House of Grace 2

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent unannounced Required-1 year visit for annual continuation. LPA met with Vanessa Arbis, Caregiver and Tito Riobuya, Caregiver and explained the purpose of the visit. The administrator, Michelle Aguirre was called on the phone and was not able to meet with LPA during the visit. Shortly after, Co-Administrator Rebecca Sinclair arrived to assist. LPA continued with the inspection using the Compliance and Regulatory Enforcement (CARE) tool and observed the following: Staffing: A total of (4) staff members including the Administrator provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility. Current Administrator's certificate is valid and expires on 08/28/2026. Personnel Records-Training: Staff files are maintained at the facility. LPA reviewed (2) staff files. Proof of staff training, health clearance, and vaccinations are current. Dementia care is part of training for direct care staff. Resident Rights-Information: Resident rights are posted. Facility provides internet service and phone to the residents. Planned Activities: The facility provides sufficient space to accommodate both indoor and outdoor activities. Resident Records-Incident Reports: LPA reviewed (6) Resident files. Residents files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment,Resident Personal Propert y and Residents Personal Rights observed. *****REPORT CONTINUED ON LIC809-C***** Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan which is posted. Facility conducts emergency drill (earthquake & fire) at least quarterly. Residents with SHN: Facility accepts and retains residents with dementia. Facility has sufficient space to permit residents with dementia to wander freely and safely. Co-Administrator and staff stated that there is no night shift staff on duty to supervise residents with dementia. All (6) residents have hospital bed rails with authorizations on file. (2) of (6) residents are under hospice care. Resident #3 (R3) and Resident #5 (R5's) file physician’s report has a Dementia diagnosis that are over a year old. Deficiencies cited on LIC 809D and Technical Violation issued. Exit interview, appeals rights and a copy of this report were provided to Rebecca Sinclair, Co-Administrator.the state’s words, verbatim · CDSS document, Dec 29, 2025

