Indocare House 1

Allegation investigated: Staff did not treat resident with respect. Staff did not ensure resident had enough clothing.

On 12/23/2025 at 9:30 AM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with facility licensee Paul Lomendehe and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 5. A brief interview with conducted with Paul. Allegation: Staff did not treat resident with respect It was alleged that staff did not treat resident with respect. This investigation consisted of interviews with residents and facility staff. On 12/15/2025 LPA Hughes conducted a visit to the facility, and spoke with 3 out of 4 residents in care who all stated that they have no concerns about facility staff not treating them with respect. Interview with 2 out of 2 facility staff stated that residents in care are always treated with respect. An additional interview with resident (R1) indicated at facility staff were nice to them, however R1 reported that staff did not answer questions related to their personal relationship with family, which does not indicate that R1 was treated disrespectfully. There is not enough information to corroborate this allegation, therefore the allegation is unsubstantiated. LIC 9099-C Unsubstantiated Allegation:Staff did not ensure that resident had enough clothing It was alleged that staff did not ensure resident had enough clothing. This investigation consisted of interviews with facility staff, residents, and records review. Interview with facility staff stated that the facility does not provide clothing for residents in care. However the facility licensee stated that resident (R1) arrived to the facility with very limited clothing supply, and the facility used their own funds to purchase clothing for the resident. Interview with 3 out of 4 residents in care reflected that residents have no concerns about not having adequate clothing, stating that their responsible parties purchase clothing on their behalf. Interview with resident (R1) indicated that the facility only provided used and donated clothing items to the resident. LPA reviewed records for resident (R1) which reflected that the facility Admissions Agreement does not indicate the facilities responsibility to provide clothing to residents in care, or specify an agreement that resident (R1) P&I funds should be used for clothing. Review of R1’s LIC 621 Client/Resident Personal Property and Valuables indicated that the resident arrived at the facility with very limited clothing items. Additional review of the LIC 405 Record of Client's/ Residents Safeguarded Cash Resources in R1’s file did not show that the facility handles cash for the resident. There is not enough information or evidence to corroborate this allegation, therefore the allegation is unsubstantiated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a copy of this report was provided to facility at the end of this visit. Interview with the facility licensee stated that resident (R1) was taken to the dentist upon their arrival to the facility in September 2020. LPA requested to review R1’s dental records but was told that the facility did not have any records on file, and the dental office where R1 received dental treatment was now closed. Interview was resident (R1) revealed that they never received dental care while residing in the facility. This allegation was observed not in compliance with Title 22 regulation Incidental Medical and Dental Care 87465(a)(2). As the facility did not ensure a resident in care dental needs were met. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Paul and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility.the state’s words, verbatim · CDSS document, Dec 23, 2025 · control 27-AS-20251210082509

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2) · Plan of correction due date: Dec 26, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance... The licensee shall provide assistance in meeting necessary medical and dental needs... This requirement was not met as evidenced by: The facility did not ensure that a resident in care (R1) was provided with routine dental care as needed.the state’s words, verbatim · CDSS document, Dec 23, 2025

Plan of correction: The licensee agrees to remain in compliance with Title 22 regulation 87465 at all times. The licensee agrees to provide assistance to routine medical and dental appointments for residents in care as needed. The licensee will retain records of routine medical and dental appts for residents in care. The licensee agrees to provide LPA Hughes with a statement of acknowledgement and understanding of the regulation by 12/26/2025 via email.

Type of visit: Required - 1 Year

On 10/07/2025 at 9:00 AM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived at the facility to conduct an unannounced annual inspection. LPA Hughes met with the facility designated administrator Teresita. The current census is 6 with 3 facility staff. This facility is a single story building licensed to serve six (6) non-ambulatory residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 111.6 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in the entry way and was last serviced on 01/31/2025. LPA observed the facility has a public telephone in the kitchen area and the facility has the required posters posted. Facility thermostat was observed at 72 degrees Fahrenheit. LPA observed toxins located in the facility garage kept locked and inaccessible to residents. LPA observed sharp knives kept locked in the kitchen and inaccessible to residents. Continuation 809-C LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 3 out of 6 residents medications and the medication administration record (MAR) was complete. The first aid kit was checked and contained the required components. LPA requested resident and staff files for review. LPA reviewed 6 out of 6 resident files and they were incomplete. LPA observed LIC 602 Physician's Report for resident (R1) incomplete, as the residents TB results were not documented on the report. LPA reviewed 3 staff files, and it was complete. LPA reviewed 3 staff files and criminal caregiver background checks are fingerprint cleared. The following documents will be emailed to the LPA by 10/10/2025 (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate (3) LIC 610 Current Emergency Disaster Plan (4) Proof of Current Liability Insurance (5) LIC 500 Current Personnel Report As a result of this annual visit, the facility is not in compliance with Title 22 Regulations, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with Teresita and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Oct 7, 2025

Type of visit: POC

On 9/18/24 at 2:15pm Licensing Program Analyst (LPA) made an unannounced Plan of Correction (POC) inspection to ensure pervious deficiencies have been addressed and corrected. LPA observed the door to the back bedroom has been replaced/repaired and is in compliance with Title 22 regulations. LPA also addressed an advisory note issued during previous inspection regarding the non-ambulatory status of a resident who's 602 identifies the resident as bed bound in comments and selected both non-ambulatory and bedridden on the resident's 602 (physician's report). LPA again asked again and provided clarification for the need of an updated LIC 602 to ensure the resident is appropriately placed and the facility is in compliance with their fire clearance. POC letter generated and a copy of this report and POC letter was left at the facility.the state’s words, verbatim · CDSS document, Sep 18, 2024

Type of visit: Required - 1 Year

On 8/28/24 at 1:40pm Licensing Program Analyst (LPA) Kevin Gould arrived at Indocare House 1 for the purpose of conducting a required 1 year annual inspection. LPA met with staff, Jendri Kolibu and together conducted a tour of the home. LPA and staff evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor and clean LPA observed one broken door on the back bedroom that is in need of repair replacement. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the water temperature, temperature measured at 113 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA observed R1's resident file and observed two conflicting physician reports regarding the resident's non-ambulatory bedridden status written days apart. LPA has informed the facility that R1's physician report must be updated and to contact LPA once completed to determine if the resident is able to reside in the facility due to the facility's fire clearance. LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 9020 client roster and current administrator certificate. Per California Code of Regulations, Title 22 the following deficiency is cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Aug 28, 2024