 5 residents bedrooms. The staff area of the facility was also inspected. The front yard and backyard were inspected. There was no obstruction to block the walkways. While touring the facility backyard. LPA's observed the facility sheds. LPA observed that behind the shed, closest to the deck, had several tools and a red container of gasoline. (Photograph was taken.) ADM put the tools inside the shed during the visit. LPA's also observed behind the shed closest exit #3 had a container of lighter fluid. LPA's also observed in the facility backyard between both sheds had several dog droppings. LPA's also observed an assortment of wheelchairs, walkers in the deck. ADM stated she plans to move them to storage. Two-day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 78 degrees F, and hot water temperature was measured at 119 degrees F in both resident bathrooms. Fire extinguisher was serviced in July 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on July 9, 2024. Page 1 Out of 2. During the tour of the facility, LPA observed residents bedrooms. LPA observed 4 Out of 5 residents beds had half side rails. LPA requested to see the doctors orders for the bed rails. ADM stated she didn't know she had to get a doctors order for the half side bed rails. LPA reviewed facility records for 3 residents. Resident R2 and R3 have a neurocognitive disorder. R2 physician's report is dated January 25, 2023 and Needs & services plan is date February 7, 2023. R3's physician's report is dated November 5, 2019 and Needs & Services plan is dated June 21, 2023. LPA reviewed 3 resident medications and centrally stored medication records. LPA's reviewed medication by cross referencing the centrally stored medication record and comparing that information with the medication bottles. While reviewing resident R2's medication bottles; LPA's observed that 4 medication bottles were not listed in the centrally stored medication log. While reviewing resident R1's medication bottles; LPA's observed 1 medication bottle was not listed on the centrally stored medication records. LPA's also observed 3 medication that had incorrect information imputed in the centrally stored medication record. LPA reviewed 3 staff records. LPA's requested to review V1's health statement & Health screening documents. ADM stated she does not have V1's health statement & health screening documents. LPA conducted interviews with 2 staff and 2 residents. Deficiencies are being cited during today's visit. This report was reviewed with Administrator Qui Nguyen and a copy of the signed report was provided. Appeal rights were provided. Page 2 Out of 2. END OF REPORT.the state’s words, verbatim · CDSS document, Aug 8, 2024

Type of visit: Collateral

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Collateral visit and met with Carmina Amaral. During visit, LPA Marrufo interviewed a resident as part of a complaint investigation for another facility. No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Carmina Amaral and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 26, 2024

Allegation investigated: Resident had to wait a few hours for incontinence care Facility TV is not functional Food at facility does not meet the recommended dietary food allowance