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required-1 year visit. LPA met with Vanessa Arbis, Caregiver and Tito Riobuya, Caregiver and explained the purpose of the visit. At 1:50pm, Rebecca Sinclair, Co-Administrator arrived and assisted LPA with the inspection. The facility is licensed to serve six (6) non-ambulatory residents ages 60 years of age or older. The facility may retain a maximum of (6) hospice residents. LPA inspected the facility using the Compliance and Regulatory Enforcement (CARE) tool and observed the following: Infection Control: Staff are adhering to infection control requirements. The staff use disposable gloves to clean and disinfect the high touched surfaces in the common areas. Facility has sufficient PPE supplies and has an Infection Control Plan maintained at the facility. Physical Plant/Environment Safety: The facility is a single-story home which consists of: living room with covered fireplace, dining area, kitchen, (3) bedrooms (3 residents and 1 staff), 3 bathrooms, laundry area, back yard, front yard and detached garage where part of it is used as caregivers bedroom. Resident bedrooms were inspected. The bathrooms are clean and operational. The hot water temperature was tested throughout the facility. Water temperature readings did not measure within the required 105 - 120 degrees Fahrenheit. At approx. 1:30pm, readings were 140 deg F in bathroom #2 and 133.8 deg F in bathroom #2. At 2:30pm, LPA re-checked the hot water temperature and readings were 135.3 deg F in bathroom #2 and 130.7 deg F in bathroom #3. LPA observed sufficient food supply of (2) days of perishables and (7 days) of non-perishables. Knives, disinfectants, and cleaning solutions are kept locked and inaccessible to residents. Smoke detectors and carbon monoxide detectors were tested and operable. Fire extinguisher is fully charged and last serviced on 05/13/2025. The first-aid kit is fully stocked w/first-aid manual. The front yard is free of debris/hazards and the outdoor and passageways are free of obstruction. A shaded area with outdoor furniture is provided in the back yard. The backyard is free of debris/hazards. There is no evidence of bodies of water (pool) or security bars nor weapons on the premises. LPA observed part of the garage is being used as a sleeping room for staff. Operational Requirements: The facility accepts and retains residents with dementia. The plan of operation includes training for staff who provide dementia special care. Facility maintains liability insurance in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate which expires on 06/16/2026. According to the co-administrator, the facility does not handle cash resources for the residents. *****REPORT CONTINUED ON LIC809-C***** Food Service: The kitchen was inspected and sufficient food supplies of 2 day perishable and a week of non-perishable are observed. Pesticides and cleaning supplies are kept away from the food preparation areas. Incidental Medical Services: Residents medications were reviewed. The facility does not use the Medication Administration Record (MAR) or other type of documentation log to document medications given. Medications were stored in a locked cabinet and inaccessible to residents. Due to time constraints, the annual continuation will be conducted at a later time. There were deficiencies found during today’s inspection. Deficiencies are cited on the attached LIC809D. Exit interview was conducted with and a copy of this report was provided to Rebecca Sinclair, Co-Administrator.the state’s words, verbatim · CDSS document, Dec 18, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alberto conducted the required annual inspection. LPA arrived unannounced and met with Caregiver Maedna Arbis who allowed the entry of the facility and explained the purpose of the visit. Shortly after the administrator Michelle Aguirre arrived and assisted with the visit. The facility is licensed for residents ages 60 and over, may retain a maximum of four (4) hospice residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. 2. Operational Requirement: The Infection Control Plan has been added to the Operation Plan. The facility has a Dementia Waiver in place. A Hospice Waiver for 6 residents is approved. Liability Insurance is updated and in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place. 3. Physical Plant and Environmental Safety: The facility is a single-story house and located in a residential neighborhood area. The facility includes Dining area, kitchen, sitting room, three residents bedrooms, two resident bathrooms, one guest bathroom, laundry room, live in staff room and a detached garage. Each resident bedroom has two beds, two drawers, required beddings and furniture and sufficient lighting and closet space. The two residents bathrooms are clean, sanitary and in a good working condition. Both bathrooms have the required grab bar and non-skid mat. The two bathrooms hot water temperature were tested between 127.9 and 129.9 degrees F. which is not within the Tittle 22 regulation. All the appliances in the kitchen and living room are working well. The sharp knives are stored in a locked kitchen drawer. (Continue on 809C) All the cleaning supplies and chemicals are stored and locked in a cabinet in the laundry room. The linen and towels are stored in the hallway cabinet. The extra personal hygiene products are stored in the laundry room cabinet. The carbon monoxide detectors were inspected, and they are working properly. The facility has patio with table and chairs for resident to utilize outdoor activity. The Passageway, walkway and patio are free of obstruction. 4. Staffing: The facility has sufficient staffing, and the night supervision staff did receive planned emergency training. 5. Personnel Record-Training: All the staff files are maintained in the facility. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. All the direct care staff received Medication Management Training. The first aid training certificates for staff is current. 6. Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, 1 resident does not have current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. 7. Resident Rights-Information: The Complaint, ombudsman and CCLD poster and Residents personal rights are posted by the main entry. Visiting hours were posted at facility. 8. Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability. 9. Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be very clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept very clean and free from rodents. 10. Incidental Medical and Dental: The medication is centrally stored and locked in the medication cabinet in the kitchen. Four (4) centrally stored resident medications were reviewed, which contained 30-day supply of medications. R4 did not have doctor’s order or label. Facility will provide transportation to resident for medical and dental appointment if needed. 11. Disaster Preparedness: The last fire drill was conducted on 0910/2024. Records of resident Appraisal and Needs services plans are part of Emergency training. The facility has an Emergency Disaster Plan (LIC610E) dated on 09/14/24 that needs to be update. The facility has two alternative temporary shelter location. 12. Resident with Special Health Needs: Two (3) residents are receiving home health services. One (3) receive hospice care. No resident is currently on postural support. Half and full bed rails for mobility assistance were observed in resident rooms with physician order. Individual Service Plans and Appraisals are on file. No residents have prohibited health conditions. Deficiencies observed during today’s visit. Technical Advisory provided. An exit interview was held. A copy of this report, one technical advisory note, and appeal rights were provided.the state’s words, verbatim · CDSS document, Oct 7, 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.

