Kelly's Almagro Villa

Type of visit: Required - 1 Year

On 3/2/26, Licensing Program Analysts (LPAs) Kyle Wellington and Janette Romero made an unannounced visit to the facility to conduct an annual inspection. LPAs met with employee (staff), Joanna Dizon, who was informed of the purpose of the visit. Adminstrator (Admin), Garrett Welker, arrived shortly thereafter. LPAs observed 2 (two) staff and six (6) residents present at the facility. The census at the facility is six (6) residents with two (2) of the residents receiving hospice care. LPAs received a LIC 9020 from the staff. LPAs toured the inside and outside of the facility with the staff. LPAs conducted an observation, interviews and record review at the facility for the inspection. Facility Overview: The facility is a one story house with six (6) resident bedrooms, one (1) staff room, three (3) bathrooms, kitchen, family room, dining room, laundry room and attached garage. There are no pools, bodies of water or firearms at the facility. The facility has a fire clearance to serve six (6) non-ambulatory residents and facility has a hospice waiver for six (6) residents. Infection Control: LPAs observed soap dispensers in the bathrooms and hand sanitizers in the facility. Cleaning supplies were locked in the garage and available for regular facility maintenance. LPAs reviewed the facility’s infection control plan which met the department’s requirements. Physical Plant: LPAs observed the inside and outside of the facility to be clean, safe and well kept. The floors, windows and doors were clean and well maintained. The living room and dining room furniture was in good repair. The halls had night lights and were free of obstruction. The residents’ bedrooms were neat, organized and had the required bedding, furniture and lighting. Bathrooms were clean, tidy and contained handrails and non-slip tile floors in the shower. The hot water temperature in the bathroom was measured at 105.7 F. Clean linens and towels were available in the hall closet. Laundry equipment appeared to be in good working condition. The one (1) fire extinguisher was charged and bought on 1/6/25. Staff tested one (1) of the smoke and carbon monoxide detectors and LPAs found them to be hard wired and operational. The backyard was clean, free of hazards and contained outdoor furniture & shaded area for the residents. Kitchen/Food Service: LPAs observed the kitchen to be clean, organized, and well maintained. The kitchen had the ability to prepare and store food in a safe and clean environment. Kitchen equipment appeared to be in good working condition. Dishes, containers, pot/pans and silverware appeared clean and in good condition. All sharp and dangerous objects were kept in a locked room inaccessible to residents. Cleaning supplies were kept in a locked cabinet under the sink inaccessible to residents. The refrigerator/freezer was clean, stocked and at the required temperatures. Food in the refrigerator/freezer and cabinets in the kitchen and in the garage were stored properly and not expired. The facility has at least a two day supply of perishable foods and a seven day supply of non perishable foods. The hot water temperature in the kitchen was measured at 105.2 F. Care & Supervision: LPAs observed the facility had sufficient staff present to supervise the residents. Administration: LPAs observed personal rights information, facility sketch, emergency phone numbers, Ombudsman information and phone numbers and complaint procedures were posted near the front door. Admin holds a current Administrator Certificate and a current CPR Certification. Admin has a criminal record clearance. Record Review and Resident/Staff Files: LPAs compared the staff present at the facility and on the staff roster to the Guardian staff roster for criminal record clearance. LPAs reviewed the records of two (2) staff files and three (3) residents’ files. The files contained all the required documentation and paperwork. The staff and residents’ files were kept in a locked closet in the kitchen inaccessible to unauthorized individuals. Health Related Services/Incidental Medical Services: LPAs observed all residents’ medications were locked in a closet in the kitchen inaccessible to residents. No medication was stored in a refrigerator with food items. LPA reviewed the facility’s medication administration record (MAR) to make sure all medication was accounted for and dispensed correctly. First Aid kit contained all the required items and was kept in a locked closet in the kitchen. Disaster Preparedness: LPAs reviewed the facility’s emergency and disaster plan. The plan was current and up to date. Safety and fire drills are conducted every three (3) months with the last drill occurring on 2/1/26. LPAs observed all facility exits were clear of obstructions and had the required signage. No deficiencies were cited during this visit. Exit interview was conducted with the Administrator and a copy of this report was given to the Administrator.the state’s words, verbatim · CDSS document, Mar 2, 2026