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Administrator (ADM) Dieu-qui H Nguyen. Facility TV is not functional On October 11, 2021, the Department received a complaint alleging Facility TV is not functional. On October 19, 2021, LPA Bui conducted an unannounced 10-day complaint investigation visit. LPA toured the facility and observed 3 Out of 3 resident televisions turned on. LPA observed the living room television was also functional. Page 1 Out of 5. Unfounded On January 11, 2024, LPA Manuel Monter toured the facility and resident bedrooms. LPA observed all resident’s 4 Out of 4 televisions as functional. LPA observed the television in the facility living room as functional. LPA Monter interviewed the ADM and four staff members, S1-S4. ADM the televisions in the facility work. 4 Out of 4 staff interviewed stated the televisions at the facility work. S1 stated if a television doesn’t work, they can just swap that television with another one from the bedrooms that are not occupied. On January 11 & 13, 2024 & October 14, 2021, the Department interviewed residents, R1-R5. 1 Out of 5 residents stated their television in their bedroom did not work. 2 Out of 5 residents stated the televisions in the facility work. The remaining 2 Out of 5 residents interviewed stated they did not want to be interviewed. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Resident had to wait a few hours for incontinence care On October 11, 2021, the Department received a complaint alleging a resident had to wait a few hours for incontinence care. On October 19, 2021, LPA Bui interviewed 2 staff (S1 & S2). S1 stated staff do night rounds every 2 hours at night and that's when they check if a resident needs their diaper changed. S1 and S2 stated R1 had a bell she could ring if she needed assistance at night. S1 and S2 stated residents did not have to wait a few hours to get their diaper changed. Page 2 Out of 5. On October 12, 14 and 19, 2021, the Department interviewed residents R1-R3. R1 stated staff did not respond to his/her request for assistance with incontinence needs and he/she had to lay wet for 2-3 hours. R1 stated he/she was given a bell to ring if he/she needed help. R1 stated the facility was aware he/she needed assistance changing his/her undergarments, and staff helped him/her about 3 times per night. R1 stated the night staff realized he/she needed his/her undergarments changed more at night, like up to 4 times at night. R1 stated someone always responded, but it took them a long time to get there. R2 was unable to answer LPA’s questions due to neurocognitive disorder. R3 stated he/she did not have to wait a long time for assistance with the bathroom. On January 11 & 13, 2024, LPA Manuel Monter interviewed residents, R2-R5. 2 Out of 4 residents stated the facility does assist them with toiletry needs in a timely manner. The remaining 2 Out of 4 residents interviewed stated they did not want to be interviewed. On January 11, 2024, LPA Manuel Monter interviewed staff S1-S4 and ADM. 4 Out of 4 staff members stated, the facility changes residents every two hours. 2 Out of 4 staff members stated, the residents have call bells to ring if they need assistance. S4 stated he/she the residents are checked every 2 hours and to re-position them as well. ADM stated the facility has a rotation of staff checking the residents throughout the night. ADM stated the residents ring for help, the staff will respond. ADM stated if a resident needs to be changed, then the facility staff will help that resident and they will be changed. The staff respond very quickly if a resident calls for help. On January 11 & 13, 2024 and February 27, 2024 LPA Manuel Monter toured the facility. LPA did not observe or smell any residents who were left soiled during LPA’s visit. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 3 Out of 5 Food at facility does not meet the recommended dietary food allowance On October 11, 2021, the Department received a complaint alleging food at facility does not meet the recommended dietary food allowance. On October 12, 14 & 19, 2021, The Department interviewed residents, R1-R3. R1 stated the food service is inadequate. R1 stated residents are given 1 or 2 pieces of triangle toast with a muffin, sandwiches for lunch. R1 stated residents are also given half a slice of toast with 1 or two strawberries cut into small pieces. Residents R2 and R3 stated the food is fine. LPA Bui interviewed staff S1 and S2. S1 stated she cooks for the residents and the menu is posted on the board. S1 stated no residents have complained about the food. S2 stated the residents gets food like oatmeal and bananas for breakfast, sandwiches for lunch, chicken or beef and vegetables for dinner. S2 stated residents have not complained about the food. On January 11 & 13, 2024, LPA Manuel Monter interviewed residents, R2-R5. 2 Out of 4 residents stated the home makes a variety of food that they like and makes food that meets their needs. The remaining 2 Out of 4 residents interviewed stated they did not want to be interviewed. On January 11, 2024, LPA Manuel Monter interviewed staff S1-S4 and ADM. 4 Out of 4 staff stated the home makes healthy food for the elderly residents. S1 stated the facility will also make the foods that the residents request. S1 stated the home makes food to meet the residents needs as they high cholesterol and we need to be careful what we serve them. ADM stated the types of food the home makes is based on the dietary needs the elderly have. ADM stated the facility also use spices to avoid using salt. ADM stated the facility also provide vegetables; kale, tomatoes, butternut squash, lettuce. Fruits, bananas, prune bread. Page 4 Out of 5. On January 11 & 13, 2024 and February 27, 2024 LPA Manuel Monter conducted an unannounced complaint investigation. LPA toured the home and observed the facility’s food supply. LPA observed sufficient 2-day perishable and 7 day non perishable food supply. LPA observed a variety of vegetables and fruit. LPA also observed staff asking residents what they would like to eat the following day. On January 11, 2024, LPA observed residents eating lunch, which included a vegetable soup, a sandwich with a fruit salad. On January 13, 2024, LPA observed residents eating breakfast which included a veggie omelet, with toast and fruit. On February 27, 2024, LPA observed residents eating lunch which included a taco, with ground beef, tomatoes, onions and cilantro. Residents were also offered Jello, water and juice. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. Page 5 Out of 5 END OF REPORT. On February 27, 2024, LPA Monter arrived to the facility at 1:00pm. LPA observed the ADM was not in the facility. LPA interviewed 3 Out of 3 staff. 2 Out of 3 staff interviewed stated the ADM did not come to the facility on 02/27/2024, 02/26/2024 and 02/25/2024. On March 12, 2024, LPA Simi Rai conducted an unannounced complaint investigation to open a new complaint. LPA Rai arrived at the facility at 9:00am. Facility staff contacted ADM, who stated he/she is in Sunnyvale and would take 30-40 minutes to arrive. LPA Rai concluded her visit at 11:40am and the ADM did not arrive during LPA’s visit. On April 3, 2024, LPA Monter interviewed facility ADM. ADM stated she does have a part time job doing assessments and consulting. ADM stated the hours she works are as needed basis. ADM stated she does come to the facility, but her hours are variable, as she has to go when she needs to do an assessment. When asked how many hours per day she works at the facility Monday-Friday, 8am-5pm, ADM responded at least 3 hours. Based on a review of ADM’s Resume and Applicant information, the ADM works for Vista Verde Home Care from July 1, 2014 to present. Under duties, the Applicant information form states ADM conducts 1:1 care of seniors in their homes. On September 20, 2022, the Department was informed by the Licensee/Administrator when asked if he/she holds a fulltime employment other than overseeing this RCFE facility. In reply, he/she confirmed that he/she does assessment and 1:1 transportation to appointments Monday to Thursday. Licensee/Administrator stated he/she is on duty Friday to Sunday. Licensee sent a LIC500, dated September 20, 2022, which states, he/she works Wednesday thru Sunday, 8am-7pm. The Department has investigated the above allegation. Based on interviews conducted, and records reviewed, the preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC9099-D. Exit interview was conducted with Administrator Dieu-qui H Nguyen and a copy of the signed report & appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 11, 2024 · control 26-AS-20211011110448

