Jbm Residence Home

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Evelin Rios is conducting and unannounced Case Management - Other visit. In conjunction to a POC visit 07/13/2026. On 7/03/2026 LPA received a verbal notification by the Licensee about voluntarily forfeiting their license. Licensee confirmed residents were only verbally notified of future closure on 07/04/2026. LPA was informed that Resident #2 (R2) was "discharged" from the facility on Friday, July 10, 2026. At approximately 10:56 a.m. Resident #1 (R1) was picked up by a scheduled transport. LPA contacted R1's and R2's responsible person(s) and confirmed transfer arrangements. LPA cited the facility for Eviction Procedures on POC visit 07/13/2026. During today's visit, LPA conducted a physical plant tour with the Licensee and observed there to be no residents living in the facility. LPA’s interview with the Licensee today confirms they voluntarily surrender their license to finalize the closure of the facility. This closure will take effect today 7/13/2026. The reason for closure of the facility is licensee initiated. Licensee surrendered physical License to LPA. LPA will submit the file for closure upon returning to the Woodland Hills South Regional Office. LPA will e-mail the closure survey. Exit Interview conducted and copy of this report provided to Licensee.the state’s words, verbatim · CDSS document, Jul 13, 2026

Type of visit: POC

Licensing Program Analyst (LPA) Evelin Rios arrived to this facility to conduct and unannounced POC visit for citations issued on 07/03/2026. LPA rang the door bell and was greeted by the Licensee. Licensee granted access. LPA informed Licensee the purpose of the visit. LPA was informed that Resident #2 (R2) was "discharged" from the facility on Friday, July 10, 2026 and admitted to a new assisted living facility. LPA obtained a copy of a signed document by R2's responsible person (RP) dated July 10, 2026. According to the Licensee on 07/04/2026 she verbally informed R2's and Resident #1's (R1's) RPs the facility would be closing. Licensee did not provide the residents or their RPs the required 60 day written eviction notice. The Licensee states a written eviction notice would still be provided to residents' RPs. The Licensee informed LPA, R1 will be discharged from the facility today, July 13, 2026. According to the licensee the decision to transfer the residents out were made by the residents' RPs before a written eviction notice could be provided. LPA contacted R1's and R2's, RPs and was informed that a 60 day written notice was not provided to them. Original Citations and POC's with results of the POC visit are as follows: H&S Code 1569.605: The licensee did not obtain liability insurance. POC: The licensee will obtain liability insurance by 07/06/2026. POC was not cleared. The licensee stated the Insurance Broker was not able to assist with obtaining Liability Insurance as facility's application was denied. Licensee is forfeiting their license. (Continue to LIC809-C) 87465(h)(5) Incidental Medical and Dental Care Services / Resident's medication was transferred from one bottle to another. POC: The licensee will contact R1's physician and request a refill of the medication. Licensee will conduct vendorized training regarding medication and provide copy registration to training to the department by 07/04/2026. POC was not cleared. Licensee contacted R1's RP requesting a medication refill. Licensee is closing facility. 87465(e) Incidental Medical and Dental Care Services / 2 out of 2 residents did not have a physician order for their medication. POC: The Licensee will obtain prescription orders from the residents' physicians by POC due date 07/10/2026. R2 is no longer in the facility. Licensee provided LPA a copy of physician's order for R1's medication. POC cleared today. 87463(a) Reappraisals / 2 out of 2 residents not having reappraisals once every 12 months or as necessary. POC: The licensee will update resident appraisals for both residents and send a copy to the department by POC 07/10/2026. Licensee provided LPA with re appraisals for R1 and R2. POC cleared today. H&S Code 1569.695(c) / The licensee did not conduct a quarterly emergency drill on each shift. POC:The licensee will conduct two emergency drills, one for earthquake and one for fire for every shift and send documentation of completion with staff names for each shift completed to the department by POC due date 07/10/2026. POC not cleared. Licensee will close facility. H&S Code 1569.618(a) / The administrator has not been present at the facility during normal working hours in the last month. POC: The licensee will complete time sheets when the administrator is present at the facility for the next two weeks and provide time sheets to the department by 07/17/2026. Due to the facility's closure POC will not be provided. According to the Licensee the Administrator has not been to the facility. LPA conducted a physical plant tour and observed R2 was no longer in the facility. Exit interview conducted. Deficiency cited. Refer to LIC 809-D. Copy of appeal rights and a copy of report provided to Licensee.the state’s words, verbatim · CDSS document, Jul 13, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(a)(5)(A)(1) · Plan of correction due date: Jul 14, 2026

87224 Eviction Procedures (a) The licensee may evict a resident for ... (5) Change of use of the facility. (A) ... sixty (60) days written notice, evict ... 1. ... written notice ... shall be made to the resident or the resident’s responsible person ... This requirement is not met as evidenced by: Based on interviews, the licensee did not comply with the section cited above in not providing resident R1 and R2 and their responsible person(s) a proper 60 day written eviction notice which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 13, 2026

Plan of correction: Licensee is moving forward with forfeiture of license. Licnsee will provide 60 day written eviction notices to RPs and submit copy of notice to the department.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Evelin Rios arrived to this facility to conduct and unannounced annual required visit. LPA rang the door bell and was greeted by the Licensee. Licensee granted access. LPA informed Licensee the purpose of the visit. This is an Residential Care Facility for the Elderly (RCFE), with an approved fire clearance for (6) non-ambulatory residents of which one (1) can be bedridden for a total capacity of six (6). The facility is a single story building with six (6) bedrooms and three (3) bathrooms. At approximately 9:20 a.m., LPA conducted a physical plant tour of the facility, both inside and outside, and observed the following: There is only one entrance being utilized at the facility. At the entrance LPA observed a visitor sign-in log and hand sanitizer. LPA observed required postings through out the facility. Common areas were observed clean and surfaces were clear of clutter. The dining area was observed with a table and chairs that sit the capacity of the facility. The living room was observed to be properly furnished with couches and recliner. The fireplace was observed not in use and covered with a screen inaccessible to residents. The kitchen was observed to have a sufficient amount of (2) days perishable and seven (7) days non-perishable food. Kitchen area was observed clean and free of pests. Knives and sharps were observed to be locked in a kitchen drawer inaccessible to residents. Kitchen appliances, the refrigerator, stove, dishwasher and microwave were observed functioning properly. The fire extinguisher located by the the kitchen was fully charged. (Continued on LIC 809-C) LPA observed two facility telephones. telephones were tested, and both were functioning properly. In the hallway leading to bedroom #3, #4 and #5, LPA observed a closet with extra linens. Hallways and passageways were lighted appropriately. The facility has five (5) bedrooms for resident use and one (1) staff room for live-in staff. The bedrooms have the required furniture, lighting and storage. Bedroom #5 can be shared. Exit doors in bedrooms were opened to test auditory alarms. LPA observed the auditory alarms were on and functioning properly. The bathrooms were checked for cleanliness and proper operation. Under sink cabinets are used to store cleaning supplies and were observed locked. The hot water temperature was measured in all bathrooms and read within regulations between 105.1°F and 105.4°F. The laundry room is accessible located near bedroom #4 and leads to the attached garage. Laundry detergents, cleaning agents, and other toxins are stored in a locked cabinets in the laundry room. The attached garage is accessible through the laundry room. The door leading to the garage was locked and the garage is being utilized for extra storage. The backyard of the facility is fenced in equipped with a patio and outdoor furniture for residents. Outdoor passageways were clear of obstructions. No bodies of water observed. Facility records are kept in a cabinet by the kitchen. At 11:05 a.m., LPA reviewed two (2) of two (2) resident records. Both residents do not have annual reappraisal on file or documentation indicating refusals to participate. Medications and first aid kit are kept locked in a kitchen cabinet. LPA observed a First-aid kit. LPA observed medication for residents no longer in the facility that had expired on 2022 and 2023. According to the Licensee the family members never picked it up. LPA along with the licensee reviewed two (2) of two (2) residents' centrally stored medication and their centrally stored medication records for accuracy. (Page 2 of 3) Review of Resident#1's (R1's) medication and medication records revealed their Levothyroxine bottle has an expiration date of 12/09/2025 and had more then it's 30 pill quantity indicated on the bottle. According to the Licensee they had poured the new medication into the old medication bottle to save space. R1's Banophen label states "as needed". According to the licensee she has been giving it to the resident every day. Licensee believes the doctor made a mistake on the order. According to the Licensee, the resident has needed the medication every day. The quantity on the bottle is 15 and LPA counted 5 pills. LPA review of the facility's Medication Administration Record (MAR) and it indicated they had not documented the 10 pills given to R1. LPA requested to see the PRN authorization form. According to the Licensee they do not have one and will be requesting one from the doctor. R1's, Hydrocodone label directs to take half a tablet by mouth 2 times a day. Centrally Stored Medication Records revealed it was started on 06/13/2026. LPA observed only 15 half tablets have been provided since it started. According to the licensee they did not give the second dose to R1 because they were sleeping. LPA reviewed four (4) of four (4) staff records. LPA contacted the Administrator, Divina Heidlberg and left a voicemail for a return call. According the Licensee, they last spoke to the Administrator over the phone last month and she couldn't remember when the Administrator last worked in the facility. LPA's review of the staff weekly schedule indicated Administrator was scheduled 2 hours a day from Monday to Friday. Emergency Disaster Plan (610E) had not been updated. LPA was not provided documentation of quarterly emergency disaster drills conducted within the past year. According to the Licensee she had not conducted the training. The Licensee has not obtained liability insurance. According to the Licensee they have gone to different insurance companies but they will not approve an application for liability insurance. The licensee stated they will be closing the facility to retire. The licensee will provide proper notification to residents and their responsible parties by next week. Licensee will send a copy of the notification within the time frame required to the Department. LPA observed smoke/carbon monoxide detectors through out the facility. LPA observed the Licensee test the smoke alarm and it was functioning properly. Deficiencies observed during todays visit. Refer to LIC809-D. Exit interview conducted, Appeal Rights and a copy of this report was provided to Licensee.the state’s words, verbatim · CDSS document, Jul 3, 2026

