Jessie Court Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required 1 Year Visit and met with Michael Vu. During visit, LPA Marrufo toured the facility inside and out. LPA observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed there to be locked cabinets and drawers for cleaning supplies and sharp objects. LPA Marrufo toured three out of three resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks measured between 108 F to 118 F. The bathroom showers had anti-slip mats and shower chairs. LPA toured five out of five resident bedrooms. Each bedroom had working lights and available bedding and clothing storage areas. LPA tested the smoke detector system and it functioned properly when tested. LPA tested the carbon monoxide detector and it functioned properly when tested. LPA toured the outside area of the home and the outdoor exits were clear of obstructions. LPA reviewed the Centrally Stored Medication and Destruction Records (CSMDRs) of five out of five residents. Resident R1's CSMDR had one medication that did not have it's prescription number recorded. R2's CSMDR had four medications that were not recorded. Staff recorded the missing medication information during visit. See LIC809-C page for more information. Page 1 of 2. LPA reviewed five out of five resident records and found them to be complete. LPA reviewed three staff records and found them to be complete. LPA reviewed the Emergency Disaster Drill Log and found the last drill was recorded on 10/01/2025. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information. LPA Marrufo requests that updated copies of the following documents be updated and sent to the department within seven calendar days: LIC500 Personnel Report LIC308 Designation of Administrative Responsibility Liability Insurance LIC610 Emergency Disaster Plan This report was reviewed with Vicky Ablao and a copy of this report and appeal rights were provided. Page 2 of 2. END REPORT.the state’s words, verbatim · CDSS document, Oct 15, 2025

Type of visit: POC

Licensing Program Analyst (LPA) Steve Chang Conducted an unannounced Plan of Correction visit to follow up the case management conducted on 2/5/2025, and met with House Manager (HM) Michael Vu. The facility was cited as Title 22 section 87468.1(a)(2) Personal Rights (a)(2) Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment. On 1/24/2025, around 11:00AM, resident R1 was found missing in the facility. The facility staff called police. Around 3:00PM R1 was found by police officers 1.7 miles away from the facility. R1 was sent back to the facility around 3:45PM. On 2/6/2025, the Department received a plan of correction.. LPA toured the facility with HM. HM tested 7 exit door alarms and all 7 door alarms were observed working. LPA observed 2 staff working at the facility. LPA discussed with HM regarding care and supervision to residents. LPA discussed with HM regarding the updated appraisal needs and service plan. LPA discussed with HM about the reporting requirement. LPA discussed with ADM regarding the resident behavior assessment. LPA discussed with HM regarding the staff training. LPA reviewed the staff training log. LPA discussed with HM regarding to identify high risk residents. LPA discussed with HM regarding more often checking on residents. LPA obtained R1's daily behavior notes. No citation noted today. Exit interview was conducted with HM. The report was provided to HM for review and signature. A copy of the report was provided to HM.the state’s words, verbatim · CDSS document, Mar 27, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Co-licensee Michael Vu (Co-LCN). The purpose of today's visit is to follow up with the incident report that Community Care Licensing (CCL) office received on 01/27/2025. On 01/24/2025, around 11:00AM, resident R1 was found missing in facility. R1 was last seen in his/her room on 01/24/2025, around 10:00AM. Facility staff S1 and S2 checked the facility inside and out, but were unable to find R1. S1 went out to search for R1 in the neighborhood but was unable to find R1. S2 called Licensee to notify the incident. Licensee called 911 at 11:15AM. LPA interviewed staff S1. S1 stated on 1/24/2025, resident R1 was seen at his/her room around 10:00AM. S1 stated at 11:00AM, he/she checked R1 again but was unable to find R1. S1 stated he/she and staff S2 checked the facility inside and out but were unable to find R1. S1 stated he/she went out to search for R1 in the neighborhood but was unable to find R1. LPA interviewed staff S2. S2 stated on 1/24/2025, between 10:00AM to 11:00AM, he/she was helping other residents in resident bedrooms. S2 stated he/she was notified by S1 that R1 was missing. S2 stated he/she and S1 searched for R1 but were unable to find R1. S2 stated he/she called R1' family and licensee. LPA interviewed Co-licensee (Co-LCN). Co-LCN stated on 1/24/2025 around 3:00PM police officers notified the facility that they found R1 at Campbell park. R1 was brought back to the facility around 3:45PM by police officers. The distance between the facility and Campbell Park is around 1.7 miles per google map. Co-LCN stated R1 was brought back to the facility without injury. Co-LCN stated R1 has dementia. S1 stated R1 is fine and normal after returning to the facility. Co-LCN stated R1 is unable to remember what happened about the incident. Based on the reviewed of R1's physician report dated on 11/09/2024, R1 has dementia. R1 has wandering behavior and is unable to leave facility unassisted. Deficiencies were cited per California Code of Regulations, Title 22, please see LIC 809-D. An immediate civil penalty of $500.00 is being assessed today for violation the absence of supervision. Exit interviewed was conducted with Co-LCN. The report was provided to HM for review and signature. Appeal rights was provided. A copy of the report was provide to Co-LCN.the state’s words, verbatim · CDSS document, Feb 5, 2025

