L & S Gentle Care II

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Star Stevenson arrived unannounced at approximately 10:45 AM to conduct a required 1-year annual inspection and Non-Compliance Case (NCC) management inspection related to an office meeting held in Santa Rosa on 10/29/2024 the outcome of which resulted in the facility being placed on two year non-compliance plan of quarterly visits. LPA met with caregiver Ronald Lazaro who has Designation of Facility Responsibility (RP). RP called licensee Imelda Padama, who arrived at approximately 11:30 AM to further assist with today's inspection and left at approximately 12:10 PM. At the time of the NCC office visit on 10/29/2024 the following concerns were raised to the licensee including: 1. Fire Clearance/Live-in Staff: Staff shall not sleep or reside in un-permitted/uncleared rooms or facility communal areas. 2. Staffing: Staff must be sufficient in numbers to provide adequate care and supervision to residents in care. 3. Staff Training: Staff must complete initial training hours prior to working independently with residents. 4. Staff Medication Administration Training: Staff shall complete initial training hours prior to working independently with residents. Continued on LIC809C Continued from LIC809 5. Personnel Records: Staff records shall be complete, on-site and with required documentation. 6. Resident Records: Client records shall be complete, on-site and have required documentation. 7. Administrator Qualifications and Duties: The administrator shall be present a sufficient number of hours to ensure facility is operating within compliance; typically 20 hours a week. 8. First Aid Requirements: The administrator shall ensure that all staff have proof of current First Aid. 9. Buildings and grounds: A shed in backyard and storage room in the garage on a prior visit were both observed unlocked with chemicals inside. Facility is a Residential Care Facility for the Elderly (RCFE) with a Hospice waiver for two(2), an approved dementia plan and fire clearance for six (6) residents of which five (5) can be non-ambulatory and one (1) bedridden in room #4 only, when not on hospice care. Facility current has six (6) residents, two (2) of which are receiving hospice care. At approximately 11:30 AM LPA initiated a tour with RP and observed the following. Facility was a comfortable temperature, without odors and chemicals/sharps and medicines were observed to be locked. A small room in the garage contains extra supplies and paper goods. An exterior shed was found to be locked and full of DME and extra supplies. Facility is noted have large shaded sitting area for resident. Smoke detectors and carbon monoxide detectors were tested and found to be operation. Fire extinguishers were found to be fully charged and and last inspected 07/2025. Facility has a gas generator for power back-up, as well as, first aid kit. Facility knows to conducted an Emergency and Disaster drills every 3 month and conducted drills on 06/25/2026 and 03/05/2026 Continue on LIC809C Continued from LIC809C At approximately 11:50 AM LPA reviewed six (6) staff records and observed all 5 to have required documentation. At approximately 12:30 PM LPA reviewed six (6) of 6 resident records and found all 6 to have the required documentation including Consent for Emergency Medical Care and Personal rights. **Licensee is reminded of the requirement to notify the local Fire Department of which rooms Hospice Residents are being helped in. Medicines were observed to be centrally stored and secure. Facility does not mange P & I money for residents. licensee is asked to send in copies of the following documents by 07/25/2026 to update the facility file including: LIC500 Personnel Roster with included newest employees LIC 9020 Resident Roster Updated LIC610D Emergency and Disaster Plan (updated as needed) Evidence of Liability Insurance once received. No Deficiencies are being cited. This report was reviewed with Lead Staff Ronald Lazaro, whose signature here denotes receipt.the state’s words, verbatim · CDSS document, Jun 26, 2026

