Hepzebah House

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Angela Panushkina conducted a Case Management - Incident visit. LPA met with Administrator and explained the reason for the visit. On 05/26/26, the Department received a self-reported incident report stating that Resident #1 (R1) had left the facility on 05/24/26 and did not return. The incident was reported to police (copy of the the report is also obtained). During today's visit, LPA conducted a physical plant walk through, at approximately 12:35pm, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. LPA did not observe any immediate health and safety issues during the visit. LPA conducted interview with the Administrator and attempted to contact R1's Power of Attorney. LPA also obtained copies of R1's facility records. Upon review of the physician's report dated 04/22/2026, the report states that R1 has dementia and is not able to leave the facility unassisted. Interview with the Administrator revealed that R1 lived at the above facility since 04/04/26 and was very happy with the place. The Administrator denied seeing changes in R1's behavior. Interview with S1 revealed that on a day of an incident, at approximately 8:00pm, R1 was smoking outside (backyard) and asked S1 to get pull-ups, so that R1 can change and get ready for sleep. LPA was informed that around 8:07pm S1 brought the pull-ups and did not observe R1 sitting outside. S1 looked around and went outside (to the front) and still did not observe R1. S1 immediately contacted the Administrator and the law enforcement regarding the incident. R1 is still missing and Administrator currently does not have any updated information on R1's whereabouts. LPA will conduct a follow up visit regarding this incident. Exit interview conducted and copy of this report signed and issued.the state’s words, verbatim · CDSS document, May 28, 2026

Allegation investigated: Staff left resident in a soiled brief Staff did not provide first responder with resident's records Licensee did not ensure front egress is free from obstruction

At 10:30am, Licensing Program Analyst (LPA), Angela Panushkina conducted an unannounced visit in response to the above-mentioned allegations. LPA met with the Administrator and explained the reason for the visit. At 10:35am, LPA requested residents and staff roster. At 10:40am, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Incontinence Plan of Care, Staff Training relevant to the investigation. At approximately 10:50am, LPA conducted a physical plant tour. Between 10:55am – 12:00pm, LPA conducted an interview with the Administrator and two (2) out of four (4) residents, who were able to communicate. Continue on LIC9099-C Substantiated Allegation: Staff left resident in a soiled brief It was alleged that the staff left R1 in a soiled brief. To investigate this allegation, LPA contacted the credible witness on 05/08/26, who confirmed that they responded to the facility (9-1-1 call) on 05/03/2026 at approximately 10:00am, and R1 had reportedly complained of stomachache, and when the credible witness assessed R1, they observed R1 was wearing a soiled incontinent brief. During today’s visit, LPA conducted an interview with the Administrator and was informed all residents are checked and assisted with toileting/incontinence care throughout the day and as needed. However, on the date of an incident, there was limited staff available at the facility during the time 911 arrived. Interview with the Administrator also revealed that staff are expected to provide timely assistance with toileting and incontinent care. However, the Administrator was unable to explain as to why on the day of an incident, R1 was not changed and proper care was not provided. Therefore, based on the credible witness observation and Administrator confirmation this allegation is Substantiated. Allegation: Staff did not provide first responder with resident's records It was alleged that on 05/03/2026 staff did not provide a first responder with R1’s records. To investigate this allegation, LPA conducted an interview with the credible witness and was informed that upon arrival (911 call) at the facility, staff #1 (S1) did not appear to know R1’s basic information and were unable to locate or access R1’s facility file. LPA was also informed that it took several minutes for the Administrator to arrive who was able to write down R1’s biographical information before R1 was transferred to the hospital. Interview with the Administrator revealed that S1 was newly hired and did not have access to resident records. During the interview, the Administrator acknowledged that staff should have been able to provide residents basic information and records in a timely manner. Therefore, based on credible witness observation and information gathered during today’s visit, this allegation is Substantiated. Continue on LIC9099-C Allegation: Licensee did not ensure front egress is free from obstruction It was alleged that the licensee did not ensure the front door was free from obstruction. To investigate this allegation, LPA contacted the credible witness on 05/08/26, who confirmed that when they responded to the facility (9-1-1 call) on 05/03/2026, it was difficult to exit the facility with R1 because there was furniture on the porch and a hose in the way. During today’s visit (upon arrival), LPA observed one (1) chair and one (1) table on the left side of the house (with no obstruction). However, LPA also observed the hose in the way by the ramp. Interview with the Administrator revealed that they placed the chair and the table outside in case residents have family/friends visiting they can sit outside and have privacy. Administrator also acknowledged that the walkway should remain clear and accessible at all times and that items such as outdoor furniture and hoses should not block the front entry, walkway or emergency exits pathway. The Administrator also acknowledge that on 05/03/26 the ramp was an obstructed by the hose and further stated that staff are expected to monitor the facility exterior and remove any items that may interfere with safe passage. Therefore, based on credible witness and LPA observation and information gathered during today’s visit, this allegation is Substantiated. Deficiencies issued during today's visit. Exit interview conducted. Appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, May 12, 2026 · control 31-AS-20260505111640