Type of visit: Required - 1 Year

On 2/19/2025, Licensing Program Analyst (LPA) Janette Romero made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Caregiver, Joanna Dizon who was informed of the purpose of the visit. The facility has an approved hospice waiver for six (6) and a fire clearance to serve six (6) non-ambulatory elderly adults. LPA toured the facility with Caregiver Dizon and observed the facility is made up of a one-story home with six (6) resident bedrooms, two (2) resident bathrooms, a visitor restroom, kitchen, dining room, and attached garage. Resident bedrooms had the required bedding, furniture, and lighting. Bathrooms had grab bars and non-skid mats in the showers. No bodies of water were observed on the premises. Indoor and outdoor passageways were free of obstruction. The facility has more than two-day supply of perishable foods and seven-day supply of non-perishable foods, which are stored in a safe and healthful manner. Medications are secured in a locked medication room near the kitchen. LPA toured the garage and observed an operating laundry washer and dryer along with additional incontinent supplies, cleaning solutions/disinfectants, food and water. Caregiver Dizon tested one of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed charged fire extinguishers mounted throughout the facility. The facility's certificate of liability insurance expires on 3/1/2025. Staff present have a criminal record clearance and are associated with the facility. Resident files reviewed had updated physician's reports and signed admission agreements. Long Term Care Ombudsman's contact information, complaint procedures, and facility sketch are visibly posted near the front entrance and kitchen. During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted and a copy of this report was reviewed and provided to Caregiver Dizon.the state’s words, verbatim · CDSS document, Feb 19, 2025

Type of visit: Case Management - Deficiencies

On 8/21/2024, Licensing Program Analyst (LPA) Janette Romero arrived unannounced case management visit to follow up on an exception request submitted for Resident 1 (R1). LPA met with Caregivers, Leila Tobias and Joanna Dizon who were informed of the purpose of the visit. Administrator, Kelly Welker was contacted over-the-phone and also informed of the purpose of LPA's visit. In the review of documents submitted for R1, it was discovered there was contradictory information related to the ambulatory status of R1. LPA reviewed R1's Physician's Report (LIC602A) dated 6/17/2024 which indicates R1 is non-ambulatory but also unable to independently transfer to and from bed, and noted they are bed bound. The LIC602A states R1 is not receiving hospice services, which was corroborated by facility staff. LPA was informed R1 is receiving home health services at the facility twice per week. LPA reviewed R1's home health records dated 6/12/2024 stating R1 requires consistent repositioning every two (2) hours. R1 was interviewed and reported they are unable to reposition themselves. Per a Fire Safety Inspection Request (STD. 850) dated 6/30/2022, the facility has a fire clearance for six (6) non-ambulatory elderly residents. Based on the aforementioned, the facility is in violation of their approved fire clearance. An exit interview was conducted and this report was reviewed with Administrator Welker over-the-phone and in-person with Caregivers Tobias and Dizon. A copy of this report was provided to the Caregiver Tobias along with a Confidential Names List (LIC 811), LIC809-D and LIC421M.the state’s words, verbatim · CDSS document, Aug 21, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87202(a) · Plan of correction due date: Aug 22, 2024

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal... This requirement was not met as evidenced by: Documents submitted for R1 provided contradictory information related to the ambulatory status of R1. R1 was interviewed and reported they are unable to reposition themselves. The facility is in violation of their fire clearance. This poses an immediate health/safety/personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 21, 2024

Plan of correction: Licensee reported they will contact their local fire department and report the facility has a bedridden resident. Licensee added R1 will be relocated to a facility with an appropriate fire clearance. Licensee stated POC to be submitted to LPA via email by close of business on 8/22/2024.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility to conduct an annual licensing inspection. LPA was met by Caregiver, Leila Tobias and explained the purpose of the visit. Present at the facility was Administrator Garrett Welker, who left shortly. The facility is a six (6) bedroom, three (3) bathroom one-story home. A tour of the facility was conducted inside and out. LPA conducted a general overall inspection, which included but was not limited to the following: Facility physical plant, food service, medication management, record review and facility administration. During today's inspection, LPA observed the following: Indoor and outdoor passageways were observed to be free from obstruction. There are no pools or bodies of water. Per Miss Tobias, there are no firearms or other dangerous weapons in the facility. Poisons and cleaning agents were observed to be secured and inaccessible to residents in care. Facility fire clearance is maintained in conformity with State Fire Marshal regulations. LPA toured every room in the facility. Rooms designated as resident rooms had the required furnishings and sufficient lighting available. Licensee provided each resident with clean linen, in good repair, and sufficient hygiene products for personal use. The hot water temperature measured at 108 degrees F. The facility had functioning carbon monoxide detectors, multiple smoke detectors, one operable fire extinguisher. The facility was stocked with a two-day supply of perishable food items and a seven-day supply of nonperishable food items. Staff records were reviewed and contained CPR/First Aid training, Health Screening Reports, and annual training. Resident records were reviewed and contained the appropriate medical documents in addition to Resident Appraisal, Identification and Emergency Information, Admission Agreement, and Centrally Stored Medication and Destruction Records. Medications were stored in a locked cabinet and were labeled and maintained in compliance with label instructions. During today's visit the following deficiency was observed: - The facility did not have a record keeping log of medication given. Deficiency cited. An exit interview was conducted and copy of this report, along with Licensee/Appeal Rights, was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Feb 29, 2024