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Star Stevenson arrived unannounced at approximately 11:00 AM to conduct a required Non-Compliance Case (NCC) management inspection related to an office meeting held in Santa Rosa on 10/29/2024 the outcome of which resulted in the facility being placed on two year non-compliance plan of quarterly visits. LPA met with caregiver Ronald Lazaro who has Designation of Facility Responsibility (RP). RP called licensee Imelda Padama, who arrived at approximately 11:15 AM but then had to leave for a family commitment. At the time of the initial office visit on 10/29/2024 the following concerns were raised to the licensee including: 1. Fire Clearance/Live-in Staff: Staff shall not sleep or reside in un-permitted/uncleared rooms or facility communal areas, LPA Karina Canela cited for the same deficiency 07/10/2023 after numerous discussions regarding the same issue on 04/19/2023, 01/25/2023, 06/28/2022, 06/02/2022, 05/23/2022. 2. Staffing: Staff must be sufficient in numbers to provide adequate care and supervision to residents in care. 3. Staff Training: Staff must complete initial training hours prior to working independently with residents. 4. Staff Medication Administration Training: Staff shall complete initial training hours prior to working independently with residents. 5. Personnel Records: Staff records shall be complete with required documentation. 6. Residnet Records: Client records shall be complete with required documentation. Continued on LIC809C Continued from LIC809 7. Administrator Qualifications and Duties: The administrator shall be present a sufficient number of hours to ensure facility is operating within compliance; typically 20 hours a week. 8. First Aid Requirements: The administrator shall ensure that all staff have proof of current First Aid. 9. Buildings and grounds: The shed in backyard and storage room in the garage on a prior visit were both observed unlocked with chemicals inside, as well as chemicals and a bottle of alcohol in an unlocked cabinet in the laundry room. Facility is a Residential Care Facility for the Elderly (RCFE) with a Hospice waiver for two(2), an approved dementia plan and fire clearance for six (6) residents of which five (5) can be non-ambulatory and one (1) bedridden in room #4 only, when not on hospice care. Facility current has five(5) residents, one (1) of which is receiving hospice care. At approximately 11:30 AM LPA initiated a tour with RP and observed the following. Facility was a comfortable temperature, without odors and chemicals/sharps and medicines were observed to be locked. A small room in the garage contains extra supplies and paper goods. An exterior shed was found to be locked and full of DME and extra supplies. At approximately 11:50 AM LPA reviewed five (5) staff records and LPA observed that S1 who was not working today and had a complete record except, on-site evidence of 20 hour of annual education training and a Technical Violation of Health and Safety Code (HSC) 1569.625(b)(2) was issued. LPA was told by licensee that S1 works as an "on-call" staff member. At approximately 12:30 PM LPA review five (5) of 5 resident records and found all 5 to have the required documentation including Consent for Emergency Medical Care and Personal rights. Technical Violation is cited from the Health and Safety Code. Failure to correct the Technical Violation may result in a civil penalty assessment in the future. This report was reviewed with Ronald Lazaro and Appeal rights were given.the state’s words, verbatim · CDSS document, Apr 13, 2026

Type of visit: Case Management - Legal/Non-compliance

At approximately 9:45 AM Licensing Program Analyst (LPA) Star Stevenson arrive unannounced to conduct a Non-Compliance case management visit and was greeted by caregiver Ronald Lazaro who has Designation of Facility Responsibility (RP). Ronald called licensee Imelda Padama, who arrived at approximately 10:20 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with a Hospice waiver for two (2), an approved dementia plan, and fire clearance for capacity of six (6) residents; five (5) non-ambulatory and one (1) bedridden resident in room #4 only. Facility currently has five residents in care with their newest resident having moved in on 09/18/2025. Licensee was advised of the need to develop an Appraisal Needs and Service plan(LIC625) for their newest resident. At approximately 10:20 AM LPA conducted a facility inspection with RP and observed that all medicines were now centrally stored and locked and toxins that could pose a risk to residents in care locked as well. In addition, a cubicle in the garage that once had over night sleeping furniture, continues to simply have additional paper goods, PPE and supplies. Facility was a comfortable temperature, clean and without odors. At approximately 11:00 AM LPA conducted a file review and interview with licensee and it was determined that four (4) out of five (5) residents were missing required elements of their records with R1, R2, R3 and R4 missing Consent for Emergency Medical treatment (LIC627C), as well as R2, R3, R4 missing signed Personal Rights (LIC613C). Licensee was reminded that in the case of dementia, records would need to be signed by responsible parties. (repeat Type B citation assessed) At approximately 11:45 AM LPA conducted file review of five (5) staff members with one (1) staff member noted to have TB clearance but not a full health screening and a technical violation was issued. Licensee was advised to ensure that complete records for staff were present to avoid a Type B violation and potential monetary penalty in the future. Continued on LIC809C continued from LIC809 Deficiencies and technical violations are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations, may result in a civil penalty assessment. Appeal rights provided to Licensee. Exit interview conducted with Licensee, whose signature on this document confirms receiptthe state’s words, verbatim · CDSS document, Sep 23, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Oct 3, 2025

