Joe-Sephine Residential Care Fac. for the Elderly

Type of visit: Annual/Random

On 09/01/26 at 10:00 am Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced one (1) year Required visit for this facility. LPA was greeted by Administrator Josephine Sanoy and informed of the purpose of the visit. Infection Control and Emergency Preparedness Plan: LPA reviewed facility Infection Control Plan and Emergency Preparedness Plan to make sure protocols are being reviewed and/or updated annually. Plans were discussed and updated. Emergency drills are up to date and last held on 06/17/2026, upcoming drill will be done on 09/17/2026. A tour of the physical plant was conducted with the Administrator at 11:15 AM. The facility has four (4) bedrooms and two (2) bathrooms currently occupying three (3) residents. One (1) bedroom is designated for staff use only. The facility is Fire Cleared for three (3) non-ambulatory, one (1) bedridden, and a hospice waiver for one (1) resident. LPA observed three (3) residents watching T.V in the living room. The tool kit was not used for this visit due to technical difficulties. Kitchen Area: At 11:20 am LPA conducted a tour of the kitchen and observed that there are sufficient stock of both two (2) day perishable and seven (7) day non-perishable food items. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects locked and inaccessible to residents in care. The medication cabinet was also observed to be locked. Cleaning supplies and chemicals were observed to be locked in the storage room. Continued on LIC809-C Living and Dining: At 11:30 am LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 73°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational. There is a fire extinguisher located in the living room. The Fire extinguisher was observed to be full and last serviced 6/08/26. At 12:45 pm smoke detectors and carbon monoxide detectors were tested and were operational. Garage/Laundry: At 11:45 am LPA observed the garage to be attached to the facility and is currently being used for storage. LPA observed a refrigerator and deep freezer in the garage. The Laundry room is located in the garage. All chemicals/hazardous items were observed to be locked in a cabinet. Resident Rooms: At 11:55 am LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each resident. All alarms on the exit doors are functional. Bathrooms: At 12:10 pm LPA observed all bathrooms to have the appropriate wash your hands signs posted, non-skid strips and handles. Hot water was tested and measured at 112.8°F. Surrounding Grounds: At 12:30 pm LPA observed a covered shaded area for residents. No bodies of water on the premises. LPA observed all tools in a locked gated area. Resident and Staff Files: LPA conducted a file review of staff and resident records at 01:00 pm. No discrepancies noted. Interviews: At 02:00 pm LPA interviewed residents and staff. Administrative: LPA collected Certificate of Liability Insurance, resident roster, and LIC500. Annual fee is current. No citations issued. Exit interview conducted. Copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Sep 1, 2026

Type of visit: Required - 1 Year

On 07/15/25 Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced one (1) year Required visit for this facility. LPA was greeted by Administrator Josephine Sanoy and informed of the purpose of the visit. A tour of the physical plant was conducted with the Administrator at 10:15 AM. The facility has four (4) bedrooms and two (2) bathrooms currently occupying three (3) residents. One (1) bedroom is designated for staff use only. The facility is Fire Cleared for three (3) non-ambulatory, one (1) bedridden, and a hospice waiver for one (1) resident. LPA observed two (2) residents watching T.V in the living room, one (1) was eating breakfast in the dining room. Infection control: The facility has an Infection Control Plan approved on 06/09/2022. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. Kitchen Area: At 10:20 am LPA conducted a tour of the kitchen and observed that there is sufficient stock of both two (2) day perishable and seven (7) day non-perishable food items. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects locked and inaccessible to residents in care. The medication cabinet was also observed to be locked. Cleaning supplies and chemicals were observed to be locked in the storage room. Continued on LIC809-C Living and dining: At 10:30 am LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 72°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational. There is a fire extinguisher located in the living room. The Fire extinguisher was observed to be full and last serviced 6/11/25. At 10:40 am smoke detectors and carbon monoxide detectors were tested and were operational. Garage/Laundry: At 10:45 am LPA observed the garage to be attached to the facility and is currently being used for storage. LPA observed a refrigerator and deep freezer in the garage. The Laundry room is located in the garage. All chemicals/hazardous items were observed to be locked in a cabinet. Resident Rooms: At 10:55 am LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each resident. All alarms on the exit doors are functional. Bathrooms: At 11:10 am LPA observed all bathrooms to have the appropriate wash your hands signs posted, non-skid strips and handles. Hot water was tested and measured at 108.8 °F. Outside Area: At 11:20 am LPA observed a covered shaded area for residents. No bodies of water on the premises. LPA observed all tools in a locked gated area. Resident and Staff Files: LPA conducted a file review of staff and resident records at 12:00 pm. Interviews: At 01:30 pm LPA interviewed residents and staff. Administrative: LPA collected Certificate of Liability Insurance, resident roster, and LIC500. Annual fee is current. No citations issued. Exit interview conducted. Copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Jul 15, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced one (1) year Required visit at this facility. LPA was greeted by Administrator Josephine Sanoy and informed of the purpose of the visit. LPA observed one (1) resident watching TV the living room, one (1) was eating breakfast at the dining table and one (1) was asleep in their room. A tour of the physical plant was conducted with the Administrator at 9:45 AM. The facility has four (4) bedrooms and two (2) bathrooms currently occupying three (3) residents. One (1) bedroom is designated for staff use only. The facility is Fire Cleared for three (3) non-ambulatory, one (1) bedridden, and a hospice waiver for one (1) resident. Infection control: The facility has an Infection Control Plan approved on 06/09/2022. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. Kitchen Area: At 10:00 am LPA conducted a tour of the kitchen and observed that there is sufficient stock of both two (2) day perishable and seven (7) day non-perishable food items. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects locked and inaccessible to residents in care. The medication cabinet was also observed to be locked. Cleaning supplies and chemicals were observed to be locked in the storage room. Continued on LIC809-C Living and dining: At 10:10 am LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 74°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational. There is a fire extinguisher located in the living room. The Fire extinguisher was observed to be full and last serviced 6/18/24. Garage/Laundry: At 10:15 am LPA observed the garage to be attached to the facility and is currently being used for storage. LPA observed a refrigerator and deep freezer in the garage. The Laundry room is located in the garage. All chemicals/hazardous items were observed to be locked in a cabinet. Resident Rooms: At 10:20 am LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each resident. All alarms on the exit doors are functional. Bathrooms: At 10:22 am LPA observed all bathrooms to have the appropriate wash your hands signs posted, non-skid strips and handles. Hot water was tested and measured at 106.4 °F. Outside Area: At 10:25 am LPA observed a covered shaded area for residents. No bodies of water on the premises. LPA observed all tools in a locked gated shed. Staff Files: LPA conducted a file review of staff records at 10:30 am. Resident Files: LPA conducted a file review of resident records at 11:00 am. Interviews: At 11:45 am LPA interviewed residents and staff. Administrative: LPA collected Certificate of Liability Insurance, resident roster, and LIC.500. Annual fee is current. No citations issued. Exit interview conducted. Copy of this report was emailed to the Administrator.the state’s words, verbatim · CDSS document, Jul 31, 2024

