Jc Cottages - Hollydale

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Administrator (AD) Maria Parungao and discussed the purpose of the inspection. LPA reviewed Infection Control requirements. At about 9:30AM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 5-bedroom, 4-bathroom, one-story house with an attached garage that is used for storage. There is a back yard with a patio cover for the residents. LPA observed 2 staff and 5 residents present at the facility in addition to AD. Resident Bedrooms: the 4 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPA inspected the 1 staff bedroom. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 113 and 116 degrees F in the 3 resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the laundry room. Toxins: observed locked in the laundry room. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 7:45AM, LPA reviewed 5 resident files and 4 staff files, interviewed 2 residents and 2 staff, and inspected medications for 5 residents. Facility does not handle resident money. During the inspection, LPA and AD observed the following: based on documents, the physician's report for R5 is on the old form and does not include required information, including behavioral expressions, and R5's file also does not have a TB test result. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jun 29, 2026

Type of visit: Required - 1 Year

This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Elluissa Gonzalez and discussed the purpose of the inspection. Administrator (AD) Maria Parungao appeared via telephone. LPA reviewed Infection Control requirements. At about 1:45PM, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 5-bedroom, 4-bathroom, one-story house with an attached garage that is used for storage. There is a back yard with a patio cover for the residents. LPA observed 3 staff and 5 residents present at the facility. Resident Bedrooms: the 4 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPA inspected the 1 staff bedroom. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 109 and 113 degrees F in the 3 resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the laundry room. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 2:45PM, LPA reviewed 5 resident files and 3 staff files, interviewed 2 residents and 2 staff, and inspected medications for 5 residents. Facility does not handle resident money. During the inspection, LPA and S1 observed the following: based on documents, the facility does not have an Infection Control Plan; based on observation, the facility's fire extinguisher has not been serviced or replaced since 2021; and based on observation, the licensee did not ensure medications and supplements were inaccessible in the non-lockable staff bedroom. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.the state’s words, verbatim · CDSS document, Jul 10, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA’s) Bernadette Allen made an unannounced visit to the facility to conduct a required comprehensive annual inspection. LPA met with Sotera Nicholas- Support Staff who allowed entry into the facility. Jay Parungao arrived at the facility approximately at 10:00AM and toured the facility with LPA. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. The water was measured at 103.2 degrees. LPA observed sufficient furniture and lighting throughout the facility. The facility is equipped with operating smoke detectors, fully charged fire extinguisher, and carbon monoxide detectors. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. LPA observed there was a designated storage space for resident/staff files. Medications are kept locked in pantry in kitchen inaccessible to residents in care. Medications were audited at random and appeared to be dispensed appropriately by staff members. Overall, the facility is clean, in good repair, and operating in safe conditions. Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed two (2) residents files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Based on the observations made during today’s visit, no deficiencies were cited. An exit interview was conducted, and this report was discussed and provided to Jay Parungao at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 19, 2024