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(a) · Plan of correction due date: May 19, 2026

Basic Services: (a) The services... shall be conducted so as to continue and promote, to the extent possible, independence and self-direction for all persons accepted for care... This requirement is not met as evidenced by: Based on the credible witnesses visit conducted on 05/03/26, the licensee did not comply with the section cited above by not changing R1's soiled incontinence brief, which posed a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: The Administrator agreed to create an Incontinent Plan of Care and provide in-service training to all current and future staff members. Proof of training will be submitted to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(f)(1) · Plan of correction due date: May 19, 2026

Incidental Medical...: Emergency care requirements shall include the following: (1) The name, address, telephone number of each resident's physician... shall be readily available to... and facility staff. This requirement is not met as evidenced by: Based on credible witnesses visit conducted on 05/03/26, licensee did not comply with the section cited above by failing to provide R1's emergency record during 911 visit. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Administrator agreed to create an emergency card for residents that will be used/provided to first responders. Also in-service training will be conducted with all staff and copies will be submitted to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(d)(6) · Plan of correction due date: May 19, 2026

Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Based on LPAs observation, licensee did not comply with the section cited above by not ensuring that the outside (front) hose is away from the ramp and properly placed/rolled on a hook. This poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: During today's visit the Administrator removed the hose from the front lawn. The Administrator agreed to conduct in-service trainig with all staff regarding this section. Copy of training will be submitted to LPA by POC date.

Type of visit: Case Management - Deficiencies

At 10:30am, Licensing Program Analyst (LPA) Angela Panushkina conducted unannounced visit to this facility in conjunction with a complaint, control #31-AS-20260505111640. LPA met with the Administrator and explained the reason for the visit. Upon arrival LPA observed the following: S1 present during the incident that occurred on 05/03/2026 was not fingerprint cleared/associated with the facility During the visit, LPA also conducted review of all incident reports on a system and did not observe an Incident Report submitted to the Community Care Licensing Department (CCLD) in a timely manner. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO). Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPAs informed the Administrator that all staff members are mandated reporters, and they are all responsible for reporting. LPA informed the Administrator to submit an incident report that occurred on: 09/10/2025 Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are cited and noted on LIC 809D.the state’s words, verbatim · CDSS document, May 12, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(A,B&D) · Plan of correction due date: May 19, 2026

Requirements: (a) Each licensee shall furnish to the licensing agency such reports... (1) A written report shall be submitted to the licensing agency and to the person... ... any of the events specified in (A), (B) & (D)... This requirement is not met as evidenced by: Based on interviews and record reviews conducted by LPA, the licensee did not comply with the section cited above by failing to notify CCLD regarding R1's hospitalization on 05/03/26, which poses a potential health and safety risk to persons in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: Licensee shall ensure a written report is submitted to the licensing agency and to the person responsible for the resident within seven (7) days of the occurrence of any of the events. Incident report shall be submitted to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87355(e)(2) · Plan of correction due date: May 19, 2026

Criminal Record Clearance: (d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement under penalty of perjury. This requirement is not met as evidenced by: Based on LPA interview and record review, licensee did not comply with the section cited above by failing to obtain S1's fingerprint clearance prior to employement. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 12, 2026

Plan of correction: The Administrator agreed to complete S1's fingerprints and associate them with the facility prior to employement. Copy of LIC500 and proof of association will be submitted to LPA by POC date.