Type of visit: POC

On 2/5/2024 at 9:00 am Licensing Program Analyst (LPA) Casillas arrived at facility to conduct a Plan Of Correction visit for complaint visit dated 2/2/2024. LPA observed that both bathrooms had anti-slip strips that are compliance. LPA forgot to get signature for this report on 2/5/2024. LPA Casillas could not return to the facility due to state of emergency related to severe weather watch, however Licensing Program Manager (LPM) Nichelle Gillyard approved for LPA Casillas to return at a later date to get Administrator signature and provide a copy of this report. On 2/8/2024 LPA Casillas returned to the facility to deliver report and get signature. A copy was given to Administrator.the state’s words, verbatim · CDSS document, Feb 5, 2024

Allegation investigated: Staff did not ensure non-skid mats were used in all bathtubs and showers.

Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced initial 10day complaint visit at 9:45 am. LPA met with Administrator Josephine Sanoy and explained the purpose of the visit. LPA conducted a physical plant tour at 10:00 am. It is alleged that residents do not have non-slip mats in their shower. LPA requested and obtained copies of facility files and documents including but not limited to staff and resident rosters. LPA interviewed Administrator and staff at approximately 10:30 am. During the investigation the administrator and staff confirmed they do not provide non-slip mats to residents. LPA observed two (2) out of two (2) bathrooms to not have non-slip mats in the shower. Not having non-skid mat or strips is a potential slip and fall hazard. Based on inspection, observations, and interviews there is enough evidence to prove the alleged violation did occur, therefore the allegation is SUBSTANTIATED at this time. Deficiency cited. Exit interview conducted. Copy of report given to Administrator and appeal rights discussed. Substantiatedthe state’s words, verbatim · CDSS document, Feb 2, 2024 · control 31-AS-20240131150759

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87030(e)(5) · Plan of correction due date: Feb 5, 2024

87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include...(5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidence by: During the time of the investigation LPA observed two (02) out of two (2) bathrooms to not have non-slip mats in the shower. This may pose a potential Health and Safety risk to persons in care.the state’s words, verbatim · CDSS document, Feb 2, 2024

Plan of correction: Licensee will purchase non-slip mats for all bathroom showers and provide invoice to LPA by email by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced one (1) year Required visit at this facility. LPA was greeted by Administrator Josephine Sanoy and informed of the purpose of the visit. LPA observed two (2) residents watching TV the living room and one (1) was eating breakfast at the dining table A tour of the physical plant was conducted with the Administrator at 9:45 AM. The facility has four (4) bedrooms and two (2) bathrooms currently occupying three (3) residents. One (1) bedroom is designated for staff use only. The facility is Fire Cleared for three (3) non-ambulatory, one bedridden, and a hospice waiver for one resident. Infection control: The facility is following current infection control recommendations. The main door is the only entrance being utilized at this facility. The required poster are posted at the main door. Screening area is located immediately after entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the door. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. Food Inspection: LPA conducted a tour of the kitchen and observed that there are sufficient stock of both perishable and non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp object being locked and inaccessible to residents in care. The medication cabinet was also observed to be locked. Cleaning supplies and chemicals were observed to be locked in the storage room. (continued from LIC 809) Living and dining: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 73°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational. There is a fire extinguisher located in the living room. The Fire extinguisher was observed to be full and last serviced 6/24/23. Garage/Laundry: LPA observed the garage to be attached to the facility and is currently being used for storage. LPA observed a refrigerator and deep freezer in the garage. The Laundry room is located in the garage. All chemicals/hazardous items were observed to be locked in a cabinet. Resident Rooms: LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident. All alarms on the exit doors are functional. Bathrooms: LPA observed all bathrooms to have the appropriated wash your hands signs posted. Hot water was tested and measured at 118.1°F and within the range. Physical environment: LPA observed a covered shaded area for residents. No bodies of water on the premises. LPA observed all tools in a locked gated area. Staff and residents records were checked. Staff present has criminal record clearances and associated to this facility. Staff records appear to be complete and current. Client records were also reviewed and appeared to be complete and current. Disaster drill was last conducted on 09/14/23. Required posting are observed to be complete and current and displayed properly at the facility. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Oct 15, 2023