87506 Resident Records (a) The licensee shall ensure that a...complete... record is maintained for each resident in the facility...readily.. for.. licensing staff. This requirement is not met as evidence by: Based on observation, record review and interview, the licensee did not comply in four(4) out of five (5) resident records missing signed personal rights and/or consent for emergency medical treatment which poses a potential health, safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 23, 2025

Plan of correction: Licensee to submit evidence of signed personal rights and consent for emergency medical treatment for R1, R2, R3, and R4 by themselves or their responsible parties when appropriate, as well as certify that all staff have review regulation 87505(a) by 10/03/2025

Type of visit: Required - 1 Year

At approximately 9:45 AM, Licensing Program Analyst (LPA) Star Stevenson arrived unannounced to conduct a required 1-Year Visit and Non-Compliance (NCC) quarterly visit and was greeted by caregivers Ronald Lazaro and Laila Lazaro. In addition, a private caregiver that a family member had hired to support a resident was present from the ABBA agency. Although not required, it was recommended that this private caregiver be associated to the facility if long term care continues. Imelda Padama, Licensee was contacted via phone and arrived at approximately 10:30 AM. LPA was informed there are four (4) residents in care and all were present during inspection. Facility is a Residential Care Facility for the Elderly (RCFE) with a Hospice waiver for two (2), an approved dementia plan, and fire clearance for capacity of six (6) residents; five (5) non-ambulatory and one (1) bedridden resident in room #4 only. At approximately 10:35 AM, LPA initiated a tour of the facility and observed the following: Facility is a one story home, was a comfortable temperature, free from odors and passageways were free from obstructions. Water temperature in clients' bathrooms measured were above the required range of 105 to 120 degrees F per Title 22 regulations, and licensee had prominent signs warning of the hotter than normal water per regulation. A technical advisory was given to reduce the water temperature to reduce the risk or scalding injuries and licensee turned down the water heater while I was in the facility. LPA observed client showers with grab bars an non-slip mats as required. LPA observed a supply of clean linens, incontinent care products, and paper products available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets in communal areas of the facility containing cleaning supplies and other items that could pose a risk were observed locked. Continued on LIC809C Continued from LIC809 LPA observed toxic chemicals under the sink of bedroom number six (6) and Licensee immediately removed and secured the items making them inaccessible to residents in care. Three (3) of four (4) residents rooms, residents R1, R2 and R3 were noted to have a combination of unsecured prescription and non-prescription medicines and a type A deficiency was cited. In addition, it was noted that one (1) of 4 residents (R1) had over-the-counter (OTC) medicines in their room despite their LIC602 indicating the inability to manage or store their own meds and a Technical Violation (TV) was issued. LPA noted that facility has at least two days of perishable foods and one week of non-perishable foods. Medications were centrally stored and locked. There is outdoor space for activities. A locked shed was noted to have extra supplies. LPA observed an activity schedule and games available for resident use. Facility has two fire extinguishers, which were last inspected July 2025 and are fully charged. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts disaster drills every three (3) months, and the most recent drill was conducted July 2025. LPA observed the facility's infection control plan, first aid kit, PPE, other emergency supplies, and a back-up generator. LPA noted emergency water supply present as required per regulation. At approximately 11:30 AM, five (5) staff files and four (4) resident files were reviewed. All staff files reviewed had the required CPR and First Aid training certificates, as well as documentation of health and TB clearance and training hours. One (1) of five (5) staff files were not maintained at the facility and needed to be brought over from their sister facility and a technical violation was issued. At approximately 12:30 PM LPA observed one (1) of four (4) resident files missing a pre-placement appraisal, appraisal service and needs plan, signed personal rights, or consent for emergency medical treatment and licensee set out to have items signed by resident that could sign for themselves and a technical violation was issued. Continued on LIC809C Continued from LIC 809C Licensee states residents' families coordinate and arrange transportation to and from their medical and dental appointments. Facility does not manage cash resources for residents. Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: 1)LIC610- Emergency Disaster Plan 2)LIC500 - Personnel Report 3)Updated Liability insurance 4)LIC9020 - Registration of facility residents. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations, may result in a civil penalty assessment. Appeal rights provided to Licensee. Exit interview conducted with Licensee, whose signature on this document confirms receiptthe state’s words, verbatim · CDSS document, Jul 9, 2025