Type of visit: Required - 1 Year

At 11:45am, Licensing Program Analysts (LPAs), Angela Panushkina and Huma Rahimi conducted an unannounced annual inspection at the facility mentioned above. LPAs met with the Administrator and explained the reason for the visit. Facility is licensed for capacity of six (6) Non-Ambulatory, of which one (1) may be Bedridden in room #1 only. Hospice waiver is granted for two (2) residents. At approximately 12:00pm, LPAs toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. There is a fire extinguisher in the kitchen was fully charged. LPAs observed five (5) bedrooms designated for residents’ use. All bedrooms have sufficient lighting, properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational. Facility also has awake staff at night. There are two (2) full bathrooms. All bathrooms were observed to be clean and in good repair. Properly supplied with toilet paper, soap and paper towels. The hot water temperature measured at 105.8°F. LPAs observed appropriate grab bar and non-skid mat. All trash cans in bathrooms had fitted lids to protect them from cross contamination. The facility maintains a comfortable temperature at 75°F. The Common areas are furnished with adequate furniture to accommodate a maximum capacity of six (6) residents. Continue on LIC809-C At approximately 12:30pm, LPAs observed medications are centrally stored and locked in the kitchen cabinet, and inaccessible to residents in care. The first-aid kit has been inspected which has at least the following: tweezers, scissors, antiseptic, bandages, gauze, thermometer; including a current First Aid manual. The laundry is located by the kitchen. The washer/dryer appears to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision. At 12:50pm, smoke and carbon monoxide detectors were tested and observed to be operable. At 1:00pm, LPAs toured the outside area of the facility. LPAs observed appropriate outdoor furniture, with a covered shaded area for residents. The outdoor area was free of visible immediate hazards. LPAs discussed the importance of maintaining care and supervision to meet the needs of residents. Between 1:10pm to 2:00pm, LPAs reviewed records of five (5) residents and two (2) staff. Client and staff records appeared to be complete and updated. LPAs were informed that no Certificate of Liability Insurance is available at this time and will be provided to the department within two (2) weeks. Deficiency issued during this visit. Exit interview conducted and copy of this report signed.the state’s words, verbatim · CDSS document, Apr 8, 2026

Type of visit: Required - 1 Year

At 9:30am, Licensing Program Analyst (LPA) Huma Rahimi arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with the staff. Vanisa Campbell, who granted access to the facility and Administrator Sylvia Jackson was contacted via phone. The Administrator arrived shortly after. LPA explained the reason for the visit. At 9:45am LPA conducted a tour of the physical plant and observed the following: Facility is licensed for capacity of six (6) non-ambulatory, of which one (1) may be bedridden (in room #1). Facility also has a hospice waiver for two (2) residents. Kitchen: At approximately, 9:45 AM LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps observed to be locked in a kitchen drawer. LPA observed that all cleaning supplies and laundry detergents are locked under the kitchen sink. LPA observed a fire extinguisher hanging on the kitchen wall and fully charged and purchased on 01/23/2025. Laundry is located by the kitchen and the washer and dryer were actively running and operational. Medications: At approximately, 9:50 AM LPA observed medications are centrally stored and locked in a kitchen cabinet. At 12:55 PM, during the medication review for Resident #1 (R1), LPA could not verify the accuracy of the medication administration due to the lack of incomplete Centrally Stored Medication Destruction Form. Administrator informed LPA that the Administrator did not complete the form and was unable to provide a reason. Continue on LIC 809C Bedrooms: LPA observed total of four (4) bedrooms designated for residents use. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Facility has awake staff. Bathrooms: LPA observed two (2) bathrooms and both appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and client's bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. At 10:00 AM, hot water temperature measured at 113.7°F. Common Areas: The facility maintains a comfortable temperature at 76°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. The facility does not have a garage. LPA observed two closets, one by bedroom #4 where the extra linen and towels were stored, and another one by the living room where PPE supplies were stored. Outside areas: At approximately, 10:10 AM LPA toured the outside area of the facility. LPAs observed a clean covered patio and backyard furniture to accommodate the six (6) residents. Between 11:00am to 12:30pm, LPA reviewed records of five (5) residents and requested for one staff file. LPA was informed that Staff #1 (S1) file is not available for review since the Administrator did not complete a file yet. Resident files were not updated/completed. During the record review of the resident, LPA observed that Resident #4 (R4) was hospitalized twice. The first incident was on 12/09/2024, and the second incident was on 01/03/2025. LPA was informed that R4 was unresponsive on 12/09/2024 and was taken to the hospital. On 01/03/2025, R4 had a fall and R4’s lib was bleeding and R4 was taken to the hospital where R4 got stiches. LPA reviewed all incident reports on a system and did not observe any Incident Reports regarding R4. In addition, the Administrator admitted that no incident was submitted to the Regional Office (RO) since the Administrator did not know to submit an incident report to the department when such occurrences occur. Based on Title 22 Regulation: a written Unusual Incident / Injury Report shall be submitted to CCLD within seven (7) days of occurrence. LPA informed the Administrator that all staff members are mandated reporters and they are all responsible for reporting. Smoke detectors/carbon monoxide. Smoke detectors and carbon monoxide monitors were tested at 12:35 PM, and observed to be functional. Continue on LIC 809C Administrative: LPA was not provided with a Certificate of Liability Insurance, LPA collected LIC500. Deficiencies were cited during today’s visit. Appeal rights explained. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jan 23, 2025