The state marks this report as 9 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Allegation investigated: Licensee does not ensure that resident's dietary needs are met. Licensee does not assist resident with bathing.

On 01/20/2026 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to provide determinations on the above mentioned allegations. Upon arrival, LPA was greeted by staff and was granted access. LPA met with Licensee Representative, Josephine Miranda and LPA explained the purpose of the visit. To investigate the allegations, LPA conducted an initial unannounced complaint visit on 05/07/2025. From 9:50 a.m. to 11:00 a.m., LPA completed a physical plant inspection. During the facility tour, LPA interviewed two (2) hospice agency staff who were assisting a resident, as well as three (3) of the five (5) residents present. Resident #2 (R2) was sleeping, and Resident #5 (R5) did not respond to LPA’s questions. LPA also interviewed a wound care agency staff member who was assisting a resident. From 11:00 a.m. to 12:00 p.m., LPA reviewed five (5) resident records and three (3) staff records and obtained copies not limited to the following: residents’ physician’s report, pre-admission appraisals, resident appraisals and admission agreements. LPA also obtained copies of Personnel Records and the meal menu the facility uses. (Continue to LIC 9099-C) Unsubstantiated (Continued from LIC9099) LPA additionally interviewed two (2) residents’ family members who were visiting the facility. LPA conducted subsequent visits. On 05/09/2025, LPA interviewed Staff #1 (S1) and observed Josephine checking on Resident #4 (R4). At approximately 10:00 a.m., S1 began preparing breakfast for the residents. LPA obtained copies of Home Health and/or Hospice records for Resident #1(R1), Resident #2 (R2) and resident #5 (R5). On 08/11/2025, During this visit, LPA interviewed Josephine, two (2) of four (4) residents present, and a family member visiting a resident. LPA reviewed resident records and obtained copies of relevant information. On 08/20/2025, from approximately 11:20 a.m. to 12:00 p.m., LPA Rios conducted a physical plant tour and interviewed the Josephine and Staff #2 (S2). From approximately 12:00 p.m. to 12:42 p.m., LPA observed S2 cooking and preparing lunch for the residents. From 12:42 p.m. to 1:22 p.m., LPA interviewed one (1) of the three residents residing in the facility and a family member visiting Resident #4 (R4). LPA also observed three (3) out of three (3) residents eating their meals. Allegation: Licensee does not ensure that resident's dietary needs are met. It is alleged that Resident#1 (R1) is missing meals and appears to be extremely hungry and thirsty. During interviews with R1 on 05/07/2025 and 08/11/2025, the resident spoke generally about their experience at the facility but did not provide information regarding the allegation. LPA's interviews with R3 and R4 did not corroborate the allegation. LPA's interview with R4's family member on 08/20/2025, revealed they visit R4 often at different times and makes it a point to visit when breakfast is being served and again at a later time during the same day. According to R4's family member the meals are served on time, look good and R4 eats well. LPA's interview with two (2) staff and Josephine deny the allegation. LPA's Interview with three (3) representative from outside agencies providing care to residents in the facility did not corroborate the allegation. LPA interview with one (1) of R1’s family members, on 05/07/2025 and 08/11/2025 stated that R1 is eating the meals prepared by the facility. The family member reported that the food appears fine overall, but suggested that it be made softer for R1. LPA's interview with one other family member for R1 revealed R1 is hungry and thirsty every time they visit. Due to inconsistent and insufficient evidence LPA could not corroborate the allegation. Therefore, based on interviews and observations, this allegation is deemed Unsubstantiated at this time. Page 2 of 3 (Continue to LIC9099-C) (Continued from LIC9099-C) Allegation: Licensee does not assist resident with bathing. It is alleged that Resident #1's (R1's) feet are dirty and appear to be rotted. LPA's review of R1's Home Health paperwork revealed R1 was assessed for services and started services on 05/22/2025. Home Health assessment confirmed wounds on R1's right and left heal. LPA's review of R1's appraisal revealed R1 requires assistance with activities of daily living (ADL's) such at bathing. On 05/07/2025, LPA observed that R1’s toenails were uncut, however, the white bandages wrapped around both feet were clean, with no visible blood or soiling on the bandages or R1’s feet. LPA did not observe any visible dirt or smell foul odors. Interview with Josephine on 05/07/2025 revealed she made sure R1 received bed baths as they were waiting on more information regarding the assistance R1 would require. Furthermore, Josephine stated R1 was bathed two times a week. LPA's interview with two (2) staff denied the allegation. During LPA's interview with R1, the resident stated they were bathed. LPA's interviews with R3 and R4 did not corroborate the allegation. Based on interviews and observations, there was insufficient evidence to the allegation, Licensee does not assist resident with bathing. Therefore, the allegation is deemed Unsubstantiated at this time. LPA conducted a physical plant tour of the facility. No immediate health or safety hazards observed. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 20, 2026 · control 31-AS-20250429144827

Type of visit: Case Management - Deficiencies

In conjunction to complaint control #31-AS-20250429144827, Licensing Program Analyst (LPA) Evelin Rios met with licensee representative, Josephine Miranda. LPA explained the purpose of the visit. This visit is to notify the licensee representative of the facility’s ongoing concerns related to regulatory compliance under Title 22. The purpose of the visit was to address multiple non-compliance issues related to the facility’s hospice waiver, as referenced in complaint #31-AS-20240125095336 and a case management visit conducted on 08/11/2025, as well as additional deficiencies observed during recent visits. LPA informed the licensee that, due to the continued pattern of non compliance, the Department is seeking additional actions against the licensee. During today’s visit LPA requested a copy of the current Register of Facility Residents (LIC9020), Personnel Report (LIC500) and administrator’s file. According to Josephine she is responsible for the day to day operations of the facility and the administrator will come by to check on the residents, the care being provided, and medications. LPA contacted the administrator at 3:05 p.m., LPA was dialing the telephone number on file. The number would not connect. Josephine provided LPA a different telephone number. LPA dialed the number and left a voicemail for a return call. LPA has been unsuccessful at reaching current administrator, Divina Heidelberg. Exit interview conducted. Copy of this report provided.the state’s words, verbatim · CDSS document, Jan 20, 2026

Allegation investigated: Unlawful eviction. Facility staff did not seek medical attention in a timely manner.