The state marks this report as 9 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Legal/Non-compliance

At approximately 12:30 PM, Licensing Program Analysts (LPAs) Julie Florio and Ethel Contreras arrived unannounced for the purpose of conducting a quarterly Non-Compliance (NCC) visit and were greeted by Samuel Padama, Licensee. Facility is a Residential Care Facility for the Elderly (RCFE) with 3 residents in care. At approximately 12:50 PM, LPAs initiated a facility tour with Licensee and observed the following: facility was a comfortable temperature, passageways were free from obstructions, items which could pose a risk to residents in care were observed inaccessible and cabinets containing such items were locked. Medications were properly stored. LPAs inspected the structure in the garage which did not contain any personal items, clothing, or sleeping materials, indicating the room is being used strictly for its approved purpose of storage. At approximately 1:45 PM, LPAs reviewed resident and staff files which had all the required documentation. However, S1's file was observed missing proof of required medication and annual training for last 12-months (see LIC809Ds). The following deficiencies were observed and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation or the California Health and Safety Code. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with Licensees and appeal of rights provided. Signature on form confirms receipt.the state’s words, verbatim · CDSS document, Mar 28, 2025

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: Apr 28, 2025

569.625(b)(2)…[T]raining requirements shall...include an additional 20 hours annually…. This requirement is not met as evidenced by; Based on observation and record review, the licensee did not comply with the section cited above in ensuring that S1 has proof of required annual training which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 28, 2025

Plan of correction: Licensee agrees to submit proof of S1's annual training to CCL by POC due date of 4/28/2025. Additionally licensee agrees to self certify that they will ensure they have proof of all annual training hours for all staff moving forward to CCL by POC due date of 4/28/2025.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.69(b) · Plan of correction due date: Apr 28, 2025

1569.69(b) Each employee...who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. Based on observation and record review, the licensee did not comply with the section cited above in ensuring that S1 has proof of required annual medication training which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 28, 2025

Plan of correction: Licensee agrees to submit proof of S1's annual medication training to CCL by POC due date of 4/28/2025. Additionally licensee agrees to self certify that they will ensure they have proof of all annual medication training hours for all staff moving forward to CCL by POC due date of 4/28/2025.

Type of visit: Case Management - Legal/Non-compliance

At approximately 12:35 PM, icensing Program Analyst (LPA) Julie Florio arrived unannounced for the purpose of conducting a quarterly Non-Compliance (NCC) visit and was greeted by Staff 1 (S1) and new Staff 2 (S2). Licensee, Imelda Padema was contacted via telephone and informed LPA that she was out of the facility today and would be unable to make it for the inspection. Licensee gave permission for S1 to sign for today's visit. Facility is a Residential Care Facility for the Elderly (RCFE) with 5 residents in care -- 2 of whom are currently on Hospice and 1 is bedridden but is in the hospital. At approximately 12:50 PM, LPA initiated a facility tour with Designated Responsible Party (DRP) and observed the following: facility was a comfortable temperature, passageways were free from obstructions, items which could pose a risk to residents in care were observed inaccessible and cabinets containing such items were locked. Medications were properly stored. LPA inspected the structure in the garage which did not contain any personal items, clothing, or sleeping materials, indicating the room is being used strictly for its approved purpose of storage. At approximately 1:10 PM, LPA reviewed new resident and new staff files which had all the required documentation except S2 has not yet completed their CPR/First Aid Training but is scheduled to complete it. No deficiencies cited during this inspection. Exit interview conducted with DRP, whose signature confirms receipt.the state’s words, verbatim · CDSS document, Dec 5, 2024

