Kittridge RCFE

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jose Tan conducted an unannounced case management visit to this facility to ensure that the facility has totally ceased operation and no client is no longer living at the facility. LPA met with staff Michael Custodio and explained the reason for the visit. At 9:15 AM, LPA toured the facility inside and out with staff Michael Custodio and the following was observed: There was no one left at the facility, staff or resident. LPA was informed by the operator that the physical license will be mailed to CCL as it was not present at this location at this time. The last resident moved out only yesterday to a licensed facility and therefore the effective date of closure is today. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, Jul 9, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) conducted an unannounced case management to obtained documents pertaining to complaint control no.: 31-AS-20220728112027 regarding Resident #1 (R1). LPA met with staff James Olalia and explained the reason for the visit. LPA called Administrator Frances Martir and designated Mr. Olalia to sign the report. LPA conducted physical plant tour at 9:15 AM and interviewed staff and Administrator. LPA attempted to obtain documents regarding R1 but was told and observed that R1's record is longer at the facility. LPA's interview with the Administrator revealed that the Administrator is not aware of where the documents are but will try to find it and email it to the LPA. Exit interview conducted. Copy of this report issued.the state’s words, verbatim · CDSS document, May 22, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, James Olalia, and explained the reason for the visit. The administrator, Michael Custodio, could not attend the inspection at this time. At approximately 8:15am, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are interconnected. There are two (2) carbon monoxide detectors, one in the living room and one in the hallway, by resident rooms, that functions properly. The fire extinguisher is located in the kitchen. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food properly stored. Knives were stored and were inaccessible during the inspection. The laundry area is located by the kitchen. No detergents or toxins were observed accessible. LPA also did not observe any cleaning supplies accessible in the kitchen. Bedrooms: There are four (4) bedrooms designated for residents' use. Room 1 and Room 3 are shared, while room 2 and 4 are private. Room 1 is approved for bedridden. LPA observed resident bedrooms to be properly furnished with appropriate beddings and linens with sufficient lighting and closet space. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures, grab bars and non-skid mats. Hot water temperature was measured between 118 to 119 degrees Fahrenheit. LPA did not observe any cleaning supplies in either bathrooms during the day's inspection. Common Areas: These included the living room and dining area. The living room is properly furnished with couches, table, chairs and television. There is a fireplace that is properly screened. It is non-functional. No tools present. The dining room table large enough to seat up to six (6) residents. Floors were clean. Furniture is in good repair. Staffing Area: Staffing area is located next to the laundry room by the kitchen. Resident medications and medication records are stored inside the staffing area. There is a bed inside the room for staff to rest in. Staffing area remains locked at all times. No resident access. Surrounding Grounds: Entry/exits were free of obstruction. There is furniture appropriate for outdoor use. The outdoor area, both front and back was free of hazards. There is an external gate that leads into the property, that remains unlocked at all times. There is no swimming pool or any other bodies of water. Garage: Garage is attached to the home, but is kept locked at all times. Garage is used as storage for extra furniture. Resident Files: Resident files are stored locked in a kitchen cabinet. LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files: Staff files are also stored locked in a kitchen cabinet. LPA conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. Medications: Medication and Medication Records are kept locked in the staffing area. Medication and medication records were reviewed for proper storage and documentation. Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the day's inspection. Staff is advised and a copy of this report issued.the state’s words, verbatim · CDSS document, Apr 18, 2026

Allegation investigated: Staff hit resident with an object.