From the deficiency page — Deficiency type: Type A · Section cited: ILS 87468.1(a)(2) · Plan of correction due date: Feb 6, 2025

87468.1 Personal Rights (a)(2) Each resident shall be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met as evidenced by: Based on interview and record review, Licensee did not provide the necessary care and supervision to meet R1's care needs, which resulted in R1's elopement from the facility on 1/24/2025, which poses/posed an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 5, 2025

Plan of correction: Administrator stated to submit a plan of correction by the POC due date to provide the training to staff to provide care and supervision to meet residents' needs and to provide the staff training log.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Steve Chang Conducted an unannounced Case Management - Incident visit and met with Administrator (ADM) Michael Vu. On 11/07/2024, the Department received a death report of resident R1 which stating R1 was sent to hospital on 10/29/2024 due to left shoulder and abdominal pain. R1 died on 10/30/2024, around 2:00AM, facility is waiting for the information of R1's cause of death. On 11/08/2024, the Department received an updated death report of R1 with R1's cause of death. On 11/08/2024, the Department received an updated death report of R1 with description of R1's condition before R1 was sent to hospital on 10/29/2024 morning, and R1's physician report, Appraisal/Needs and Service Plan, Activities for Daily Living Questionnaire for MD review form, and Identification and Emergency Information Form. On 11/21/2024, LPA interviewed staff S1. S1 stated he/she received Colostomy training from Registered Nurse, the licensee to provide Colostomy care to resident R1. S1 stated Licensee and another staff S3 also provide Colostomy care to R1. S1 stated S3 also received Colostomy training from Register Nurse, the licensee. S1 stated R1 was able to feed self. R1 was able to comb self. S1 stated R1 was able to walk with walker or wheelchair. S1 stated he/she and S3 conducted bed bath for R1. LPA interviewed staff S2. S2 stated he/she did not provide Colostomy care to R1. S2 stated he/she cooks meals. Continue on LIC809-C. Page 1 of 2. LPA interviewed Licensee (LCN) on the phone. LCN confirmed he/she provides Colostomy training to S1 and S2 two times per month. LCN stated he/she checked R1's Colostomy bag regularly to make sure it is clean. LCN confirmed he/she also provided Colostomy care to resident R1. LPA interviewed ADM. ADM stated R1 was under restricted health condition for Colostomy. ADM stated the facility is compliance with the regulation. ADM stated staff S1 and S3 received the Colostomy training from registered nurse. ADM stated S1, S3 and the registered nurse provided Colostomy care to R1. ADM provided a copy the facility Colostomy training materials. ADM provided the twice per month Colostomy training log for S1 and S3. Checked LPA's email log with the facility Administrator(ADM), an email from ADM on 10/30/2024 stating resident R1 was sent to hospital due to shoulder pain on 10/29/2024, and the facility will send an official incident report. Based on the review of the incident reports that the facility sent to CCL office, there is no written incident report regarding R1 was sent to hospital. Based on the review of R1's physician report and Appraisal/Needs and Service Plan, R1 is non ambulatory but is not bedridden. Based on the review of the facility fire clearance records, the facility has capacity of 6 non ambulatory residents and capability of 1 bedridden resident. Based on the review of R1's physician report and Appraisal/Needs and Service Plan, R1 used colostomy bag which is restricted health conditions. For today's visit, deficiency noted, citation was issued due to the facility did not send a written incident report of resident R1 was sent to hospital to CCL office within 7 days. See LIC809-D. Exit interview was conducted with Administrator (ADM). This report was provided to ADM for review and signature. A copy of the reports was provided to ADM. Page 2 of 2.the state’s words, verbatim · CDSS document, Nov 21, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Nov 28, 2024