Allegation investigated: Staff did not provide proper supervision to resident in care. Neglect/lack of care & supervision led to resident sustaining a fracture. Staff did not seek timely medical care for resident in care. Staff did not provide a copy of the signed admission agreement to resident's representative in a timely manner.

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit regarding the above allegations. LPA met with Edna Arbis (Caregiver) and explained the reason for the visit. The investigation consisted of the following: On 04/05/2023, the Investigation Bureau (IB) accepted the complaint for investigation and assigned it to Investigator Douglass Real. On 04/06/2023, LPA Joe Katrdzhyan reviewed the file of Resident #1 (R1) and obtained copies of the following documents: Identification and Emergency Information Sheet, Admission Agreement, Agreements and Consent for Medical Treatment, Physician's Report, Resident Appraisal, Durable Power of Attorney, Unusual Incident/Injury Report, Centrally Stored Medication and Destruction Record, PRN Authorization Letter, Radiology Report, Facility Daily Logs/Notes, Transportation Invoice, Client Personal Property and Valuables, Resident Roster, Staff Roster. On On 09/03/2024, LPA Mora interviewed Administrator, Staff 1 (S1) and Staff 2 (S2) to gather additional information regarding the above allegations. During today's visit, LPA interviewed the second Administrator, Staff 1 - Staff 2 (S1 - S2), Resident 1 (R1) representative, and Resident 2 - Resident 7 (R2 - R7).(Continued to LIC 9099) Substantiated IB investigation and documents obtained revealed the following: Resident 1 (R1) was admitted to the facility on February 22, 2023. R1 physician report noted that R1 was non-ambulatory and suffered from dementia. The resident appraisal noted that resident was ambulatory (contradicted physician report), does not use a walker or wheelchair, but needs help with transfers and bathing, and was a fall risk. On February 28, 2023, at about 3 am, Staff 1 (S1) heard noises and saw R1 standing in the hallway and was taken back to bed. At around 6:30-7am, Staff 2 (S2) saw R1 on the floor near the bed. R1 could not get up on his/her own and needed assistance from staff. According to S1, the resident made a noise indicating being in pain. S1 asked R1 if it hurt and R1 pointed to the hip. Around 9am, the administrator contacted R1's POA to advise them of the incident and asked them to come and take the resident for an x-ray. The POA husband came to the facility about noon but was turned away by the staff because the resident was sleeping. Staff advised that they would contact the POA if the resident's status changed. The administrator texted the POA about 12:30pm and advised that the resident was still in pain. At 2:30pm, paramedics were called but they would not transport resident as they deemed it to be a non-emergency. On March 1, 2023 at 8:43am, the administrator texted the POA to get the resident an x-ray. The husband of the POA picked up the resident around 12pm and took him to urgent care for an x-ray. The resident returned to the facility pending the results. The following day March 2, 2023, they were notified that the resident suffered a fracture. The paramedics were called and refused to transport the resident as it was not an emergency. The administrator finally arranged for private transportation to the hospital. The resident went to the hospital and did not return to the facility. On 09/03/2024, LPA Mora conducted a subsequent visit to gather additional information and obtained the following per interviews with Administrator, S1 and S2: there was no care plan for this resident and Administrator stated because there is no Title 22 regulation that says they have to have a care plan because they are not a medical facility. Administrator also stated that staff check up on the residents while they are awake and once the residents go to sleep the staff do not conduct additional checkup because this is not a 24-hour care and supervision facility. There are no staff awake and they are just there for emergencies. S1 and S2 both confirmed that they sleep at night. S1 sleeps in the caregiver room and S2 sleeps in the living room. S1 showed LPA that they have audio baby monitor in each of resident bedrooms, and they place one in the living room for S2 and one in the staff bedroom for S1. If they hear anything on the monitors, then they wake up to go assist the residents. Both S1 and S2 confirmed that they were asleep on February 28, 2023. (Continued to LIC 9099-C) Regarding allegation "Staff did not provide a copy of the signed admission agreement to resident's representative in a timely manner" it is alleged that R1's representative requested for a copy of the admission agreement on the day of admission and administrator did not provide it in a timely manner. R1's representative stated that the other attempts to get a copy was done via text on 02/25/2023, 03/01/2023, 03/06/2023 and 03/10/2023, but administrator was still not providing the copy. It wasn't until 03/11/2023 that R1's representative received a copy. Text messages between R1's representative and the administrator were submitted to the department that were sent . The text messages dated 03/01/2023 shows R1's representative asking for paperwork and Administrator responded "Can I ask why we are so needing my paperwork? No families ask for this. But again it will be done when I can get it done". Based on IB and LPA interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 is being cited on the attached LIC 9099-D. An immediate Civil Penalty of $500.00 is being issued today due neglect/lack of care & supervision led to resident sustaining a fracture (Refer to LIC 421IM). At this time an Enhanced Civil Penalty (ECP) determination is pending in reference to Health and Safety Code 1569.49(f) and may be assessed at a later date. Exit interview conducted with staff. A copy of the report and appeal right was provided. Regarding allegation "Staff restrained resident in care" it is alleged that staff restrained R1 by sitting R1 on lazy boy recliner. The second Administrator and staff denied the allegation. Residents interviewed could not corroborate the allegation. LPA observed three residents relaxing on the recliners. Two of them were sleeping. There was a staff in the living room observing them. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Exit interview held and a copy of the report was providedthe state’s words, verbatim · CDSS document, Oct 2, 2024 · control 28-AS-20230404133757