On 06/18/25 Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced complaint visit to investigate the above stated allegation. LPA was greeted by staff and allowed entry. Staff member called back up Administrator, Michael Custodio and advised them of LPA visit. Administrator arrived shortly after, and an entrance interview was conducted. From 11:00 am to 1:30 pm LPA toured the facility, conducted interviews, reviewed staff and resident files. LPA collected LIC500, Resident Roster, Liability Insurance and Administrator certificate. LPA also requested copies of resident records and any other documents pertaining to the investigation. Continued on LIC9099-C Unsubstantiated Allegation: Staff hit resident with an object. It is alleged that staff hit a resident with an object. Regarding this allegation it is reported that staff member #1 (S1) hit resident #1 (R1) with a broom stick. LPA interviewed Back Up Administrator who indicated having no knowledge of the incident and denied that such incident happened. LPA spoke to Administrator Francis Martir over the phone who also stated that they have no knowledge of the incident and also denied the allegation. Administrator Francis stated that a county nurse inquired about R1 via text, where the nurse asked about R1’s wellbeing but did not report to Administrators or facility staff, any incidents. Furthermore, Administrators both report that R1 and S1 get along well and that no other residents have reported anything relating to S1’s behavior towards them. LPA interviewed S1 who also denied the allegation stating that they would never hit anyone, let alone a resident. LPA was able to interview five (5) out of five (5) residents who stated collaboratively that S1 is good to them, and they have no issues with any of the staff in the facility. Two (2) out of the five (5) residents stated that they have heard R1 yell at the staff but also state that this is a means for R1 to communicate with staff sometimes. All residents expressed being happy and satisfied with the services and care provided by the staff. It was also reported to LPA by all residents that they have not witnessed anyone getting hit or struck by any objects, nor have they been subject to any physical abuse. LPA interviewed R1 and R1 revealed that they made the incident up and that R1 is not sure why they lied but assured that S1 did not hit R1 with a broom or any object. R1 stated that they did not report anything to anyone to their recollection. Furthermore, R1 stated that they get along well with all the staff to include S1 and reiterated that they do not have any concerns with any of the staff at the facility. LPA interviewed staff member present, and they denied the allegation. Staff also stated that they have not witnessed any residents being stuck or hit with any objects by anyone. Therefore, based on interviews, record reviews and observations, this allegation is deemed unsubstantiated. No citation issued. Exit interview conducted. Copy of report given to Administrator.the state’s words, verbatim · CDSS document, Jun 18, 2025 · control 31-AS-20250612121844