On 09/22/2025 Licensing Program Analyst (LPA) Evelin Rios arrived to the facility to conducted an initial complaint visit to investigate the above mentioned allegations. Upon arrival, LPA was greeted by Staff #1 (S1) and was granted access. Inside, LPA met with Licensee, Josephine Miranda and explained the purpose of todays visit. At approximately 9:55 a.m., an entrance interview with the Licensee was initiated. During the course of the investigation, LPA obtained and reviewed copies of the following: facility's resident roster, Personnel Report (LIC 500), Resident #1's (R1's) admission agreement, R1's pre admission appraisal, R1's resident appraisal, R1's Unusual Incident/Injury Report, R1's Home Health documentation, R1's Physician Orders for Life-Sustaining Treatment (POLST), text messages exchanged between R1’s responsible person and the Licensee from 09/12/25 to 09/13/25, and a voicemail message left for the Licensee by R1’s responsible person on 09/12/25. (Continue to LIC9099-C) Substantiated (Continued from LIC9099) At approximately 10:21 a.m., LPA Rios conducted a physical plant tour of the facility. During the tour, LPA observed that R1 was not in the facility, Resident #2 (R2) and Resident #3 (R3) were asleep. No health or safety issues were observed at this time. Prior to today’s visit, LPA Rios conducted telephone interviews with R1’s responsible person and R1’s assigned Licensed Clinical Social Worker (LCSW), who is assisting with R1’s placement. Allegation: Unlawful eviction. It was alleged that the facility would not be accepting R1 after hospital discharge. To investigate this allegation, LPA conducted an interview with the Licensee and was informed that they had spoken to R1's LCSW sometime last week regarding R1's discharge and return to the facility. The Licensee confirmed they informed R1's LCSW that upon discharge they would not be admitting R1 due to R1's "unstageable" wounds and that she could not admit R1 because they were not allowed to take care of someone with "unstageable" wounds per Community Care Licensing (CCL). LPA's review of R1's Home Health services for wound care confirmed R1 had been receiving care for a wounds since 05/22/25 after being admitted to the facility on 04/12/25. On 08/11/25, an unannounced Case Management – Deficiencies visit was conducted. During the visit, the facility was cited for retaining R1, who had a prohibited health condition. As part of the plan of correction, the Licensee submitted an exception request to retain R1 at the facility. Licensee had not received a approval or denial from CCL. Upon LPA’s request, the Licensee could not provide R1's re appraisal regarding changes in the level of care. Additionally, the investigation revealed the Licensee did not serve R1 or their responsible person a written 30-day Eviction notice. On 09/17/25, a telephonic interview with R1's responsible person revealed that they had anticipated R1 going back, and had conversations with the licensee about making their monthly payment on 09/14/25 however, on the 09/16/25, R1's LCSW informed R1's reasonable person that the Licensee stated R1 requires a higher level of care. No re-appraisal and no conversation with R1's responsible person was done by the facility's Licensee to inform that the facility can no longer meet R1's needs. On 09/17/25, a telephonic interview with R1's, LCSW revealed they had made contact with the licensee to arrange R1's return when the Licensee informed them they would not be taking R1 back due to R1's Stage 3 wound and Licensing. Licensee also asked the LCSW to help with placement. Based on interviews and record review this allegation is Substantiated at this time. (Continue to LIC9099-C) Page 2 of 3 (Continued from LIC9099-C) Allegation: Facility staff did not seek medical attention in a timely manner. It was alleged that the Licensee informed R1's family that R1 may have had a "stroke" but did not call 911 until the next day. To investigate this allegation, LPA conducted an interview with the Licensee and was informed that around noon of 09/12/25 R1's family member in the presence of R1's Home Health nurse asked the Licensee why R1 was "screaming" and complaining of pain when they attempted to stretch out R1's left arm which was bent at the elbow. According to the Licensee and a review of text messages, the following is a representation of the events that occurred: On 09/12/25, the Licensee informed R1’s family member that they believed the contractions in R1’s arm and leg could be due to a “mini stroke.” According to the Licensee, R1’s family member appeared anxious and contacted R1’s responsible person. R1’s responsible person then reached out to the Licensee same day via telephone, sending a text message at 6:05 p.m., followed by a voicemail at 6:21 p.m., requesting that the Licensee call 911 if they believed R1 was experiencing a stroke. At approximately 8:27 p.m., the Licensee followed up with R1’s responsible person to clarify that they suspected R1 may have had a “mini stroke” that had gone unnoticed. When asked by the LPA why they believed R1 had experienced a "mini stroke", the Licensee explained that they had observed contractions in R1’s leg and now arm and asked their friend in the neurology field, who suggested there are different reasons but according to the Licensee their friend said based on the resident's age an symptoms it could indicate a stroke. The Licensee stated that they chose not to immediately call 911 because they wanted to monitor R1 and contact R1’s Home Health provider. However, since the provider was closed at that time, they waited until the next morning. On 09/13/25, at approximately 8:00 a.m., the Licensee contacted Home Health, who advised that if the Licensee believed R1 had suffered a stroke, they should call 911. Licensee admitted that they did not call 911 immediately after Home Health because they were gathering R1’s documentation to provide to the EMT. 911/Paramedics arrived to the facility at approximately 11:00 a.m. On 09/17/25, LPA Rios confirmed with R1’s Licensed Clinical Social Worker (LCSW), and later on 09/22/25 with R1’s responsible person, that R1 did not experience a stroke. However, the Licensee believed R1 had symptoms consistent with a stroke and still delayed seeking medical attention. Based on the information obtained this allegation is deemed Substantiated at this time. Deficiencies cited on LIC9099-D. Exit interview conducted, appeal rights explained and copy of this report signed and delivered. Page 3 of 3the state’s words, verbatim · CDSS document, Sep 22, 2025 · control 31-AS-20250917093042

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(g) · Plan of correction due date: Sep 23, 2025

87465 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... This requirement is not met as evidenced by: Based on interviews the licensee failed to call 911 immediately after the licensee suspected R1 had a "mini stroke" on 09/12/25 at approximately noon and waited to call 911 on 09/13/25 at approximately 11:00AM, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 22, 2025

Plan of correction: Licensee agreed to complete training on the regulation cited from a consultant. Licensee will provide the name of the consultant and training information along with the date the training is scheduled to LPA by POC due date 09/23/2025. Licensee will send a copy of the training completion certification to LPA.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87224(a) · Plan of correction due date: Sep 23, 2025

Eviction Notification (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required... This requirement is not met as evidenced by: Based on interviews the licensee failed to reassess R1 and failed to provide a 30 days written eviction notice to R1 and/or their responsible person, which posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 22, 2025

Plan of correction: According to R1's responsible person, R1 will not be returning to the facility. Licensee agreed to complete training on the regulation cited from a consultant. Licensee will provide the name of the consultant and training information along with the date the training is scheduled to LPA by POC due date 09/23/25. Licensee will send a copy of the training completion certification to LPA.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Case Management - Other visit to this facility in conjunction with a complaint control #31-AS-20250917093042. LPA met with the Licensee and explained the reason for the visit. During the course of the investigation for complaint control #31-AS-20250917093042, regarding the allegation of unlawful eviction of Resident #1 (R1), the LPA’s interview with the Licensee on 09/22/2025 confirmed that the Licensee had received a $3,200 payment for September 2025 but would not be re-admitting R1 into the facility following their hospital discharge. Furthermore the Licensee informed LPA, R1's Licensed Clinical Social Worker (LCSW) and R1's responsible party had requested September's month fee be returned as it would be needed to place R1 into another facility. According to the Licensee they had informed the responsible party that the $3,200 would be returned to them by 09/24/2025. The Licensee informed LPA that the check amount deposited into their account had been removed and they suspected the R1's responsible party had requested the money returned through their bank. R1's family member arrived to the facility today at approximately 3:30 p.m., and removed R1's personal belongings. Licensee will contact R1's Home Health to take R1's hospital bed. The matter of the monthly fee is considered resolved. No deficiency cited. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 22, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Evelin Rios conducted a Plan of Correction (POC) Visit. LPA Rios met with Licensee Josephine Miranda. Entrance interview was conducted. Purpose of the visit was explained. LPA conducted a physical plant tour of the facility. LPA reviewed POCs that have not been completed. LPA provided Licensee a Non-Compliance Conference letter requesting the Licensee and Administrator to attend a meeting in the Woodland Hills South Regional Office (RO) The following deficiency were not corrected: Health and Safety Code 1569.605: Licensee did not maintain liability insurance. POC has not been cleared as of POC due date 08/29/2025. 87615(a)(1) Prohibited Health Conditions: Licensee retained R1 who is not receiving hospice services and has a Stage 4 pressure injury. Licensee agreed to submit an exception letter to CCLD to retain resident with a prohibited health condition. Licensee failed to provide exception letter by POC due date 08/12/25. 87202(a)(2) Fire Clearance: Facility has fire clearance for one (01) bedridden resident in room #3, and based on physician's reports the facility currently has two (02) bedridden residents. POC has not been cleared as of due date 08/11/2025. The facility removed bed rails that extend the entire length of the bed for R1 and replaced them with half bed rails. Although a bed rail that extends from the head half the length of the bed and used only for assistance with mobility is allowed the facility has not obtained a written order from a physician indicating the need for the postural support. Exit interview conducted. Deficiency cited (refer to LIC809-D). Civil Penalty Assessed for failure to correct (refer to LIC421FC). Appeals rights provided. Copy of report provided.the state’s words, verbatim · CDSS document, Sep 5, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.605 · Plan of correction due date: Sep 6, 2025