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(c)(4)(A) · Plan of correction due date: Oct 3, 2024

In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement was not met as evidenced by Based on interviews and records, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. R1 had dementia which required that the facility had at least one night staff awake. Both S1 and S2 were asleep on 02/28/2023.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: Licensee is to comply with Title 22 Section 87705 at all times. Additionally, Licensee will submit a statement on how they will comply with this regulation to Community Care Licensing Division (CCLD) by 10/03/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.2(a)(4) · Plan of correction due date: Oct 3, 2024

Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not met as evidenced by: Based on interviews and records, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. The facility failed to develop a care plan based on the resident’s specific needs and to address the resident as a fall risk.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: Licensee is to comply with Title 22 Section 87468.2 at all times. Additionally, Licensee will submit a statement that they will comply with this Title 22 regulation to Community Care Licensing Division (CCLD) by 10/03/2024.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Oct 3, 2024

Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4). This requirement was not met as evidenced by Based on interviews and records, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. The staff found the resident on the floor between on 02/28/2023 at 6:30-7am and showed signs of pain. Administrator did not contact 911 until 2:30pm.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: Licensee is to comply with Title 22 Section 87465 at all times. Additionally, Licensee will submit a statement that they will comply with this Title 22 regulation to Community Care Licensing Division (CCLD) by 10/03/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(e) · Plan of correction due date: Oct 3, 2024

Admission Agreements (e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any, immediately upon signing the admission agreement or modification. The licensee shall provide additional copies to the resident or resident’s representative upon request. This requirement was not met as evidenced by Based on interviews and records, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Administrator failed to provide a copy of the admission agreement to R1's representative in a timely manner.the state’s words, verbatim · CDSS document, Oct 2, 2024