Type of visit: Office

A Subsequent Non-Compliance Meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager, Bethany Moellers, Licensing Program Analysts, Julie Florio, and Licensee, Imelda Padema. The purpose of the Subsequent Non-Compliance Meeting was to discuss areas of non-compliance and ongoing observed concerns during inspection on September 19, 2024, in the of the operation of L & S Gentle Care II, facility #486803974. Facility was placed on a Non-Compliance Plan on 07/13/2023 and received Technical Support Provider (TSP) consultations on 08/14/2023 and 08/28/2023. Today, the Licensee were informed that further and/or repeat citations may result in extending the facility’s non-compliance plan or possibly administrative action. The legal administrative action process was explained to attendees. Items addressed in today's meeting include patterns of non-compliance in the following areas: 1. Fire Clearance/Live-in Staff: Staff shall not sleep or reside in un-permitted/uncleared rooms or facility communal areas, (see pictures). LPA Karina Canela cited for the same deficiency 07/10/2023 after numerous discussions regarding the same issue on 04/19/2023, 01/25/2023, 06/28/2022, 06/02/2022, 05/23/2022. 2. Staffing: Staff must be sufficient in numbers to provide adequate care and supervision to residents in care. 3. Staff Training: Staff must complete initial training hours prior to working independently with residents. 4. Staff Medication Administration Training: Staff shall be complete initial training hours prior to working independently with residents. Continued on LIC809C... Continued from LIC809... 5. Personnel Records: Staff records shall be complete with required documentation. 6. Client Records: Client records shall be complete with required documentation. 7. Administrator Qualifications and Duties: The administrator shall be present a sufficient number of hours to ensure facility is operating within compliance. 8. First Aid Requirements: The administrator shall ensure that all staff have proof of current First Aid given by American Red Cross. 9. Buildings and grounds: The shed in backyard and storage room in the garage were both observed unlocked with chemicals inside, as well as chemicals and a bottle of alcohol in an unlocked cabinet in the laundry room. 10. Submission of requested documents by due dates Documents requested during September 19, 2024, facility visit were not provided to CCL. Below documents were requested again during today’s meeting and Licensees agrees to submit to CCL by 11/15/2024: · LIC500 personnel summary and include all staff specific days/hours on shift, including administrator. · LIC9020 – Register of Residents Citations and Civil Penalties issued today: 1. Licensee was informed that a citation and an immediate civil penalty are being issued today for the personnel requirements violation observed during Case Management – Legal Non-Compliance quarterly visit conducted on September 19, 2024, due to staff files for S1 and S2 did not have proof of initial training hours completed and were observed working independently with residents. Upon interview with Licensee and staff, LPA discovered that the staff both started the day prior, 09/18/2024. Facility was cited for the same deficiency during Case Management – Legal Non-Compliance quarterly visits on 04/12/2024 and 7/17/2024. This is the second repeat of this violation within a 12-month period, (see LIC809D). Continued on LIC809C... Continued from LIC809C... 2. Licensee was informed that a citation is being issued today for a care of persons with dementia violation observed during Case Management – Legal Non-Compliance quarterly visit conducted on September 19, 2024, where Licensee did not ensure that R1’s physician ordered alcohol was kept in a secure place that is not accessible to persons in care. LPA observed an almost full 1.75-liter bottle of Seagram’s Extra Dry Gin on a shelf in an unlocked cabinet in the facility’s unlocked laundry room, along with a bottle of bleach and a bottle of laundry detergent. LPA further observed cleaning and toxic chemicals accessible to residents in care in the unlocked garage, unlocked storage room in the garage, and the unlocked storage shed in the backyard (see pictures), (see LIC809D). 3. Licensee was informed a citation is being issued for staff medication administration training due to upon observation, interview, and record review, LPA discovered that new staff (S1 and S2) passed medications to the residents in care the morning of 9/19/2024 without having completed any documented medication administration training. Further it was revealed that both staff were hired on 9/18/2024, (see LIC809D). 4. Licensee was informed a citation is being issued for resident records due to LPA observing numerous required documents either incomplete or missing from multiple residents’ records upon file review, (see LIC809D). The following documents were observed incomplete or missing from the indicated residents’ records: § Proof of Negative TB results: R1 § Admissions Agreement not signed and/or dated: R1 & R4 § LIC9172 - Functional Capability Assessment: R1, R2, R4, & R5 § LIC625 -- Appraisal/Needs and Services Plan: R1, R2, R4, & R5 § Consent for Emergency Medical Treatment: R1, R2, R4 § Centrally Stored Medication Destruction Record (CSMDR): R1 § LIC601 - Identification and Emergency Information: R1 & R4 Continued on LIC809C... Continued from LIC809D... 5. Licensee was informed a citation is being issued for staff living/sleeping in the un-permitted/uncleared room in the garage and communal areas of the facility due to LPA’s observation and staff interviews which confirmed this was occurring (see pictures), (see LIC809D). Licensee was informed to be in compliance at all times with fire clearance on file which does not include clearance for the structure in the garage. Licensee informed LPA that they are unable to have the structure permitted due to costs involved. Licensee was informed to contact local code enforcement to request written approval to use the room for storage only, followed by approval from the local fire department. If unable to get approval, Licensee has agreed to disassemble the structure in the garage. 6. Licensee was informed a citation is being issued for personnel records due to LPA’s observation, interviews and record review which revealed numerous required documents were either incomplete or missing from multiple staff members’ records as observed during file review and as noted below, (see LIC809D). · Proof of First Aid Certification: S1, S2, & S3 · Proof of CPR certification: S1 & S3 · LIC501: Job application: S1, S2, S5, S7, & S9 · LIC503: Health Screening: S1, S2, S3, S6, S7, & S10 · Proof of Negative TB results: S1, S2, S3, S4, S6, S7, & S10 · Initial Orientation and Training Hours: S1 & S2 · Initial Medication Administration Training Hours: S1 & S2 7. Licensee was informed a citation is being issued for administrator duties and qualifications due to LPA’s observations, interviews, and record review which revealed that adequate attention to the management and administration of the facility was not occurring as evidenced by the above noted deficiencies and that administrator had untrained staff working independently, (see LIC809D). The following deficiencies were observed and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation or the California Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with Licensees and appeal of rights provided. Signature on form confirms receipt.the state’s words, verbatim · CDSS document, Oct 29, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Oct 30, 2024