...all residential care facilities for the elderly,... shall maintain liability insurance covering injury to residents and guests 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, ... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in not maintaining liability insurance which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 5, 2025

Plan of correction: Licensee will obtain liability insurance and send a copy of certification to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87202(a)(2) · Plan of correction due date: Sep 6, 2025

(a) All facilities shall maintain a fire clearance...Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance...(2)Bedridden persons. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above in that the facility has fire clearance for one bedridden resident and the facility currently has two bedridden residents which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 5, 2025

Plan of correction: The Licensee will ensure that the facility is in compliance with the fire clearance approved by the city or county fire department at all times. The Licensee will submit a written plan of action that will be implemented to ensure that the facility comes back into compliance and LIC200 with updated facility sketch to obtain additional bedridden fire clearance.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Sep 6, 2025

(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on record review and interviews the licensee did not comply with the section cited above by retaining R1 who is not receiving hospice services and has a unstageable wound which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 5, 2025

Plan of correction: Licensee agreed to submit an exception letter and required documentation to CCLD to retain resident with a prohibited health condition by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87608(a)(3) · Plan of correction due date: Sep 9, 2025

(a) Based on the individual's ... appraisal... Postural supports may be used under the following conditions. (3)A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. This requirement is not met as evidenced by: Licensee did not comply with the section cited above by not obtaining a written order from a physician indicating the need for bed rail that extends from the head half the length of the bed which poses an immediate health, safety personal rights risk.the state’s words, verbatim · CDSS document, Sep 5, 2025

Plan of correction: Licensee agreed to obtain a written order from a physician indicating the need for the bed rail. A copy of the order will be provided to LPA by POC due date.

Allegation investigated: Licensee does not ensure that resident's grooming needs are met Licensee does not assist resident with ambulating

Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced subsequent complaint visit to this facility to deliver determinations on the above allegations. LPA met with the licensee representative Josephine Miranda and explained the reason for the visit. To investigate the allegations LPA conducted an initial complaint visit on 05/07/2025. During initial visit LPA interviewed the licensee, Josephine Miranda and from 9:50 a.m. – 11:00 a.m., LPA Rios conducted a physical plant inspection. While conducting the facility tour LPA interviewed three (03) out of five (05) residents. Resident #2(R2) was sleeping, and Resident #5 (R5) did not respond to LPA's questions. From 11:00 a.m. to 12:00 p.m., LPA reviewed five (5) resident records and obtained copies, including but not limited to: R1’s Admission Agreement, a handwritten note regarding R1’s health conditions, and an after-visit summary page. LPA also interviewed two (2) relatives of Resident #1 (R1) who were visiting the home. (Continue to LIC9099-C) Substantiated (Continued from LIC9099) On a subsequent visit conducted on 05/09/2025, LPA Rios obtained contact information for R1's home health agency. According to the licensee only the contact information could be provided as an assessment was only recently completed. During visit LPA Rios interviewed one (01) staff and re-interviewed the licensee. On an annual visit conducted on 05/21/2025 LPA reviewed resident's records and obtained copies, including but not limited to: R1's pre placement appraisal, resident appraisal, physician's report, home heath's plan of care, daily menu, weekly bath schedule. On a subsequent visit conducted on 08/11/2025, LPA conducted a physical plant tour of the facility. During the tour, LPA re-interviewed the licensee, two (2) out of four (4) residents (R1 and R4), and Resident #4’s (R4’s) family member who was visiting at the time. One resident, admitted in June, was not interviewed as they were not present in the facility when LPA arrived. Allegation: Licensee does not ensure that resident's grooming needs are met. It is alleged that Resident #1 (R1) is not groomed. Review of Resident #1’s (R1’s) admission agreement confirmed that grooming was an agreed-upon basic service for which R1 required assistance. During the physical plant tour on 05/07/2025, LPA observed that R1 was not wearing socks, allowing for direct observation of R1’s feet. LPA noted that while R1’s feet were clean, the toenails were long, cracked, and chipped. LPA also observed that R1 had long fingernails. During the interview with R1, the resident spoke generally about their experience at the facility but did not provide information specific to the allegation. Review of physician's report on 05/21/2025 confirmed R1 requires assistance with grooming. In an interview with the licensee conducted today, the licensee stated that R1 had been sent to a podiatrist but acknowledged that staff had not clipped R1’s nails. The licensee explained that R1 required a podiatrist, but added that the facility is now addressing the issue and that "everything is good." LPA requested paperwork for podiatrist visit. Licensee to obtain copies from responsible party and provide copies to LPA. Based on LPA’s observations, interviews, and record review, there is sufficient evidence to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Page 2 of 3 (Continue to LIC9099-C) Allegation: Licensee does not assist resident with ambulating. It is alleged that resident #1 (R1) is kept in bed. During the interview with R1, the resident spoke generally about their experience at the facility but did not provide information specific to the allegation. During and interview with the licensee on 05/07/2025 they revealed they and staff do not provide assistance with ambulation because there is no doctor's order in place to do so. Licensee stated they are planning to ask R1's insurance and physician for a hoyer left and geriatric chair because R1 is very heavy for the licensee to move alone and R1 cannot be placed on a regular chair as they may fall forward. Review of physician's report on 05/21/2025 confirmed R1 requires assistance with transferring in and out of bed and is unable to stand or walk on their own. On 08/11/2025 licensee provided LPA a picture of R1 on a geriatric chair in the living room. Based on LPA’s observations, interviews, and review of documentation there is sufficient evidence to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Deficiencies cited (Refer to LIC9099-D). Exit interview conducted. Appeals provided. Copy of report provided. Page 3 of 3the state’s words, verbatim · CDSS document, Aug 20, 2025 · control 31-AS-20250429144827

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 5, 2025

(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above in not meeting R1's grooming needs which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 20, 2025

Plan of correction: The Licensee has trimmed R1's nails twice as of admission. Submit a grooming schedule for R1 to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(d) · Plan of correction due date: Sep 6, 2025

(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs...This requirement is not met as evidenced by: Based on interviews and record review, the licensee did not comply with the section cited above in not meeting R1's ambulating needs which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 20, 2025

Plan of correction: The Licensee will submit a physical therapy schedule and what the staff at the facility most assist with regarding physical therapy plan to LPA by POC due date.

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Facility does not provide the quality of food necessary to meet residents dietary needs.