Allegation investigated: Facility did not ensure that resident can attend a video visit with a physician. Facility confiscated resident's personal item. Staff engaged in verbal altercation in presence of resident Resident doesn't have a call assistance button or a pendant

At 10:00am, Licensing Program Analyst (LPA), Angela Panushkina, conducted a subsequent visit to deliver final report. LPA met with Staff #1 (S1), Eka Darsono, who granted access to the facility. Administrator was contacted and LPA explained the reason for the visit. Administrator was unable to come in and designated S1 to sign for the report. During the initial visit conducted on 05/13/23, LPA requested resident and staff roster. At 10:05am, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, relevant to the investigation. At approximately 10:10am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:30am – 12:10pm, LPA interviewed the Administrator, two (2) staff and five (5) out of five (5) residents. Continue on LIC9099-C Unsubstantiated Administrator informed LPA that R1’s visitor, who was not R1’s Power of Attorney (POA), would be very demanding and request S1 to provide detailed, daily information regarding R1’s food intake, care, etc. LPA was also informed that it was not fair to other residents that S1 was not available due to the "interrogation" process conducted by R1's visitor. So, the Administrator asked R1’s visitor, in a very professional tone of voice, to stop questioning facility staff and requesting extra work, since the facility staff is well aware of their duties and responsibilities. In addition, five (5) out of five (5) residents interviewed, expressed no concerns regarding this allegation. Therefore, based on interviews and LPA observation, this allegation is deemed Unsubstantiated at this time. Allegation: Resident doesn't have a call assistance button or a pendant It was alleged that the facility has no call assistance button/pendant for the resident. To investigate this allegation, LPA conducted an interview with the Administrator and was informed that although the facility has call buttons available to provide to the residents, currently none of their residents required/requested to have call buttons/pendants. Moreover, LPA was informed that all residents are verbal and when called for an assistance, the staff can easily hear the resident, since all four (4) bedrooms are located so close to one another. Two (2) staff members interviewed corroborated the statement provided by the Administrator. LPA was also informed that R1 has a bell, however, R1 never used it for an assistance. Instead, R1 just verbally called for help/assistance. During the interview with R1, at 12:20pm, LPA asked R1 to call the staff for an assistance. LPA observed R1 verbally called for help and S1 immediately responded. Lastly, five (5) out of five (5) residents interviewed, expressed no concerns regarding this allegation. Therefore, based on interviews and LPA observation, this allegation is deemed Unsubstantiated at this time. No deficiency cited during today's visit. Exit interview conducted and copy of this report signed and delivered. Allegation: Facility did not ensure that resident can attend a video visit with a physician. It was alleged that the facility did not provide residents (R1 in particular) with Wi-Fi to be able to have a virtual/zoom appointment with their Physician. To investigate this allegation, LPA conducted an interview with the Administrator and two (2) staff, who denied the above allegation. LPA was informed that the facility does have a Wi-Fi and Administrator provided the password. LPA was able to connect and use the facility Wi-Fi. Administrator also informed LPA that every time R1 is scheduled to see a doctor (in person or via zoom), the staff is willing to help/assist to get in, but R1 finds a reason to cancel and or reschedule. LPA conducted an interview with R1 who confirmed the statement provided by the Administrator. R1 also informed LPA that he/she didn’t feel well and canceled another appointment today (on 05/13/23) with the Dermatologist. Lastly, five (5) out of five (5) residents interviewed, expressed no concerns regarding this allegation. Based on interviews and LPA observation, this allegation is deemed Unsubstantiated at this time. Allegation: Facility confiscated resident's personal item. It was alleged that a package was delivered to the facility and a proof of delivery photo was available, however, the facility confiscated the order from R1. To investigate this allegation, LPA conducted an interview with the Administrator and was informed that all packages/mail delivered for residents are always being distributed to their right owner. Moreover, interview with two (2) staff revealed that no package was delivered for R1 that was confiscated by the facility. In addition, interview with five (5) out of five (5) residents expressed no concern regarding this allegation. Lastly, LPA requested a photo proof of the package delivery at the door (from the witness) to be emailed/texted, but it was never provided. Therefore, based on interviews this allegation is deemed Unsubstantiated. Allegation: Staff engaged in verbal altercation in presence of resident It was alleged that the Administrator is yelling at residents and their visitors. To investigate this allegation, LPA conducted an interview with the Administrator and two (2) staff, and all parties interviewed denied the above allegation. Continue on LIC9099-Cthe state’s words, verbatim · CDSS document, Nov 21, 2024 · control 31-AS-20230501105604