Type of visit: Required - 1 Year

On 3/20/25 at approximately 8:45am an unannounced annual visit was conducted by Licensing Program Analyst (LPA) Perchui Milena Khurshudyan. Upon arrival, LPA met with the Caregiver James Olalia, who granted access to the facility. LPA introduced herself by showing her badge and explained the reason for the visit. Shortly after the Administrator, Michael Custodio arrived and helped with staff/residents’ files and medications. During today's visit, LPA conducted a physical plant walk through, at approximately 9:35am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22. The following was observed: The facility is a single-story home and is licensed for capacity of six (6) residents, of which six (6) may be Non-Ambulatory and of which fire clearance for one (1) Bedridden. Facility also has a hospice waiver for six (6) residents. There are four (4) bedrooms and all four are designated for residents’ use. All bedrooms observed to be appropriately furnished and have appropriate lighting. There are two (2) bathrooms in the facility of which two (2) are designated for residents’ use and one (1) for staff use. LPA observed bathrooms have soap, paper towels and hand washing signs. The hot water temperature measured at 10:00am to be 118°F. Extra towels and linens were readily available in the linen closet located in the hallway next to bedroom #2. There are grab bars for each toilet and shower, bathrooms have non-skid mats. All trash cans in bathrooms had fitted lids to protect from cross contamination. LPA observed facility alarms were present on all exit doors and all of the signals were functional. SMOKE DETECTORS/CARBON MONOXIDE. The smoke detectors and carbon monoxide are hard wired, inter-connected and were located throughout the facility. At 12:00pm they were tested and observed to be operational. The facility has one (1) fire extinguisher that was last purchased on 4/8/2024. Continue on LIC809-C KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, dish washer and sink. The kitchen appliances and fixtures were functional. LPA observed the kitchen area, there was sufficient stock of one week non-perishable foods and two days of perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed that sharp objects were stored inside staff room which was observed to be locked and inaccessible to residents in care. Extra emergency food was properly stored inside the kitchen cabinets. The common areas which include dining and living room appeared clean and were properly furnished. Temperature was comfortable it was measured at 10:35am to be 68°F. No obstructions and or tripping hazards throughout the facility found. MEDICATION: LPA observed centrally stored medication is locked inside the staff room next to the kitchen area. First Aid kit was locked inside the kitchen cabinet, inaccessible to residents in care and it was checked by the LPA to be complete with new manual attached to it. Facility has two (2) staff for AM shift and two (2) awake caregiver for PM shift. COMMON AREAS: LPA observed living room and a dining room that appeared generally clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. Facility has land line; LPA checked its operational. LAUNDRY ROOM: Laundry machines are located by the kitchen area and observed to be operational. LPA observed chemicals and detergents were stored and locked inside the staff room. LPA discussed the importance of keeping potentially dangerous items locked at all times. SURROUNDING GROUNDS: LPA observed sufficient yard space with fenced backyard. Appropriate outdoor furniture, with covered shaded area available for residents to rest and enjoy outside weather. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. Exit doors were unlocked and free of obstructions. The facility does not have a swimming pool or body of water. There is a garage in the property, which is currently being used for storage. FILE REVIEW: Between 11:15am to 12:30pm, LPA reviewed records and files of six (6) residents and five (5) staff/caregivers. A review of staff and resident records appeared to be complete. Resident’s files contain signed admission agreements and a medical assessment, and all other required documentarians. Continue on LIC809-C A review of staff records indicates that all facility staff and who required caregiver background checks have received criminal record clearances. There are no residents with prohibited conditions residing at the facility. Facility provides activities to the residents in care, they also have activity coordinator who arrives once a week.An emergency exit plan/sketch along with other posting requirements are posted on the wall by the entrance area. Medications Review: At approximately 12:35pm. LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. Facility also maintains Medical Administration Records (MAR). PRN medications have written orders from a physician. Potentially dangerous items are kept inaccessible to residents in care. LPA collected LIC500, LIC9020, copy of Liability Insurance Certificate, and copy of Administrator Certificate. No citation issued during today’s visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Mar 20, 2025

Allegation investigated: Staff are not meeting resident's hygiene needs. Staff are not meeting resident's medical needs.

At 9:45am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an unannounced initial 10 day complaint visit at this facility to investigate the above allegations. LPA met with James Olalia S2, who granted access to the facility. The House Manager Michael Custodio arrived shortly after, and LPA explained the reason for the visit. The administrator Francis Martir was unable to be present due to having an intake in her other facility. During course of the investigation, interviews and record review were made. At 10:00am, LPA requested resident and staff roster. At 10:10am, LPA requested copies of pertinent information which include, but not limited to Admission Agreement, Physician’s Report, Appraisal Needs and Services Plan, Personal & Incidental (P&I) Log, relevant to the investigation. At approximately 10:15am, LPA conducted a physical plant tour, to ensure health and safety of the residents are protected and physical plant is in compliance with Title 22 Regulations. Between 10:20am – 2:00pm, LPA interviewed the Administrator, the House Manager, two (2) staff members, six (6) out of six (6) residents, and Social Worker. Continue On LIC9099C Unsubstantiated Allegation: Staff are not meeting resident's hygiene needs. It was alleged that on 08/15/2024 a credible witness conducted a routine inspection at the facility and observed R1 had overgrown toenails. To investigate this allegation, LPA conducted an interview with the Administrator, House Manager, two (2) staff members, six (6) residents, R1's Social Worker. Based on today’s interview and the information gathered, R1 is overseen by Social Worker and Case Manager who are assigned to assist R1 to manage and arrange medical and dental appointments. LPA was also informed by the Administrator, Social Worker and two (2) staff members that R1 refuses to have services of any kind and prefers to have long nails and hair. Although, the facility has a in-home Podiatrist who provides services, every three (3) months, R1 continuously declines the services. Lastly, interview with R1 confirmed that the facility encourages R1 to have toe/fingernails trimmed. R1 informed LPA that it is his/her Personal Rights and cannot be violated. Therefore, based on the information received the allegation: staff are not meeting resident's hygiene needs is Unsubstantiated. Allegation: Staff are not meeting resident's medical needs. It was alleged that on 08/15/2024 a credible witness conducted a routine inspection at the facility and observed R1 has severely dry and peeling skin. To investigate this allegation, LPA conducted an interview with the Administrator, House Manager, two (2) staff members, six (6) residents, R1's Social Worker, and PCP Medical Office. LPA was also informed by R1's Social Worker and PCP Medical office that R1 had arranged doctor's appointment to see Primary Care Physician PCP and obtain a referral for a Podiatrist. Unfortunately, he missed the appointment and the new has been scheduled for September 12, 2024. Based on today’s interview and the information gathered, R1 is overseen by Social worker and Case Manager who are assigned and assisting R1 to manage and arrange medical and dental appointments. Therefore, based on the information received the allegation: staff are not meeting resident's medical needs is Unsubstantiated. Exit interview conducted. Copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Aug 21, 2024 · control 31-AS-20240816081746