87211 Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, (1) A written report shall be submitted to the licensing agency ... within seven days of the occurrence ...(D)Any incident which threatens the welfare, safety or health of any resident ... The requirement was not met as evidenced by: Based on the records reviewed, Administrator did not send the incident report of resident R1 was sent to hospital within 7 days of the incident occurrence, this poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 21, 2024

Plan of correction: Administrator stated to read the regulation and send plan of correction by the POC due date to ensure the facility to send incident report to CCL office in timely manner.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Kristine Vu. LPA checked 2 resident files and 2 staff files. LPA toured the facility with ADM. License, Administrator Certificate and Personal right posters were observed in the facility. There are 2 staff live-in rooms, 5 resident rooms, and 3 restrooms in the facility. Grabbing bars and Non skid pads were observed in the bathrooms. 3 staff and 4 residents were observed in the facility. LPA toured the kitchen, dining room, family room, laundry room and living room. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. The room temperature was 72 degree F, and the hot water temperature was 106 degree F. The temperature of the refrigerator was measured at 38 degree F, and the temperature of freezer was measured at 0 degree F. Medication cabinet was observed locked. Knives cabinet was observed locked. Cleaning chemical products cabinet under the sink were observed unlocked. ADM locked it immediately. Fire extinguisher was serviced on 05/08/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by ADM, and were working fine. First aid box, flash light for emergency, audio door alarm for the main entrance and night light were observed in the facility. LPA toured backyard with ADM. No obstacles were observed blocked the walkway in the backyard. Two storage rooms were observed at the backyard. A empty swimming pool was observed locked at the back yard. The facility had emergency and fire drill on 10/01/2024. No Deficiencies were noted today. Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of the report was provided to ADM.the state’s words, verbatim · CDSS document, Oct 25, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with House Manager (HM) Michael Vu. LPA checked 5 resident files and 3 staff files. LPA toured the facility with HM. License, Administrator Certificate and Personal right posters were observed in the facility. There are 2 staff live-in rooms, 5 resident rooms, and 3 restrooms in the facility. Grabbing bars and Non skid pads were observed in the bathrooms. 3 staff and 5 residents were observed in the facility. LPA toured the kitchen, dining room, family room, laundry room and living room. The screens of windows in 3 bedrooms were observed not in good repair. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. The room temperature was 70 degree F, and the hot water temperature was 108 degree F. The temperature of the refrigerator was measured at 40 degree F, and the temperature of freezer was measured at 0 degree F. Medication cabinet was observed locked. Knives cabinet was observed locked. Cleaning chemical products cabinet under the sink were observed unlocked. Fire extinguisher was serviced on 05/18/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors was tested by HM, and were working fine. First aid box, flash light for emergency, audio door alarm for the main entrance and night light were observed in the facility. LPA toured backyard with HM. No obstacles were observed blocked the walkway in the backyard. Some stuff were stocked at the backyard, HM stated the facility is going to clean it up. One storage room was observed at the backyard. A swimming pool was observed locked at the back yard. The facility had emergency and fire drill on 10/01/2023. Deficiencies were noted today. See LIC809-D. Exit interview was conducted with HM. The report was provided to HM for signature. A copy of the report was provided to HM.the state’s words, verbatim · CDSS document, Oct 25, 2023