Kimberly's Elder Kare Kottage

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced Required 1 Year inspection. LPA met with Licensee Debra Hall, Administrators (ADM) Annabelle Esperanza and Kendall Hall. LPA toured the interior and exterior of the facility with Licensee and ADM Annabelle to include the kitchen, resident rooms, dining room, bathrooms, back and front of the facility. All exit and passageways were free and clear of obstruction. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the refrigerator temperature at 43 F and Freezer at -4 F. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. The facility was equipped with smoke and carbon monoxide detectors. All smoke detectors functioned properly when tested by ADM Kendall. Fire extinguishers were purchased on 2/3/2026. LPA reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed. The facility's last drill was on 5/7/2026. LPA toured 2 resident bedrooms. All 2 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 3 resident bathrooms. All 3 bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. 4 bedrooms were vacant (no residents). Page 1 of 2 LPA measured water temperature with a range of 105 F to 112.4 F. During tour of 4 resident bedrooms, (2 occupied, 4 vacant/no resident living in the room), LPA observed the auditory alarms on the door were not functioning when tested by Licensee. ADM Kendall repaired all auditory alarms on resident bedroom door exits (sliding glass doors/doors). A Technical Assistance was issued, see LIC9102 for more information. LPA reviewed 2 resident records. LPA reviewed 2 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). LPA reviewed 2 staff records. No deficiencies were cited during today's visit per California Code of Regulations Title 22. A Technical Assistance was issued, see LIC9102 for more information. An exit interview was conducted with Licensee Debra Hall and Administrator Annabelle Esperanza, and a signed copy of this report was provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, Aug 19, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year Visit and met with staff Elizabeth Gonzalez. During visit, LPA toured the facility inside and out. LPA toured the kitchen area and 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 the first aid kit and found it to be complete. LPA toured two out of two resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks were 112 F and 116 F. LPA tested the smoke detectors in the hallways and in six out of six resident bedrooms. Each smoke detector functioned properly when tested. LPA tested one out of one carbon monoxide detector and it functioned properly when tested. LPA toured six out of six resident bedrooms and found each bedroom to have working lights. All the occupied bedrooms had available bedding and clothing storage areas. During visit, LPA observed that a sliding glass door did not completely close and lock and two staff were needed to open and close the sliding door. LPA observed a hole about 3 inches in diameter in one of the resident bedrooms. LPA toured the outside area and found the outdoor exits were clear of obstructions. The Emergency Disaster Drill Log indicates the last disaster drill was conducted on 06/06/2025. See LIC809-C page for more information. Page 1 of 2. LPA Marrufo reviewed three out of three resident records, including Centrally Stored Medication and Destruction Records. Resident R1 had the wrong prescription number for one medication. LPA reviewed 5 staff records. Staff S1 was missing a Health Screening Form. S2 was missing a current first aid certification. Advisory Notes were issued. See LIC9102 forms for more information. A deficiency was cited as per California Code of Regulations Title 22. See LIC809-D page for more information. LPA Marrufo requests that the following records be updated and sent to LPA Marrufo within 5 business days: LIC500 Personnel Report Current Liability Insurance Record Emergency Disaster Plan This report was reviewed with staff Elizabeth Gonzalez and a copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 22, 2025

Allegation investigated: Staff interferred with the Long Term Care Ombudsman's facility visit.

On 1/18/2025, Licensing Program Analyst (LPA) Arvin Villanueva arrived unannounced at this facility to conduct a follow up complaint visit regarding the allegation noted above. LPA initially met with staff on duty and stated the purpose of the visit. The administrators, Kendall Hall and Annabelle Esperanza arrived shortly after. Present during today's visit were 5 residents in care with 2 staff on duty. The investigation in to the above allegation consisted of interviews and record reviews. Based on an interview with an Ombudsman representative (Omb), it was revealed that the visiting ombudsman on May 2023 was asked to leave the facility. Omb stated they subsequently spoke with the facility licensee to explain the ombudsman’s role during visits. Omb also disclosed that the ombudsman team was short-staffed at the time and did not become fully staffed until November 2024. Efforts have since been made to resume regular visits. The ombudsman who conducted the May 2023 visit is no longer with the agency and could not provide further information regarding that visit. {1 of 2} Unsubstantiated Omb confirmed that they reviewed the photos taken during the May 2023 visit and confirmed that the photos taken did not contain photos of residents and/or staff. Additionally, Omb stated there were no subsequent ombudsman visits to the facility until November 2024 due to staffing challenges. Omb noted that any issues arising during the November 2024 visit would have been reported but confirmed no concerns were brought to their attention. Interviews with facility staff indicated that during the May 2023 visit, the ombudsman that visited was perceived as rude toward caregivers. Staff also reported that the ombudsman began taking photos of residents without their permission, which prompted staff to intervene to protect residents’ privacy. Staff further stated that follow-up visits by other ombudsman representatives occurred after the incident, during which no issues were reported. According to staff, the most recent ombudsman visit occurred on January 10, 2025, and no concerns were noted during this visit. A review of past Department visit reports from August 7, 2024, July 26, 2024, May 31, 2023, September 1, 2022, August 3, 2022, and August 25, 2021, found no evidence of facility staff interfering with these visits. Based on the information gathered during this investigation, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies are being cited from today's visit. Exit interview was conducted with the administrators and a copy of this report and appeal rights were provided. {2 of 2}the state’s words, verbatim · CDSS document, Jan 18, 2025 · control 26-AS-20230523085525