On 08/20/2025 Licensing Program Analyst (LPA) Evelin Rios arrived to the facility to conducted an initial complaint visit to investigate the above mentioned allegation. Upon arrival, LPA was greeted by Staff #1 (S1) and was granted access. LPA met with Licensee, Josephine Miranda and LPA explained the purpose of the visit. An entrance interview was conducted. Allegation: Facility does not provide the quality of food necessary to meet residents dietary needs. It is alleged that the licensee stored expired food in the pantry and freezer, failed to serve meals at appropriate times and allowed staff to serve one resident’s leftover food to another. To investigate the allegation, from approximately 11:20 AM, to 12:00 PM, LPA Rios conducted a physical plant tour of the facility and while conducting tour LPA interviewed the licensee and S1. At approximately 12:00 PM to12:42 PM, LPA made observations of S1 cooking and preparing lunch for resdients. (Continue to LIC 9099-C) Unsubstantiated (Continued from LIC9099) From 12:00 PM to 12:30 PM, LPA also reviewed and obtained copies of food purchase receipts, daily menu and food service information from facility's program. From 12:42 PM to 1:22 PM, LPA interviewed one (01) out of three (03) residents residing in the facility and a family member visiting Resident #3 (R3). Resident #1 (R1) was no longer in the facility and not included in today's census. Resident #3 (R3) and Resident #4 (R4) did not respond to LPA's questions. LPA observed residents eating meals. LPA's observation of the refrigerator found that shelves are labeled for residents and for employees. LPA randomly pulled out food from the refrigerator, freezer and pantry and observed they were not past best by dates or expiration dates. Employee's food was in containers with no date but did not smell or look spoiled. There is a second refrigerator in the backyard and according to the licensee it is only meant for staff. LPA's interview with R2 did not corroborate the allegation. R2 provided limited answers, primarily 'yes' or 'no' and did not elaborate on answers. LPA's interview with R3's family member, revealed they visit R3 often at different times and makes it a point to visit when breakfast is being served and again at a later time during the same day. According to R3's family member the meals are served on time, look good and R3 eats well. LPA's interview with staff deny the allegation. Interview with S1 revealed R1 preferred to prepare their own meals which staff supervised and provided assistance when needed. S1 further stated that R1 would request breakfast be served at 4 AM. Interview with the licensee revealed they purchased specific food R1 requested and had to provide a notice posted on the dining room wall about reasonable meals times. There was not enough evidence to corroborate the allegation. Therefore, Based on interviews, and observations this allegation is deemed Unsubstantiated at this time. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 20, 2025 · control 31-AS-20250812100818

Allegation investigated: Facility air conditioning is in disrepair.

On 08/11/2025 Licensing Program Analyst (LPA) Evelin Rios arrived to the facility to conducted an initial complaint visit to investigate the above mentioned allegation. Upon arrival, LPA was greeted by staff #1 (S1) and was granted access. LPA met with Licensee, Josephine Miranda and LPA explained the purpose of todays visit. Entrance interview conducted. Allegation: Facility air conditioning is in disrepair. In regards to the allegation it was reported the facility's air conditioner (AC) is not working. To investigate the allegation, from 12:00 p.m., to 1:06 p.m., LPA conducted a physical plant tour of the facility. While conducting the tour LPA interview the licensee, a resident's visitor and two (02) out of four (04) residents. LPA obtained copies of text message communication between the hired AC company and the licensee regarding scheduled visits, receipt of payment for the July 18th visit, resident roster and staff schedule. According to the administrator the AC had stopped working previously on July 18th, 2025 but was fixed the same day by a technician. (Continue to LIC9099-C) Substantiated (Continued from LIC9099) Then sometime on the first week of August it stopped working and a technician visited the facility again on August 5th, 2025 and placed an order for an AC part. According to text communication between the company and the licensee a technician will be out to the facility tomorrow, August 12th, 2025 between 8AM and 12PM to fix the AC. Interview with resident #1 (R1) and resident #2 (R2) stated not verbatim that they did not feel uncomfortable with the temperature in the facility. Interview with R2's visitor stated they believed the AC was not working during their last visit, Thursday, August 7th, 2025, but had also not felt uncomfortable with the temperature in the facility. According to the licensee resident #3 (R3) did complain the facility was too hot and was upset that AC was not working. According to the licensee a portable swamp cooler was purchased for R3's bedroom. LPA Rios observed the portable unit in R3's bedroom and the facility's thermostat was observed inoperable. LPA also observed the ceiling fans on in residents' bedrooms. Resident #4 (R4) was sleeping during today's visit. The temperature outside at 1:34 p.m., based on the Weather.com is 105 degrees Fahrenheit. Based on interviews and observation this allegation is deemed Substantiated. Deficiency cited (refer to LIC9099-D). Exit interview conducted. Appeal rights provided. Report signed and copy provided.the state’s words, verbatim · CDSS document, Aug 11, 2025 · control 31-AS-20250811110935

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(b)(2) · Plan of correction due date: Aug 15, 2025

(b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range... or in areas of extreme heat to 30 degrees F less than the outside temperature. This requirement is not met as evidenced by: Based on LPA's interviews and observation the facility's air conditioning system was observed to be inoperable which poses an potential Health, Safety or Personal Rights risks to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2025

Plan of correction: The licensee will email LPA Rios the receipt of service showing the air-conditioning (AC) was fixed. Licensee will purchase portable AC units for each room with a residnet if the AC is not working on August 12, 2025.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Case Management - Deficiencies visit to this facility in conjunction with a complaint control #31-AS-20250429144827. LPA met with the Licensee and explained the reason for the visit. LPA may also be citing citations that have not been corrected by Licensee and those citations LPA failed to conduct a follow-up visit, within 10 business days after the POC due date. Previously cited on case management visit 05/07/2025. While conducting the physical plant tour today LPA observed "full" bed rails on resident #1's (R1's) bed. LPA observed the bed rails extended the entire length of the bed. Review of R1's and resident #2 (R2's) Physician's Reports revealed their ambulatory status as bedridden. Review of the facility sketch revealed only bedroom #3 can retain a bedridden resident. R2 is in bedroom labeled #3 according to the facility sketch. R1 in not in a bedroom cleared for bedridden. According to the Licensee R1 is able to be placed on a wheel chair with the use of a hoyer lift. According to Licensee the bedridden status is temporary and they are working with physical therapy to change status. According to R1's physician's report (LIC602A) the status is expected to persist 365 days or maybe permanent. According to the licensee they believe the LIC602A for R1 is incorrect and will request R1's family to get an update and accurate physician's report. (Continue to LIC809-C) (Continued from LIC809) Previously cited on annual visit 05/21/2025. At 3:04 p.m., licensee revealed they have not completed Medication records for centrally stored medications had still not been updated and did not accurately reflect the medication stored for four (04) out of four (04) residents. Licensee stated they were unable to renew the facilities lability insurance and are still currently working on it. On today's visit LPA reviewed Home Health Certification and Plan of Care for resident #1 (R1). Records revealed R1 has a prohibited health condition. LPA's interview with wound care agency staff revealed R1 has an unstageable wound on left heel. LPA requested more information regrading wound care. During the investigation LPA asked Licensee on 05/07/2025 and 05/09/2025 how many Hospice residents the facility had. The licensee provided the same information on both days stating only resident R#3 was receiving Hospice service for a terminal illness Licensee went on to say R2 was previously on Hospice but was discharged prior to R3 admittance tot the facility. Licensee proceeded to provide LPA with R2's Hospice file from the previous year. LPA was able to confirm with R2's hospice agency on 5/15/2025, that resident #2 (R2) was receiving Hospice services. R2 and R3 were both on Hospice since R3's admittance on 3/31/2025 until R3's passing on 05/09/2025. LPA provided regulations for exception requests, and Hospice waiver. LPA reiterated to Licensee that they currently only have a hospice waiver for one resident. Deficiencies cited (refer to LIC 809D). Exit interview conducted, appeal rights and copy of report provided.the state’s words, verbatim · CDSS document, Aug 11, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5)(B) · Plan of correction due date: Aug 12, 2025

(a) ...Postural supports may be used under the following conditions. (5)... (B)Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care...This requirement is not met as evidenced by: Licensee did not comply with the section cited above by utilizing full bed rails for R1 who does not receive hospice care services which poses an immediate health, safety personal rights risk .the state’s words, verbatim · CDSS document, Aug 11, 2025

Plan of correction: Licensee will remove bed rails that extend the entire length of the bed for R1 send a picture to LPA by POC due date . Half bed rails may be obtained if a written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87202(a)(2) · Plan of correction due date: Aug 11, 2025

(a) All facilities shall maintain a fire clearance...Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance...(2)Bedridden persons. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above in that the facility has fire clearance for one bedridden resident and the facility currently has two bedridden residents which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2025