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training.... This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above for S1 and S2 who Licensee stated were hired the day prior, 9/18/2024 and who LPA observed working independently with residents which poses a potetnial health,the state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: safety, and personal rights risk to persons in care. Licensee to submit self-certification stating they "will ensure all the required staff training is complete and documented proof is made available for licensing personnel upon request" to CCL by POC due date 11/29/2024 EOB.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.69 · Plan of correction due date: Oct 30, 2024

§1569.69 Employees assisting residents with self-administration of medication; training requirements:a) ... 2) ...the employee shall complete...two hours of hands-on shadowing training...prior to assisting with the self-administration of medications....This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above for S1 and S2 who addmitedly gave medications on the morning of 09/19/2024 without completing any medication training which poses athe state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: potential health, safety, and personal rights risk to persons in care. Licensee to submit self-certification stating they "will ensure the required staff medication administration training is complete prior to staff giving medications and documented proof is made available for licensing personnel upon request" to CCL by POC due date 11/29/2024 EOB.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Oct 30, 2024

87705 Care of Persons with Dementia f) The following shall be stored inaccessible to residents with dementia: (2) ...alcohol, ... and toxic substances such as certain..., gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Based on observation Licensee did not ensure that alcohol, cleaning solutions, and chemicals were kept in a secure place that is not accessible to residents, which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: Licensee to submit self-certification stating they will ensure all alcohol, solutions and chemicals which pose a risk to persons in care are stored inaccessible to residents to CCL by POC due date 10/31/2024 EOB.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87307(a) · Plan of correction due date: Oct 30, 2024

