Jj Home 1

Type of visit: Required - 1 Year

On 04/17/2026 at approximately 01:00PM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct 1-Year Required visit of this licensed Residential Care Facility for The Elderly (RCFE). LPA was greeted by Staff, Mark Cabugwas. Administrator/Licensee, Josephine Sana arrived during visit shortly after. Facility has an approved fire clearance and capacity for four (4) non-ambulatory residents. Upon arrival LPA was informed that there were four (4) residents in care and two (2) staff members on-site. Facility is a 1 story building with four (4) resident bedrooms, two (2) bathrooms, and common spaces. At approximately 1:30PM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 01:45PM, LPA and Licensee toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. The amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Staff were in the process of cleaning up kitchen at the time of this inspection. Toxins are stored in a locked housekeeping closet in the laundry room and under kitchens ink. Water temperature measured 108.6 degrees F and 107.4 degrees F which is within regulation between 105- and 120-degrees F at faucets accessible to residents. Fire Extinguishers found to be last charged on 08/24/2025 at the time of visit. Carbon Monoxide and smoke detectors were present and in order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure in a cabinet next to the office space. Continued on LIC809-C Page... Continued from LIC809 page... At approximately 2:25PM, LPA reviewed three (3) resident records and found all residents have current care plans, signed admission agreements, and physician's report on file. Medication records are thorough and contained physician's orders for each resident. LPA also reviewed 3 staff records. 3 of 3 records did contain documentation of completed training records as required. Evidence of current first aid and CPR training were current. LPA was presented with proof of current CPR & 1st Aid certification. Administrator Certificate is for Josephine Sana #7003793740 expires 02/21/2028. LPA reviewed the facility emergency disaster plan. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 06/10/2026. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 04/27/2026: LIC 308 Designation of Facility Responsibilities LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan (Last review page) LIC 9020 Register of Facility Client’s/Resident’s Copy/Proof of Updated Certificate of Liability Insurance No deficiencies were observed in the areas inspected, No citations were issued during today’s visit. Exit interview conducted. Copy of report provided to Licensee. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Apr 17, 2026

Type of visit: Required - 1 Year

At approximately 12:50 PM, Licensing Program Analyst (LPA) Elias Magdaleno arrived unannounced to conduct a required 1-year annual inspection and was greeted by Caregiver. Administrator Josephine Sana was contacted and arrived at approximately 2:00 PM. Facility is a Residential Care Facility for the Elderly (RCFE) with four (4) residents in care. Facility has a Dementia Care Plan with one (1) dementia resident in care and is approved for all non-ambulatory residents. LPA was informed that one (1) resident was home with the rest at Day Program. At approximately 1:30 PM, LPA initiated a tour of the facility with Caregiver and observed the following: Facility is a one (1) story home, was a comfortable temperature, and passageways were free from obstructions. Fire extinguishers were last inspected 5/24. Sprinklers and smoke/carbon dioxide detectors are hardwired and last serviced by vendor 8/24. Water temperature measured 110.2 degrees F and 111.2 degrees F, which is within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA observed at least a two (2) day supply of perishable and seven (7) day supply of non-perishable food, as well as an emergency water supply. Food was found to be stored in a safe manner with open items covered. There is a shaded seating area in the backyard with outdoor space for activities. Facility telephone was tested and operational during inspection. LPA observed toys, games, an activity schedule, musical instruments, and each resident is provided an internet accessible tablet. Continued 809C... Continued from 809... Facility conducts monthly disaster drills, and the most recent drill was conducted 4/25. LPA observed facility's infection control plan and emergency disaster plan which was last updated 4/24. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights. At approximately 2:10 PM LPA conducted a review of four (4) resident records. All required documentation present. At approximately 2:30 PM LPA conducted review of five (5) staff records. All required documentation present. At approximately 3:00 PM LPA and Administrator conducted a spot check of medication and medication records. Medication is centrally stored and locked. At approximately 3:10 PM LPA and Administrator conducted check of P&I. All records present and cash is reconciled. Josephine Sana Administrator Certificate 7003793740 expires 2/21/2026. All fees are current as of this time. Updated copies of the following documents were received during this visit: LIC500 - Personnel Report LIC308 - Designation of Responsibility LIC400 - Affidavit Regarding Client Cash Resources LIC402 - Surety Bond LIC610D - Emergency Disaster Plan No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, May 8, 2025

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: Required - 1 Year

At approximately 8:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a 1-Year Required Visit and met with Staff Member, Mark Cabugwas who was the only staff member present. LPA was informed that there are 4 clients in care and all were away at day program, which is Monday - Friday from 8:00 AM - 3:00 PM. Licensee/Administrator, Josephine Sana was contacted and arrived at approximately 8:50 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with 1 dementia client in care. Facility has an approved fire clearance and capacity for 4 non-ambulatory clients. At approximately 8:55 AM, LPA initiated a tour of the facility and observed the following: Facility is a one-story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed client showers with grab bars an non-slip mats as required. LPA observed a supply of clean linens, incontinent care products, and paper products available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Two cabinets in communal areas containing cleaning supplies and other items that could pose a risk were observed unlocked. Licensee removed the items immediately and placed them in a locked cabinet in the locked garage. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. There is outdoor space for activities. LPA observed toys, games, ipads for each resident, an activity schedule, musical instruments and other supplies for client activities. The facility is hardwired with automatic fire doors, which were tested and operational. Fire extinguisher was last serviced July 2023. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts regular monthly disaster drills, and the most recent drill was conducted April 2024. LPA observed the facility's infection control plan, first aid kit, emergency supply of water, PPE, and other emergency supplies. Licensee states facility has a back-up generator if one is needed. LPA reviewed facility's emergency disaster plan and plan of operation and informed Licensee that both need to be updated to make considerations for clients with dementia. Licensee updated the facility's emergency disaster plan during visit and submitted it to LPA. Continued on 809-C... At approximately 9:45 AM 5 staff files and 4 client files were reviewed. All staff have required CPR and First Aid training certificates. LPA observed 2 of 5 staff do not have the required LIC503 - Health Screening signed by a physician and 1 of 5 staff files had LIC501 - Job application missing the staff member's signature. LPA also observed 1 of 5 staff files deficient in both annual and dementia training hours. LPA observed 5 of 5 staff files contained all the remaining required documentation. LPA reviewed 4 of 4 client files and observed 1 of 4 with their individual service plan not signed by the responsible party. LPA observed that 4 of 4 client files had all the remaining required documentation per regulation. Facility coordinates and takes the clients to their medical and dental appointments as needed. LPA reviewed medications and medication records which are maintained in compliance with regulation. LPA reviewed P&I monies and logs, which were organized and maintained according to regulation. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: Proof of Staff Training Staff Health Screenings Signed by Physician Signed Client ISP LIC610D- Disaster Plan Updated Plan of Operation to include Dementia Care Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted with Licensee whose signature on this document confirms receipt. This report was reviewed with Licensee and Appeal Rights were given.the state’s words, verbatim · CDSS document, May 22, 2024