K & J Residential Care Home

Type of visit: Required - 1 Year

On 06/08/2026 at 8:45 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Direct Care Staff, Betty Ali and explained the purpose of the visit. Co-Administrator, Warlia Rivac arrived shortly after. LPA toured facility inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 3 bedrooms are occupied by the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 68 degrees Fahrenheit. LPA observed lighting in all rooms is adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 105 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 06/18/2025. First aid kit was observed to be complete. Emergency disaster drill was last conducted on 06/01/2026. At 10:30 AM, LPA reviewed 3 residents records. At 11:08 AM, LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility. At 1:30 PM, LPA reviewed a sample of resident’s medications. Continued to LIC809-C... Continued from LIC809... Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/19/2026: LIC 500 Personnel Report LIC9282 Infection Control Plan THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 9:19 AM, LPA observed a bed in the living room area. At 9:50 AM, LPA observed multiple medications in the living room, eye drops in R1's room, and R2's medications in the fridge unlocked and accessible to residents. At 10:08 AM, LPA observed rotten onions in the garage. At 10:10 AM, LPA observed food items such as cereal, cocoa almond spread, etc. in the same storage cabinet as cleaning chemicals. At 10:39 AM, LPA observed a staff room in a shed outside in the backyard filled with a fridge, bed, electricity, etc. Interview with S1 revealed that S1 will sometimes sleep there or inside the facility. At 12:49 PM, record review showed that the facility does not have the liability insurance on file for review. At 1:38 PM, LPA observed that the Medication Administration Record (MAR) for May 2026 and June 2026 is not filled out. The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted with Administrator. Appeal Rights, LIC421FC, and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 8, 2026

The state marks this report as 10 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

On 01/26/2026 at 9:25 AM, Licensing Program Analyst (LPA) P. Manalo conducted an unannounced Case Management visit regarding a self-reported death report. The facility sent in a death report on 01/08/2026. LPA met with Co-Administrator, Warlita Rivac, and explained the purpose of the visit. Death Report (LIC624A) indicated that on 01/07/2026 Resident 1 (R1) passed away on 01/07/2026. Report indicated that R1 was alert and responsive, and the immediate cause of death was respiratory problem. During the visit, LPA reviewed and obtained documents including but not limited to Admission Agreement, After Visit Summary, Incident Report, Facility’s Communication Log, Physician Report, Physician Orders for Life-Sustaining Treatment (POLST), and Identification and Emergency Information. LPA interviewed Co-Administrator and Staff 1 (S1). LPA will be requesting for a death certificate. LPA may return at a later time. No deficiency cited during today’s visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Jan 26, 2026

Type of visit: Case Management - Other

On 01/26/2026 at 10:35 AM, Licensing Program Analyst (LPA) P. Manalo conducted an unannounced Case Management. LPA met with Warlita Rivac, and explained the purpose of the visit. While LPA was at the facility for another visit, LPA observed the following deficiencies: At 10:35 AM, LPA observed unlocked sanitizing wipes and hydrocortisone ointment in the bathroom. A civil penalty of $250 is assessed for repeat citation. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. A copy of this report, LIC421FC, and appeal rights provided.the state’s words, verbatim · CDSS document, Jan 26, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jan 27, 2026

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects...in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above by having unlocked sanitizing wipes and hydrocortisone cream in the bathroom which posed an immediate safety risk to persons in care.the state’s words, verbatim · CDSS document, Jan 26, 2026

Plan of correction: Staff agrees to lock the items and send proof to CCLD by POC date.

Type of visit: Required - 1 Year

On 06/18/2025 at 9:15 AM, Licensing Program Analyst (LPA) P. Manalo arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Back Up Administrator, Warlita Rivac and explained the purpose of the visit. The Administrator was unable to come during the visit and gave authorization for Back Up Administrator to sign the report. Administrator certificate is current. LPA toured facility with inside and out including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are occupied by the residents, 1 bedroom is occupied by staff, and one office space. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 109.2 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 06/18/2025. Emergency disaster drill was last conducted on 03/10/2025. At 10:44 AM, LPA reviewed 5 residents records. At 11:08 AM, LPA reviewed 3 staff records and all have current first aid training and associated to the facility. At 12:00 PM, LPA reviewed two sample of resident’s medications. Continue to LIC809-C... Continue from LIC809... Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/26/2025: LIC 500 Personnel Report LIC 610E Emergency Disaster Plan Liability Insurance Current Administrator’s Certificate Infection Control THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 9:30, LPA observed unlocked cleaning supplies such as Ajax, Lysol Spray, Borax and unlocked medications such as Nyquil, Allergy Medicine, and Suppositories. At 9:37 AM, LPA observed a rotten tomato in the fridge and expired canned goods in the storage room. At 11:35 AM, LPA observed the facility does not have the Administrator records on file. At 11:38 PM, record review showed that there was no staff training conducted. At 11:55 AM, LPA observed all residents' record is incomplete. At 12:16 PM, LPA observed R1, R2, and R4 have half bed rails with no doctor's order for it. The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 18, 2025

The state marks this report as 11 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 6/21/2024 at 7:55 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Warlita Agmata-Rivac and explained the purpose of the visit. The facility’s fire clearance was approved for 6 non-ambulatory. LPA toured facility with Warlita Agmata-Rivac including but not limited to bedrooms, bathrooms, kitchen, common area and backyard. The facility consists of 7 total bedrooms which 6 bedrooms are for the residents and 1 bedroom is occupied by staff. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 71 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 113.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents. Smoke detectors and carbon monoxide detector were in operating condition during visit. Fire extinguisher was last serviced on 8/11/2023. Emergency Disaster Plan was last posted on 1/1/2024. First aid kit was observed to be complete. At 8:15am, LPA reviewed 5 residents records. At 11:00am, LPA reviewed 3 staff records and 3 of 3 have current first aid training and associated to the facility. Report continues on LIC809-C THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT: At 8:00am LPA observed a bed set up in the living room that is used by staff to sleep on during the night. Administrator confirmed that the staff sleep on the bed. Also At 9:40am during facility tour LPA observed that in the backyard a shed has been converted and is being occupied by a caregiver. The structure is not cleared on the facility sketch and Administrator confirmed that the shed was converted after the last annual inspection was conducted. (Repeat Violation:87307(a)(2)(B)) $250 At 8:30am during file review LPA observed that R2 does not have an Needs and Services Plan. Administrator confirmed they have not done the appraisal. (Repeat Violation: 87506(b)) $250 At 8:50am during file review LPA observed that R3's physicians report lists them as BEDRIDDEN. LPA contacted the primary care physician to confirm this diagnosis. Physician confirmed resident is bedridden. Facility is not cleared for bedridden. (Immediate Civil Penalty: 87202(a)(2)) $500 At 9:28am during facility tour LPA observed the dishwasher being used as a storage place for dishes. LPA observed a large cooking knife with a yellow handle stored inside. Administrator removed and locked away knife. Also at 9:29am during facility tour LPA observed ZZZQuil unlocked in the bottom kitchen counter. Administrator removed and locked away PRN. At 10:17am LPA contacted desk duty to inquire about the status of the Administrators certificate. There is no certificate application pending. The last certificate expired 12/17/2021.(Repeat Violation:87412(d)) $250 At 11:22am during file review LPA did not observe a disaster drill on file. Administrator states they have not done any drills this year. ***An immediate civil penalty is being assessed today for $500 for fire clearance violation 87202(a)(2)*** **A civil penalty is being assessed today for $750 for all other repeat violations {$250 per violation x 3}** Civil penalty total= $1,250 The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.the state’s words, verbatim · CDSS document, Jun 21, 2024