87307 Personal Accommodations and Services: (a) ....The facility shall...provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. This requirement is not met as evidenced by: Based on observation and interviews the Licensee did not ensure that staff who may reside or sleep in the facility are provided private accommodations within the scope of their fire clearance which poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: Licensee to submit self-certification stating they will ensure no staff are living or sleeping in the structure in the garage or in communal areas of the faciity, as well as provide written proof that they have contacted Code enforcement requesting approval to use the room for storage only to CCL by POC due date 10/31/2024 EOB. Additionally, Licensee to submit written proof of the decision from Code Enforcement to CCL by second POC due date 11/15/2024.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Oct 30, 2024

87506 Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on observation, interview, and record review, the licensee did not comply with the section cited above for R1, R2, R4, and R5 whose files were all missing two or more required documents which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: Licensee to submit self-certification stating they "will ensure all resident files have all of the required paperwork prior to admitting residents and will have it available to Licensing personnel upon request" to CCL by POC due date 11/29/2024 EOB.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: Oct 30, 2024

87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Based on observation, interview, and record review, the licensee did not comply with the section cited above for S1, S2, S3, S4, S5, S6, S7, S9, and S10 whose files were all missing one or more required documents which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: Licensee to submit self-certification stating they "will ensure all staff files have all of the required paperwork prior to staff beginning work in the facility and will have it available to Licensing personnel upon request" to CCL by POC due date 11/29/2024 EOB.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Oct 30, 2024

. 87405 Administrator - Qualifications and Duties: (a)....The administrator...shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility....This requirement is not met as evidenced by: Based on observation, interviews, and record review, the licensee did not comply with the section cited above in ensuring compliance and by having untrained staff working independently which poses a potential health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 29, 2024