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Christine Dolores, Marcela Yanez, and Kiran Jain arrived unannounced to conduct the facility's annual required - 1 year annual inspection. LPAs met with Administrator, Annabelle Esperanza. During visit, LPAs toured the facility to include the resident bedrooms, staff bedrooms, bathrooms, kitchen, living room, dining room, and exterior. All fire exits and passageways are clear of obstruction. Fire extinguisher last serviced on 12/01/2023. Facility has a carbon monoxide detector. Facility temperature maintained at 76 degrees Fahrenheit. Bathroom shower supplied with grab bars and non-slid mats. Hygiene products and linens available. Hot water temperature in bathrooms maintained at 106 degrees Fahrenheit. Bedrooms equipped with beds, linens, dressers, night stands and adequate lighting. 1 resident bedroom observed with half bed rails and oxygen. Oxygen in use sign posted on the bedroom door. Facility has at least 2 days of perishables and 7 days worth of non-perishables foods. Chemicals, disinfectants, and medications observed locked. LPAs reviewed 3 resident files. 3 resident files contains an admission agreement, physician's report, appraisal/needs and services plan, consent form, and personal rights. 3 out of 3 residents centrally stored medication and centrally stored medication records observed maintained. The resident who utilizes the oxygen and bed rails has physician's order on file. LPAs reviewed 3 staff files. 3 out of 3 staff contains a health screening, TB result, fingerprint clearance, and 1st aid certification. 3 out of 3 staff are provided annual training. Facility has an emergency disaster plan. Emergency disaster drills are being conducted quarterly. Documents obtained to include the Administrator Certificate, LIC308, LIC500, Liability insurance, and Emergency disaster plan. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Annabelle Esperanza and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 7, 2024

Allegation investigated: Resident sustained multiple pressure injuries while in care Staff refused to administer residents medication Staff did not notify residents authorized representatives in a timely manner of incidents Residents were left unsupervised Staff restricted resident from having visitors

On 7/26/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator Annabelle Esperanza and explained the purpose of today's visit. Regarding the allegation of Resident sustained multiple pressure injuries while in care, Reporting Party (RP) stated that when RP came back after an out of town event, hospice was there, and they rolled resident (R1) onto their side and found that R1 had bedsores from neck down to R1s feet. LPA Dolores was able to interview two staff members. One staff (S1) stated that R1 developed bed sores but hospice addressed that and it healed. Staffing in the facility is 2 caregivers per shift. Each caregiver check on resident every two hours to rotate the resident. It was also stated that a family member (F1) didn't want the staff to take R1 out of bed because if staff move R1, he/she'd be in pain. page 1 of 3 Unsubstantiated Regarding the allegation that staff refused to administer residents’ medication. RP stated that when R1 returned to the facility, hospice was brought in two day a week to care for R1. RP stated that they had put R1 on morphine twice a day and staff (S3) didn’t want to give resident the medication because he/she was too heartbroken about R1s condition dwindling. During the interview, S1 and S2 mentioned that R1 was given morphine and the staff are not allowed to fill the syringe. Hospice needs to do it. A nurse comes to give it to R1. Based on records review, the staff are able to assist the resident by giving morphine which is in tablet form and also a PRN. Facility has showed records of days where PRN medication was administered and documented results. Regarding the allegation of staff did not notify residents authorized representatives in a timely manner of incidents, RP stated that R1 had a UTI in April, and the facility staff did not call the family to inform them. The staff called an ambulance at 6pm and staff did not call family when R1 was already at the hospital. According to S2, during this time R1 had a fever and S2 called the responsible party/POA and was advised to bring R1 to the hospital. Regarding the allegation of residents were left unsupervised, RP stated that R1 had been sitting in a soiled diaper and the padding on the bed was brown which means that it hadn’t been changed in a while, when RP went to look for staff, no one was around. According to S1, the Licensee (L1) came to the facility immediately when it was reported that there was no staff. S2 arrived 2 seconds from L1 and saw 1 caregiver. Three other Staff members, S4, S5 & S6 was at the facility at that time. During this time, S6 was on break. S5 was at the other part of the house helping another resident. page 2 of 3 Regarding the allegation of staff restricted resident from having visitors, RP stated that after the death of R1, RP tried to go back and visit another resident (R2) and the administrator wouldn’t let him/her in. RP stated that this R2s responsible party came to visit and called RP saying that R2 wanted to see him/her. Based on interviews, S1 mentioned that RP came back to the facility to visit another resident, who RP became friends with. RP was allowed to visit R2. S2 also confirmed that RP was able to visit R2 during that day. Based on records review, visitation logs show that RP was able to enter the facility and visit R2. Based on interviews & records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. page 3 of 3the state’s words, verbatim · CDSS document, Jul 26, 2024 · control 26-AS-20220831120143

Type of visit: Case Management - Other

On 7/26/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint visit to deliver findings. LPA met with Administrator Annabelle Esperanza and explained the purpose of today's visit. During the investigation of complaint control #26-AS-20220831120143, LPA Donato found that the facility did not report an incident to Licensing in which a resident was sent to the emergency room due to UTI. Deficiency of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Co-Administrator and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Jul 26, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Jul 27, 2024

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident...(D)Any incident which threatens the welfare, safety or health of any resident... This was not met as evidenced by: Based on interviews, Licensee did not report an incident to Licensing which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jul 26, 2024

Plan of correction: Licensee to submit a plan to address reporting requirement issues in the facility. Licensee to submit plan by POC deadline.