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Apr 12, 2024

87405 Administrator - Qualifications and Duties (a) All … The administrator shall … shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility … fulfill his/her responsibilities ... This requirement was not met as evidence by: Based on record reviews and interviews conducted, the ADM is not spending 20 hours a week in the facility Monday-Friday, during working hours, 8am-5pm. This poses an immideate safety and health risk to residents in care.the state’s words, verbatim · CDSS document, Apr 11, 2024

Plan of correction: ADM stated she will send a written plan of action on how she will ensure she is at the facility 20 hours a week, Monday-Friday, during working hours, 8am-5pm. ADM stated she will send the written plan of action by POC date April 12, 2024

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

Allegation investigated: Facility screen door is broken

Licensing Program Analyst (LPA) Monter conducted an unannounced complaint inspection to deliver the findings on the above allegations. LPA met with Dieu-qui H Nguyen On October 11, 2021, the Department received a complaint alleging facility screen door is broken. On October 19, 2021, LPA Anna Bui conducted an unannounced 10-day complaint investigation visit. LPA toured the facility and observed a tear along the vertical side of the lower portion of the screen door, in bedroom #4. LPA took photographs of the screen door. LPA Bui interviewed staff S1. S1 stated the screen door in Room #4 was broken for about a week. Page 1 out of 2. Substantiated On January 11, 2024, LPA observed resident bedroom #4 with a damaged facility screen door. ADM confirmed that resident bedroom #4 has a damaged screen door. The Department has investigated the above allegation. Based on observation, resident bedroom #4’s sliding screen door had a tear and was broken. The preponderance of evidence standard has been met. Therefore, the Department found the above allegation to be SUBSTANTIATED. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC9099-D. Exit interview was conducted with Administrator Dieu-qui H Nguyen and a copy of the signed report & appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 11, 2024 · control 26-AS-20211011110448

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jan 18, 2024

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include ... for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by; Based on LPA's observation, bedroom #4's screen door has holes and is not in good repair. ADM confirmed that the screen door is damaged as well. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 11, 2024

Plan of correction: ADM stated she will send plan of action on how the facility will ensure facility screens shall be in good repair. ADM stated she will send POC to LPA by 11/18/2024.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Manuel Monter conducted an unannounced annual inspection visit, and met with Administrator Dieu-Qui H Nguyen. During visit, LPA observed 4 residents and 3 staff. LPA toured the facility inside out with ADM which included; the Living room, kitchen, dining room, 3 restrooms and 4 residents bedrooms. The staff area of the facility was also inspected. Front yard and backyard were inspected. There was no obstruction to block the walkways. Two day perishable food supplies and seven day nonperishable food supplies were observed. LPA observed the medication closet, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. Room temperature was at 75 degrees F, and hot water temperature was measured at 117 degrees F in both resident bathrooms. Fire extinguisher was serviced in July 17, 2023. The facility was equipped with smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were functional. LPA observed facility first aid kit and facility fire/earthquake drill log. The facility's last drill was on July 28, 2023. LPA reviewed facility records for 3 staff and 3 residents, ADM stated she did not have staff records available for LPA to review, ADM stated its on her hard drive and would get them once her computer is fixed. LPA reviewed 3 resident medications and centrally stored medication records. LPA conducted interviews with 4 staff (S1 to S4) and 2 residents (R1-R2). While interviewing Staff S2, S2 stated he/she sleeps in bedroom #3. ADM confirmed that staff S2 was sleeping in bedroom #3. ADM stated she would move that staff member to the staff area instead. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. Exit interview was conducted with Administrator Dieu Qui H Nguyen and a copy of the signed report & appeal rights were provided.the state’s words, verbatim · CDSS document, Jan 11, 2024