Plan of correction: The Licensee will ensure that the facility is in compliance with the fire clearance approved by the city or county fire department at all times. The Licensee will submit a written plan of action that will be implemented to ensure that the facility comes back into compliance and Licensee will submit an LIC200 and updated facility sketch to obtain a bedridden fire clearance if they decide to retain a second bedridden resident.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Aug 12, 2025

(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on record review and interviews the licensee did not comply with the section cited above by retaining R1 who is not receiving hospice services and has a unstageable wound which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2025

Plan of correction: Licensee agreed to submit an exception letter to CCLD to retain resident with a prohibited health condition. Licensee will request Wound Care Plan from wound care agency and facilities own care plan (LIC622) submit it to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.605 · Plan of correction due date: Aug 29, 2025

...all residential care facilities for the elderly,... shall maintain liability insurance covering injury to residents and guests 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, ... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in not maintaining liability insurance which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2025

Plan of correction: Licensee will obtain liability insurance and send a copy of certification to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87632(a) · Plan of correction due date: Aug 12, 2025

(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department... and any future residents who may request acceptance, ... This requirement is not met as evidenced by: Based on record review and interviews the licensee did not comply with the section cited above in accepting a second resident receiving hospice services when the facility has a hospice waiver for only one resident which posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2025

Plan of correction: Currently facility is back to serving only one(01) resident with Hospice services. The Licensee will ensure that the facility is in compliance with their hospice waiver at all times. The Licensee will submit a written statement of understanding about their current Hospice waiver and Licensee will submit statement to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87207 · Plan of correction due date: Aug 29, 2025

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. Based on interviews the licensee did not comply with the section cited above in false or misleading statements on two different days regarding the same question about the number of residents receiving Hospice services in the facility which posed an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 11, 2025

Plan of correction: The Licensee will submit a written statement of understanding about the cited regulation and submit statement to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: Aug 29, 2025

(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained... This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above in four (04) out of four (04) residents' centrally stored medication not being properly recorded which poses a potential health, safety or personal rights risk to persons in carethe state’s words, verbatim · CDSS document, Aug 11, 2025

Plan of correction: The Licensee has agreed to updated Centrally Stored Medication and Destruction Records (LIC622) for each resident as per facility program. Copy of LIC 622 will be sent to LPA by POC due date.

Type of visit: Required - 1 Year

At 12:30 p.m., Licensing Program Analyst (LPA) Evelin Rios arrived at the above mentioned facility to conduct an unannounced annual inspection. LPA was greeted by Licensee, Josephine Miranda and staff #1(S1). LPA explained the reason for the visit. An entrance interview was conducted. At 12:45 p.m., LPA toured the facility inside and outside and observed the following: Upon entry LPA observed appropriate postings except for the Complaint Poster (PUB 475) or a poster created by the facility with the same information. LPA provided a an email link to PUB 475 to Licensee. The facility has six (06) total bedrooms and three (03) total bathrooms. Five (05) out of the six (06) bedrooms are for residents' use of which one (01) is shared. Bedrooms have appropriate furniture such as beds, night stands, chairs and enough storage for residents' belongings. In bedroom labeled 4, LPA observed an extra bedframe with mattress leaning against the wall on the left side of the resident's bed. According to Josephine the resident would be transferred to the newer furniture and a company would be by to pick up the extra furniture. LPA observed auditory alarms on exit doors working properly. Bathrooms were observed clean and were supplied with toilet paper, hand soap, paper towels, grab bars by toilets and showers and showers had non slip flooring. In the shared bathroom LPA observed boxes of incontinent care stacked on top of each other blocking access to a shower. Licensee stated she and S1 would be moving the boxes to a storage area tonight. At 3:22 p.m. LPA tested the hot water temperature in one (01) bathroom and it read 110.7 degrees Fahrenheit, within regulation. (Continue to LIC809-C) (Continued from LIC809) The laundry room was observed locked and leads to the attached garage. In the laundry room LPA observed a washer and dryer. The facility keeps cleaning supplies and detergents locked in the garage. Common areas include the living room, dining area and backyard. In the living room LPA observed a television with appropriate furniture that sits the capacity of the facility. Dining areas had appropriate tables and chairs. LPA observed two (02) facility telephones, operational. The backdoor in the living room area leading to the backyard is missing a door knob. The facility has attached two strings, one on the inside of the door and the other on the outside to open and close the door. According to the Licensee she is working on getting it fixed. The backyard is fenced in and LPA observed a covered patio with outdoor furniture and a shed that is kept locked. Outside LPA also observed a refrigerator used to store extra food and a non working refrigerator, washer and dryer. According to Josephine the appliances are used for storage but will be working on removing them from the property. Exits and passageways were observed free of obstructions. The kitchen was observed to be clean and clear of clutter. Appliances and fixtures were functioning properly. There is a one (01) week supply of nonperishable, and two 02) day supply of perishable food. LPA observed one (01) fire extinguisher fully charged. LPA observed a first aid kit and resident medications in a locked kitchen cabinet. At 2:30 p.m., LPA reviewed four (04) of four (04) resident records and two (02) staff files. At 3:30 p.m., LPA reviewed residents medication and centrally stored medication and destruction records. Medication records for centrally stored medications had not been updated for the month of May 2025 and did not accurately reflect the medication stored for three (03) out of four (04) residents. Licensee stated they were unable to renew the facilities lability insurance. Licensee provided information to change administrator. Deficiencies were observed, refer to (LIC809-D). An exit interview was conducted. Appeal rights provided. A copy of this report was signed and delivered.the state’s words, verbatim · CDSS document, May 21, 2025

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Case Management - Deficiencies visit to this facility in conjunction with a complaint control #31-AS-20250429144827. LPA met with the Licensee and explained the reason for the visit. Review of R2's and resident #5 (R5's) Physician's Reports revealed their ambulatory status as bedridden. Review of the facility sketch revealed only bedroom #3 can retain a bedridden resident. R5 is in bedroom labeled #3 according to the facility sketch. R2 in not in a bedroom cleared for bedridden. Prohibited health condition for resident #3 (R3). R3, Licensee and wound care agency staff confirmed resident has a wound. According to the wound care agency staff it is a stage 4. LPA was not provided documentation or a care plan or exception letter requesting to retain resident. R1 may also have a wound. LPA requested Home Health documentation. While conducting the physical plant tour LPA observed three (03), Resident #1 (R1), R2 and R5 have "full" bed rails. LPA observed the bed rails extended the entire length of the beds. According to Josephine only Resident #2 (R2) is receiving Hospice services. While reviewing resident records LPA did not observed a Pre-Admission Appraisal for R1 and R2. R1 was missing a Physician's Report with tuberculosis (TB) test results. According to Josephine the LIC602A form was provided to R1's doctor and the facility is waiting for it to be completed and returned. Josephine provided an updated LC500 to LPA. Review of staff #1's (S1's) record revealed they do not have a health screening with TB results. According to Josephine S1 last worked on Monday, May 5th 2025. During physical plant tour LPA passed by room labeled #1 and it had a urine odor coming from inside the bedroom. According to wound care agency staff they agreed the room smelled of urine. At 4:30 p.m., LPA observed Licensee changing a resident's soild undergarments without gloves. Deficiencies cited (refer to LIC 809D). Exit interview conducted, appeal rights and copy of report provided.the state’s words, verbatim · CDSS document, May 7, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a)(2) · Plan of correction due date: May 8, 2025

(a) All facilities shall maintain a fire clearance...Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance...(2)Bedridden persons. This requirement is not met as evidenced by: Based on observation and record review the licensee did not comply with the section cited above in that the facility has fire clearance for one bedridden resident and the facility currently has two bedridden resdients which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: The Licensee will ensure that the facility is in compliance with the fire clearance approved by the city or county fire department at all times. The Licensee will submit a written plan of action that will be implemented to ensure that the facility comes back into compliance by 5/09/2025 and Licensee will submit an LIC200 and updated facility sketch to obtain a bedridden fire clearance if they decide to retain a second bedridden resident.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87608(a)(5)(B) · Plan of correction due date: May 8, 2025

(a) ...Postural supports may be used under the following conditions. (5)Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B)Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by: Licensee did not comply with the section cited above by utilizing full bed rails for R1 and R5 who are no longer on hospice which indicates the need which poses an immediate health, safety personal rights risk .the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: Licensee will remove bed rails that extend the entire length of the bed for R1 and R5 and send a picture to LPA by POC due date 05/08/2025. Half bed rails may be obtained if a written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: May 16, 2025