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Michael Cava conducted a Case Management (CM) visit to the facility to follow up on complaint control #31-AS-20220728112027. During the course of the investigation, it was revealed that Staff 1 (S1) and Staff 2 (S2) did not have their required staff training to satisfy section 87411. LPA met with staff, James and Susan Olalia, and advised them of the visit. This visit is made in conjunction with a required annual. Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies were cited (please refer to LIC 809-D for Required One Year dated 01/03/2024). Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Jan 3, 2024

Type of visit: Required - 1 Year

In conjunction with a Case Management (CM) visit, Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, James and Susan Olalia, and explained the reason for the visit. At approximately 10:42am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are interconnected. There are two (2) carbon monoxide detectors, one in the living room and one in the hallway, by resident rooms, that functions properly. The fire extinguisher is located in the kitchen. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored and were inaccessible during the inspection. The laundry area is located by the kitchen. No detergents or toxins were observed accessible. LPA also did not observe any cleaning supplies accessible in the kitchen. Bedrooms: There are four (4) bedrooms designated for residents' use. Room 1 and Room 3 are shared, while room 2 and 4 are private. Room 1 is approved for bedridden. Passageways were free of obstruction during the time of the visit. All bedrooms, in use by residents were were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 114 degrees Fahrenheit. LPA did not observe any cleaning supplies in either bathrooms during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. Floors were clean. Furniture were in good repair. Entry and exits were clear of obstruction. Staff Room/Quarters: Staff quarters is located next to the laundry area by the kitchen. Resident medications and medication records are stored inside staff quarters. There is a bed inside the room for staff to rest in. Staff quarters remains locked at all times. No resident access. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area, both front and back was free of hazards. There is an external gate that leads into the property, that remains unlocked at all times. The garage is detached, and is located at the front of the home. The garage is only used for storage. It is locked at all times. Resident Files: Resident files are stored locked in a kitchen cabinet. LPA conducted a file review of resident records to insure compliance of licensing forms. Staff Files: Staff files are also stored locked in a kitchen cabinet. LPA conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms. Medications: Medication and Medication Records are kept in staff quarters. Medications were reviewed for proper storage and documentation. Pursuant to Title 22 Division 6 of the CA Code of Regulations, deficiencies were cited (refer to LIC 809-D). Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.the state’s words, verbatim · CDSS document, Jan 3, 2024

Allegation investigated: Due to inadequate supervision, resident suffered from a fall causing severe injuries.