Type of visit: Required - 1 Year

At 9:30am, Licensing Program Analysts (LPAs) Angela Panushkina and Perchui Milena Khurshudyan arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPAs met with the Administrator, who granted access to the facility. LPAs explained the reason for the visit. At 9:45am LPAs conducted a tour of the physical plant and observed the following: Facility is licensed for capacity of six (6) Non-Ambulatory, of which one (1) may be bedridden (in room #1). Facility also has a hospice waiver for two (2) residents. There are four (4) bedrooms designated for residents use, two (2) bathrooms and LPAs were informed that the facility has awake staff at night. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs were observed. The hot water temperature measured at 113.7°F. Extra towels and linens were readily available. During the LPAs did not observe any immediate health and safety concerns. Smoke detectors and carbon monoxide monitors were tested at 11:20am and observed to be functional. Facility maintains a temperature of 77°F. LPAs observed there to be sufficient stock of one-week perishable foods and two-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. The fire extinguisher was observed in the kitchen area and was last serviced on 10/26/2023. Laundry is located by the kitchen, and LPA observed all chemicals and detergents are kept locked and inaccessible to residents in care. LPAs observed a clean covered patio and backyard furniture to accommodate the six (6) residents. Between 11:00am to 12:00pm, LPA reviewed records of four (4) clients and one (1) staff. Resident and staff records appeared to be complete and updated. LPA collected Certificate of Liability Insurance and LIC500. No citations issued during this visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jan 24, 2024

Type of visit: Case Management - Other

At 09:30am, Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Angela Panushkina conducted an unannounced Case Management Visit. The team met with the Administrator Sylvia Jackson and explained the reason for the visit. The purpose of todays visit is to review all residents and staff files for an accuracy. Team was informed that the facility currently has five (4) residents. Facility also has three (2) staff members, but during today's visit the team observed one staff member (S1) on duty. The team checked the Licensing Information System (LIC) and observed that (S1) is associated with this facility and the fingerprints are cleared. Resident Files: At 9:40am team conducted resident and staff records review. The following was observed. Four (4) out of four (4) resident facility files had all required documents. Staff Files: Administrator stated that the facility currently has four (2) staff members. All required documents and trainings are on file. No deficiencies are issued during today’s visit. Exit interviewed conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jan 24, 2024

Type of visit: Case Management - Other

At 09:30am, Licensing Program Analysts (LPAs) Angela Panushkina, Huma Rahimi, Leslie Ngo-Castaneda and Gina Saucedo conducted an unannounced Case Management Visit. The team met with the Administrator and explained the reason for the visit. On 12/01/22, an informal meeting was held at the Regional Office (RO) with the Administrator and concerns from Complaint #31-AS-20220210102557 were addressed. At that time, Regional Manager (RM) and Licensing Program Manager (LPM) advised the Administrator to conduct thorough pre-admission appraisals and complete staff training on Basic Services. The purpose of todays visit is to review all resident and staff files for an accuracy. Team was informed that the facility currently has five (5) residents. Facility also has three (3) staff members, but during today's visit the team observed one staff member (S1) on duty. The team checked the Licensing Information System (LIC) and observed that S1 is associated with this facility and the fingerprints are cleared. Resident Files: At 9:45am team conducted resident and staff records review. The following was observed. Five (5) out of five (5) resident file were either not available and or incomplete. Files were missing TB test results for four (4) out of five (5) residents, ID Emergency Sheets, and personal rights. Resident appraisals that were in the file did not have services explained and were missing signatures from the resident, and or responsible party. Please see LIC858 included with this report. Staff Files: Administrator stated that the facility currently has four (4) staff members. However, none of the staff members had a facility file available for review. Therefore, the following deficiencies are issued per CA Code of Regulations, Title 22. See LIC809-D. Exit interviewed discussed, appeal rights explained and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Oct 12, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Oct 19, 2023

87506 Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. Resident records were incomplete and or missing documents, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: Licensee agreed to complete five (5) out of five (5) resident files.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: Oct 19, 2023

87412 Personnel Records: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. Upon LPA's request Licensee/Administrator was unable to provide S1's facility records. LPA was informed that S1 got hired in Fabruary 2023 and no file was completed. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 12, 2023

Plan of correction: Licensee agreed to have a individual file for each staff member along with the training certificate.