87458(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above in that the facility did not obtain a medical assessment with TB test for R1 prior to admittance which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: Licensee states R1's doctor has the form and is waiting for it to be completed and provided. Licensee will provide a statement of understading regarding the regulaton cited and submit to LPA by POC due date 05/16/2025. Licensee will obtained and a copy of R1's medical assessment/Physician's Report (LIC602A) with TB test results and will submit a copy as proof of correction.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87457(c)(1)(A) · Plan of correction due date: May 16, 2025

(c) Prior to admission a determination of the prospective resident's suitability... (1) The appraisal shall document, at a minimum:(A)An evaluation of the prospective resident's functional capabilities...This requirement is not met as evidenced by: Licensee did not comply with the section cited above in two out of five resdients had no preplacement appraisal on file which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: The Licensee will complete the appraisal forms for R1 and submit a copy of the forms to LPA by POC due date 5/16/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: May 16, 2025

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above in that LPA smelled a urine odor in bedroom #1 and the section of the facility where the bedroom is located by the formal dining area smelled of urine which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: Licensee will make sure that the residents rooms are free of odors and sanitary at all times. Licensee will submit a plan to LPA for how the facility will return and remain in compliance by POC due 05/16/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a)(11) · Plan of correction due date: May 16, 2025

(a) The licensee shall ensure that personnel records are maintained on... each employee. Each personnel record shall contain the following information:(11)A health screenings specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Based on record review the licensee did not comply with the section cited above in that staff #1's (S1's) record was incomplete missing health screening and TB test result which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: Licensee stated she will not return to work until health screening with TB is completed. Licensee will provide a copy S1's health screening with TB test results by POC due 05/16/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: May 8, 2025

(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by: Based on record review and interviews the licensee did not comply with the section cited above by retaining R3 who is not receiving hospice services and has a stage 4 wound which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: Resident expressed they do not wish to live anywhere else at this time but will eventually like to live somewhere else. Licensee will submit an exception letter to CCLD to retain resident with a prohibited health condition. Licensee will request Wound Care Plan from wound care agency and submit it to LPA by POC due date 05/08/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87470(4)(A)(3) · Plan of correction due date: May 16, 2025

(4) All facility staff and volunteers shall use gloves...(A)Gloves shall always be worn when: 3...assisting with incontinence when there is a risk of contact with blood, body fluids or other potentially infectious material. This requirement is not met as evidenced by: Based on observation LPA Rios observed the Licensee change a resident without using gloves, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2025

Plan of correction: Licensee will take vendorized training on infection coltrol porocedures and submit certificate of completion to LPA by POC due date 05/16/2025.

Allegation investigated: Staffing insufficient to meet the needs of residents.

On 11/19/24 Licensing Program Analyst (LPA) Evelin Rios arrived to the facility to conducted a subsequent complaint visit to continue investigation and deliver the determination on the above mentioned allegation. Upon arrival, LPA was greeted by staff #6 (S6) and was granted access. LPA met with Administrator, Josephine Miranda and LPA explained the purpose of todays visit. Entrance interview conducted. On 01/31/24 LPA Rios conducted an initial visit. A physical plant inspection was conducted. From 10:12 a.m. to 11:40 a.m. LPA reviewed six (6) resident records and obtained copies of pertinent information. From approximately 12:12 p.m. to 1:30 p.m. LPA interviewed the administrator, S1, a family member of resident #3 (R3) and residents at the facility. At approximately 2:09 p.m. LPA reviewed seven (7) staff records. On 10/16/24 on a subsequent visit, the administrator did not make themselves available or got in contact with LPA at the time of visit. On todays visit LPA reviewed and obtained copies of the Personnel Report (LIC500) and resident roster. LPA also reviewed six (6) resident files and six (6) staff records. (Cont. to LIC9099-C) Substantiated Allegation: Staffing insufficient to meet the needs of residents. It is alleged, the administrator only has one (1) caregiver for 5 to 6 residents. On 1/24/24 LPA's review of resident roster revealed prior to LPA's initial visit six (6) residents had been at the facility. At time of the initial visit the facility census was five (5) because one resident had passed away. Three (3) residents were physically at the facility and two (2) were hospitalized. LPAs interview on 1/24/24 with staff #1 (S1) revealed that they had assisted up to (5) five residents with the help of S2. S1 stated they now assist three (3) residents and administrator helps. On 1/24/24 LPA attempted to interview three (3) residents, two (2) did not respond to questioning. LPAs interview with resident #2 (R2) revealed they have no issues or concerns with the assistance provided. On 1/24/24 administrator presented LPA with LIC 500 from January 2023. Administrator noted they had not updated personnel report. According to the administrator at time of visit the facility had one reliever (on-call), staff #4 (S4) and one full time staff, S1. A second reliever staff #5 (S5) was no longer able to work at the facility. Facility had lost one full time caregiver, staff #3(S3) on 12/23/23. S1 took over the schedule and according to administrator another caregiver, staff #2(S2) had stopped working a week prior to initial visit. According to administrator reliever and herself were working with S1 until she could hire a second staff. On 01/24/24 LPA attempted to contact previous staff and reliever. LPA left voicemail for return call for S3 and S5. Administrator could not provide contact information for S2. S4's telephone was disconnected. Review of five (5) out of seven (7) staff records on 01/24/24 revealed S1 and S4 did not have complete training. Review of S1 and staff #6 (S6) record on 11/19/24 revealed S1 has completed training since initial visit and S6 is missing orientation training. Review of six (6) resident records revealed they required assistance with incontinent care and toileting. All residents were non ambulatory of which one (1) resident was temporarily bedridden and four (4) had a diagnoses of dementia. Review of six (6) resident records on 1/24/24 revealed resident #2 (R2) did not have a pre appraisal or resident appraisal conducted. Based on resident records and review of LIC500, this allegation is deemed Substantiated at this time. Deficiencies cited on LIC 9099 D. Appeal Rights provided. Exit Interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Nov 19, 2024 · control 31-AS-20240125095336

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 22, 2024

Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on the LPA's record review and interviews, the licensee did not comply with the section cited above in 2 staff not having on going training on file and S1 and administrator who was also working other shifts providing care for 5 residents which posed an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 19, 2024

Plan of correction: Licensee has hired a second staff and S1 has orientation and ongoing training on file as of todays visit. Licensee will submitt required orientation training for new staff, S6 and an updated LIC500.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Evelin Rios conducted unannounced Case Management - Deficiencies visit to this facility in conjunction with a complaint control #31-AS-20240125095336. LPA met with the Administrator, Josephine Miranda and explained the reason for the visit. 1. Administrator was not able to provide LPA with a current Administrator certificate. According to administrator they have completed training and will be sending it to Sacramento to complete re-certification. 2. Review of six (6) out of six (6) staff records revealed no 1st aid or CPR on file for staff. Deficiencies cited (refer to LIC 809D). Exit interview conducted, appeal rights and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Nov 19, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c)(1) · Plan of correction due date: Nov 29, 2024

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training...(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by: Based on the LPA's record review and interviews, the licensee did not comply with the section cited above in 6 staff not having active 1st aid and CPR certification which poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 19, 2024

Plan of correction: Administrator has AGREED to submit 1st aid CPR certification to LPA by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87407(e)(1)-(3) · Plan of correction due date: Nov 29, 2024

87407 (e)To apply for recertification after the expiration date of the certificate, but within four (4) years of the certificate expiration date, the certificate holder shall submit to the Department’s Administrator Certification Section: (1) A completed Application for Administrator Certification form LIC 9214. (2)Evidence of completion of the required continuing education hours…(3)Payment of a non-refundable delinquency fee… This requirement is not met as evidenced by: During today's inspection, the Administrator has failed to renew Administrator's certificate, or provide proof payment or training submission has been sent to Sacramento which poses an potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 19, 2024

Plan of correction: Administrator has AGREED to submit a change of administrator to LPA by POC date.