Licensing Program Analyst (LPA) Michael Cava conducted a subsequent complaint visit to the facility to deliver the findings regarding the above allegation. On July 28, 2022, Licensing received a report alleging potential neglect, as Resident 1 (R1) was present with a skull fracture, multiple bruises, and multiple scabs when admitted to the hospital. Furthermore, concerns were raised when the administrator was not forthcoming when asked about R1’s multiple falls. The 10 day visit was conducted by LPA Yelena Avetisyan on July 28, 2022. It was also referred and accepted as a full investigation by Investigation Branch (IB) Brian Static. IB investigation consisted of interviews and medical record review. Per IB report, review of hospital records reveal R1 was admitted to the emergency room on 7/24/22. EMS observed R1 with bleeding from right ear and a hematoma on the scalp, sustained from a presumed unwitnessed fall. R1 underwent a CT scan, and a left sided subdural hematoma was found. Additionally, R1 was diagnosed with intercranial hemorrhage, right parietal temporal bone fracture, and subarachnoidal Substantiated hemorrhage. On 9/13/22 and 9/23/22, IB conducted interviews with R1’s responsible party, who confirmed that R1’s falls were unwitnessed and information from facility administrator regarding the falls were not forthcoming. On 9/23/22, IB received additional information that R1 experienced another fall on 6/23/22, sustaining fractures at the left clavicle and left rib, displaced with no healing present. On 10/20/22, IB conducted interviews with the facility administrator and staff, who confirmed that R1 was observed with blood coming from the ear on the morning of 7/24/22. They confirmed that R1 was transported to the hospital, where R1 was diagnosed with a skull fracture and subdural hematoma. Staff stated they did not witness R1’s fall or other traumatic events. Staff did admit to having trouble providing care for R1 due to R1’s progressing condition. Although R1s falls were confirmed unwitnessed, the information that IB obtained reveal that R1 had a behavior that was progressing for the last few months. Furthermore, it was revealed that the facility did not implement sufficient fall preventive measures, after R1 experienced another significant injury from a fall prior, that happened on 6/23/22. The licensee was unable to provide the necessary care and supervision to meet R1’s needs. Therefore, based on the information obtained, the allegation of resident suffering fractures and injuries from falls due to inadequate care and supervision is Substantiated. Citations issued on the 9099D. An Immediate Civil Penalties will be issued today, in the amount of $500.00. At this time, the administrator, Francis Martir is out on leave. LPA spoke with her back up administrator, Michael Custodio over the telephone and informed him that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f).“Appeal Rights discussed. Exit interview held. A copy of the LIC9099, LIC9099C, LIC9099D and LIC421IM (Civil Penalty Assessment), and Appeal Rights were provided to the house manager, James Olaolia who is present during this visit.the state’s words, verbatim · CDSS document, Nov 1, 2023 · control 31-AS-20220728112027

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Nov 1, 2023

Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: R1 was displaying wandering behaviors. Their mental condition was progressing. On 06/23/22 andthe state’s words, verbatim · CDSS document, Nov 1, 2023

Plan of correction: cont. and 07/24/22, R1 experienced unwitnessed falls sustaining significant injuries. The licensee did not provide the necessary care and supervision or care plan to meet R1’s increasing needs as preventive measures for these falls. As POC, licensee will provide training to address this section section of the regulation. As proof that POC was completed, licensee will submit proof of training and training log to the Licensing agency by November 8, 2023.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(d)(1) · Plan of correction due date: Nov 1, 2023

Administrator – Qualifications and Duties: The administrator shall have the qualifications specified in Sections 87405(d)(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.This requirement was not met as evidenced by: The administrator lacked the requisite knowledge and ability to provide R1 the assistance necessary to ensure their physical and mental health.the state’s words, verbatim · CDSS document, Nov 1, 2023

Plan of correction: As POC, the administrator will review this section of the regulation and self certify that they've read and understood this section of the regulation. As proof POC is completed, self certification is due to the Licensing agency by November 8, 2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(B) · Plan of correction due date: Nov 8, 2023

Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date andthe state’s words, verbatim · CDSS document, Nov 1, 2023

Plan of correction: nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement was not met as evidenced by R1 had a fall sustaining significant injuries on 6/23/22. A facility file review was conducted and the Licensee did not submit an Incident Report (LIC 624) to the licensing agency to report this fall. As POC, the licensee will conduct training to address this section of the regulation. POC due by 11/08/23