Plan of correction: Licensee is to comply with Title 22 Section 87507 at all times. Additionally, Licensee will submit a statement that they will comply with this Title 22 regulation to Community Care Licensing Division (CCLD) by 10/03/2024.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with Caregiver Maedna Arbis who allowed the entry of the facility and explained the purpose of the visit. Shortly after the administrator Michelle Aguirre arrived and assisted with the visit. The facility is licensed for residents ages 60 and over, may retain a maximum of four (4) hospice residents. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: 1. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. The facility has submitted a COVID-19 Mitigation Plan and Infection Control Plan. All staff has an updated health screening in file. 2. Operational Requirements: The fire clearance is cleared for the facility for 6 non-ambulatory. Currently all residents are non-ambulatory and no one is bedridden. The facility has the sufficient amount for liability insurance covering injury to residents and guests. Liability Insurance in the amount of at least ($1,000,000) per occurrence and total amount of aggregate ($3,000,000) is in place. 3. Physical Plant and Environmental Safety: The facility is a single story house and located in a residential neighborhood area. The facility includes: Dining area, kitchen, sitting room, three residents bedrooms, two resident bathrooms, one guest bathroom, laundry room, live in staff room and a detached garage. Each resident bedroom has two beds, two drawers, required beddings and furniture and sufficient lighting and closet space. The two residents bathrooms are clean, sanitary and in a good working condition. Both bathrooms have the required grab bar and non-skid mat. The two bathrooms hot water temperature were tested between 114.1 and 1118.2 degrees F. which is within the Tittle 22 regulation. All the appliances in the kitchen and living room are working well. The sharp knives are stored in a locked kitchen drawer. All the cleaning supplies and chemicals are stored and locked in a cabinet in the laundry room. The linen and towels are stored in the hallway cabinet. The extra personal hygiene products are stored in the laundry room cabinet. The carbon monoxide detectors were inspected and they are working properly. The facility has patio with table and chairs for resident to utilize outdoor activity. The Passageway, walkway and patio are free of obstruction. 4. Staffing: Facility has sufficient staffing to provide care and supervision the residents. 5. Personnel Record and Training: All the staff files are stored and locked in the file cabinet near the kitchen care. All the staff in the facility are over 18 years old, fingerprint cleared and associated with the facility. All the staff has the required documents in their personnel files which include health screening, TB test result, required training hours and updated first aid certificate. The administrator is Michelle Aguirre and her administrator certificate expiration date on 08/28/2024. 6. Resident's Record-Incident Reports: The resident files are stored in the cabinet in the kitchen. LPA inspected all six (6) residents files and they all have the required documents which include face sheet, admission agreement, pre-appraisal, medication list and physician report with ambulatory status. Administrator reported that currently there's one new resident admission package is on the way by mail. 7. Resident's Right/Information: LPA observed the required posters posted along the hallway include Long Term Care Ombudsman, Community Care Licensing Complaint and Personal Right Poster. The residents also have internet service for at least one internet access device for residents to communicate with their family members or physician. 8. Planned Activity : Sufficient space to accommodate both indoor and outdoor activities was observed. They do have event planner comes once a week. Also during the week, they do play bingo, music time and activity time with residents. 9. Food Service: The facility has sufficient 2 days perishable and 7 days non perishable food supply in the facility. All the food are stored properly in the facility. Currently the facility has one resident is on puree diet and LPA reviewed the doctor's order. 10. Incidental Medical and Dental: The facility staff would arrange transportation for residents' medical and dental appointment if needed. LPA inspected all 6 residents medication and they are all centrally stored and they are stored in the locked medication cabinet. They all have 30 days supply of medication. 11. Disaster Preparedness: The facility has an updated emergency disaster plan (LIC610E) and the last fire drill was conducted on 09/2023. The facility has two alternative temporary shelter location. Records of resident Appraisal and Needs services plans are part of Emergency training. 12. Residents with Special Health Needs: No residents in the facility with prohibited health condition. Currently there are four resident on hospice and two residents on home health. Individual Service Plan and appraisals are on resident's files for home health and hospice. Due to residents are at lunch and staff are busy serving them and LPA was not able to interview the residents and staff. Exit Interview Conducted and a copy of the report was provided to administrator Michelle Aguirre.the state’s words, verbatim · CDSS document, Oct 24, 2023

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.