Type of visit: Case Management - Annual Continuation

On 10/16/2024 at 11:50 a.m., Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Required – Annual Continuation Inspection. LPA was greeted and granted access by staff Annabelle Dorado. A second staff Sandra Higareda greeted LPA. LPA requested staff contact the administrator, Josephine Miranda and inform them LPA was at the facility. According to staff Josephine was unavailable due to a scheduled appointment. Staff informed LPA they sent Josephine a message but had not heard back. At 12:44 p.m. LPA contacted Administrator's cell phone number and left a voicemail. LPA then contacted Jackylyn Miranda who had their administrator certificate and telephone number displayed in the facility but nobody answered. LPA continued visit with staff. Four (4) residents and two (2) staff were present during this inspection. LPA conducted a physical plant tour of the facility inside and out. The following was attempted to complete the annual inspection: LPA attempted to review facility, staff and resident records. Staff informed LPA they did not have access to records to present to LPA. LPA had not received a copy of the facility's Infection Control Plan, LPA requested on 05/13/2024. Administrator had still not made themselves available by 2:10 p.m. Staff agreed to sign todays report. Deficiencies cited (refer to LIC809-D). Exit Interview Conducted. Appeal Rights provided. Copy of report provided.the state’s words, verbatim · CDSS document, Oct 16, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 05/13/2024 at 2:55 p.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced annual inspection using the CARE Inspection Tool. This is an Residential Care Facility for the Elderly (RCFE), with an approved fire clearance for a capacity five (5) non-ambulatory residents of which one (1) can be bedridden. LPA was greeted by the administrator Josephine Miranda and LPA explained the reason for the visit. An entrance interview was conducted. LPA requested a copy of the facility's Infection Control Plan as the Mitigation Plan submitted on 4/21/2021 was documented as incomplete. Administrator informed LPA they do not recall receiving information the plan was not complete. Administrator could not provide a copy. At approximately 3:10 p.m. LPA and the administrator toured the physical plant of the facility, and the following was observed. Kitchen/ Dinning areas: The kitchen was observed to be clean and clear of clutter. Appliances and fixtures were functioning properly. LPA observed a sufficient amount of 2-day perishable and 7-day non-perishable supply of food; properly stored. LPA observed one (1) fire extinguisher fully charged. Dining areas had appropriate table and chairs to sit the capacity of the facility. In the formal dining area LPA observed paper and boxes filling one side on the table and dining area. LPA observed, first aid kits, client medications, kept locked in a kitchen cabinet. LPA observed two (2) facility telephones, operational. Bathrooms: The facility has three (3) total bathrooms one (1) of which is in a shared bedroom for resident use. At 3:41 p.m. LPA tested the hot water temperature in one of three resident bathrooms. The hot water temperature measured approximately 109.6*F, within regulation. LPA observed both bathrooms to be clean and properly supplied with toilet paper, hand soap, paper towels and trash bins with lids. Bedrooms: There are a total of six (6) bedrooms, one (1) of which is designated for staff use. LPA inspected five (5) out of five (5) resident bedrooms. LPA observed each resident room to be properly furnished with beds, appropriate night stand, bedding and with sufficient lighting and storage. LPA observed extra linens in the hallway outside the bedrooms. (Continued on LIC809-C ) (Continued from LIC809) At 3:45 p.m. LPA observed the administrator test a smoke detector that is hardwired and interconnected to other detectors located through out the facility. Detectors were observed to be functioning properly. Due to time restraints, LPA was unable to complete the annual visit at this time. LPA did not review any staff or resident records or medication documentation at the time of this visit. A follow-up visit will be conducted at a later date to complete the annual inspection. Exit interview conducted/Copy of report giventhe state’s words, verbatim · CDSS document, May 13, 2024

Allegation investigated: Facility is operating beyond the terms and conditions of the Hospice Waiver.

On 01/31/2024 at 9:41 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived to the facility to conducted a complaint visit to investigate the above mentioned allegation. Upon arrival, LPA was greeted by staff #1 (S1) at the front door while LPA was ringing the door bell. S1 tried to enter thru the front door but it was locked. S1 went around the side of the house and opened the front door and LPA was granted access. Administrator Josephine Miranda greeted LPA and LPA explained the purpose of todays visit. Entrance interview conducted. From 9:51 a.m. – 10:11 a.m. LPA conducted a physical plant inspection to assure the health and safety of the clients. Currently at the facility was the administrator, S1 and three (3) out of five (5) residents. Two of the residents, resident #1 (R1) and resident #6 (R6) were not at the facility. From 10:12 a.m. to 11:40 a.m. LPA reviewed six (6) resident records and obtained copies of pertinent information. From approximately 12:12 p.m. to 1:30 p.m. LPA interviewed the administrator, S1, a family member of resident #3 (R3) and residents at the facility. At approximately 2:09 p.m. LPA reviewed seven (7) staff records. (Continue to LIC9099-C) Substantiated Allegation #1: Facility is operating beyond the terms and conditions of the Hospice Waiver. It is alleged that three residents are or had been receiving hospice care at the same time when the facility only has a hospice waiver approved for one (1) resident. LPA reviewed sign in sheets, physician's reports, and hospice folders which revealed, resident #1 (R1), resident #3 (R3) and resident #4 (R4) were under hospice care during the time they were at the facility together. LPA's Interview with administrator revealed they understand what a hospice waiver is and how to request one from Community Care Licensing Division (CCLD). Furthermore, the administrator produced a letter dated 08/19/2009 made out to Community Care Licensing Division (CCLD) requesting a hospice waiver for a resident in the facility. According to the administrator they did not receive a reply such as an approval or denial from CCLD. According to the administrator they did not attempt to reach out to their LPA or CCLD regional office to request a status update. Administrator stated to LPA they believed they had a hospice waiver approved for two (2). Administrator acknowledges R1 and R4 are on hospice for a terminal illness and R3 was on hospice for palliative care. As of todays visit facility only has one (1) resident receiving hospice care. Based on the information obtained through interviews and record review this allegation is deemed Substantiated. Deficiencies cited on LIC 9099 D. Appeal Rights provided. Exit Interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 31, 2024 · control 31-AS-20240125095336

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87632(a) · Plan of correction due date: Feb 1, 2024

(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department... This requirement is not met as evidenced by: Based on interview and record review, Administrator did not comply with the above section by failing to obtain a hospice care waiver and accepted or retained two (2) terminally ill residents, which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 31, 2024

Plan of correction: As of todays visit facility only has one (1) resident receiving hospice care. Administrator will sign a declaration that they will ensure the facility abides by the regulation cited. Signed declaration will be sent to LPA by POC date.

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: Case Management - Deficiencies

Licensing Program Analyst (LPA) Evelin Rios conducted unannounced Case Management - Deficiencies visit to this facility in conjunction with a complaint control #31-AS-20240125095336. LPA met with the Administrator and explained the reason for the visit. While conducting the physical plant tour administrator notified LPA resident #3 (R3) had passed away and that is why the room was vacant. A Death Report was not submitted to the department. According to administrator they have been busy and forgot to send it to the department. While reviewing resident records, resident#2 (R2) records revealed the administrator had admitted the resident without a an written appraisal. According to administrator they are currently working on it. Administrator did not have current Administrator certificate to show LPA during time of visit. Administrator will send a copy of certificate to LPA by 02/02/24. Deficiencies cited (refer to LIC 809D). Exit interview conducted, appeal rights and copy of report signed and delivered.the state’s words, verbatim · CDSS document, Jan 31, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c)(A) · Plan of correction due date: Feb 2, 2024

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs...(A)The licensee shall be permitted to use the form LIC 603 (Rev. 6/87), Preplacement Appraisal Information, to document the appraisal. This requirement was not met as evidenced by: Based on interview and record review conducted with the administrator, they failed to complete an appraisal for R2 which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 31, 2024

Plan of correction: Administrator will complete an appraisal for R2 and submit to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(A) · Plan of correction due date: Feb 2, 2024

87211(a)(1)(A) Reporting Requirements. The licensee shall send a written report to the licensing agency and the person responsible for the resident when a resident dies, regardless of cause or where death occurred, within seven days of the death. This requirement was not met as evidenced by: Based on interview conducted with the administrator, revealed that they failed to submit a death report for R3 to CCL which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Jan 31, 2024

Plan of correction: Administrator will submit Death Report along with the death certificate for R3 to LPA by POC due date.