Plan of correction: Licensee to submit an updated LIC500 to include the hours they will present in the facility as well as a self-certification stating they "will ensure they are present enough to bring the facility into compliance with regulation" to CCL by POC due date 11/29/2024 EOB.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Julie Florio arrived unannounced for the purpose of conducting a quarterly Non-Compliance (NCC) visit and was greeted by new Staff 1 (S1) and new Staff 2 (S2). Licensee, Imelda Padema was contacted via telephone and arrived at approximately 10:30 AM. Facility is a Residential Care Facility for the Elderly (RCFE) with five [5] residents in care and one more moving in this weekend. At approximately 10:40 AM, LPA toured facility with Licensee and observed the following: LPA observed cleaning detergent, bleach and a bottle of Seagram's Extra Dry Gin unsecured in the facility laundry area. Licensee secured the items immediately and stated the Gin was for a resident with physician's order for it. LPA confirmed the physician order and informed Licensee that the alcohol needs to be secured, Licensee locked the alcohol in the medication closet immediately. LPA also observed cleaning supplies and chemicals in the garage which was accessible to residents in care. Licensee states they will have the laundry room door installed with a lock. LPA observed that the constructed bedroom in the garage is being used by staff as sleeping/living quarters as evidenced by two open suitcases and additional bags filled with clothing and personal items and a sleeping cot set up (See pictures). LPA informed Licensee that the room is not permitted for staff or resident use. The room shall be used for storage only. Staff 1 (S1) stated they sleep on the couch in the facility. LPA informed S1 and Licensee that no staff or resident shall sleep in a common area of the facility per regulation. LPA observed the shed in the backyard to be unlocked with chemicals and tools accessible to residents in care. The shed was being used only for storage. LPA informed Licensee that the outdoor shed shall be locked at all times. LPA, Karina Canela cited the facility for these same areas of concern on 7/10/2023 after several discussions regarding the same issues on 04/19/2023, 01/25/2023, 06/28/2022, 06/02/2022, 05/23/2022. Today, LPA Florio re-emphasized that the "facility does not have a building permit for the staff bedroom in the garage and staff are occupying the bedroom at this time. Facility did not submit a building permit to CDSS CCL as required.... [T]he bedroom is required to be inspected and approved by the Fairfield Fire Department, and Licensee must obtain a building permit to ensure it is safe for staff to occupy. Continued on LIC809C... Continued from LIC809... [Licensee] understood. LPA informed [L]icensee that individuals (specifically staff) are not allowed to sleep or occupy the shed in backyard, staff bedroom in the garage (which does not have a permit), or common areas (living room couch, etc.)." Again today, Licensee assured LPA that the "facility will operate with an awake staff as there are no staff rooms approved." Licensee informed LPA there are no pre-poured medications being administered. Licensee stated they wait until it is time to administer residents' medications and bring them to her desk in the front room/office area to dispense one residents' medications at a time to minimize medication errors. LPA asked for the new staff members' files. Licensee stated that S1 has the required paperwork but that they are still working on S2's paperwork. Licensee stated three staff recently quit working at the facility and "it's been really hard." LPA conducted a record review of ten [10] out of ten [10] staff files. LPA observed the following missing items for the indicated staff: First Aid: S1, S2, & S3 CPR: S1 & S3 LIC501 - Personnel Application: S1, S2, S5, S7, & S9 LIC503 - Health Screening: S1, S2, S3, S6, S7, & S10 Proof of Negative TB: S1, S2, S3, S4, S6, S7, & S10 Initial Orientation and Training Hours: S1 & S2 Initial Medication Administration Training Hours: S1 & S2 LPA conducted a record review of five [5] of five [5] resident files. LPA observed the following missing items for the indicated residents: Continued on LIC809C... Continued from LIC809C... Proof of Negative TB: R1 Admissions Agreement not signed and/or dated: R1 & R4 Centrally Stored Medication Destruction Record (CSMDR): R1 LIC9172 - Functional Capability Assessment: R1, R2, R4, & R5 LIC625 - Appraisal/Needs and Services Plan: R1, R2, R4, & R5 Consent for Emergency Medical Treatment: R1, R2, R4 LIC601 - Identification and Emergency Information: R1 & R4 ***Additionally, the CSMDR, for each resident that did have them, were found to be maintained out of compliance with regulation as evidenced by incorrect fill, start, and expiration dates, pill quantities, number of refills, and filling pharmacies. LPA requested the following updated forms to be submitted to Community Care Licensing within 30 days of today's visit: · LIC 500 Personnel Report · LIC 9020 Facility Register of Client/Residents ***LPA informed Licensee that CCL will be scheduling an informal meeting in the regional office to discuss today's inspection and areas of concern. LPA also informed Licensee that citations and civil penalties may be issued at that time. No deficiencies were cited during today's inspection. Exit interview conducted with Licensee whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Sep 19, 2024

Type of visit: Required - 1 Year

At approximately 9:30 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a 1-Year Required Visit and Non-Compliance (NCC) quarterly visit and was greeted by Ramil Gilbert "Chinchin" Razon, Caregiver/Designated Responsible Party. Imelda Padama, Licensee was contacted via phone and arrived shortly after and Samuel Padama, Licensee arrived approximately 2 hours later. LPA was informed there are three (3) residents in care and all were present during inspection. Facility is a Residential Care Facility for the Elderly (RCFE) with a Hospice waiver for two (2), an approved dementia plan, and fire clearance for capacity of six (6) residents; five (5) non-ambulatory and one (1) bedridden. At approximately 9:45 AM, LPA initiated a tour of the facility and observed the following: Facility is a one story home, was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed client showers with grab bars an non-slip mats as required. LPA observed a supply of clean linens, incontinent care products, and paper products available to clients. Clients' bedrooms were inspected and observed to have appropriate furnishings as outlined in Title 22 regulations. Cabinets in communal areas of the facility containing cleaning supplies and other items that could pose a risk were observed locked. However, LPA observed toxic chemicals in the unlocked garage and outdoor storage building. Licensee removed and secured the items immediately making them inaccessible to residents in care. Facility has at least two days of perishable foods and one week of non-perishable foods. Medications were centrally stored and locked. There is outdoor space for activities. LPA observed an activity schedule and games available for resident use. Facility has two fire extinguishers, which were last inspected July 2024 and are fully charged. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Continued on 809-C... Continued from LIC 809... Facility conducts yearly disaster drills, and the most recent drill was conducted July 2023. LPA informed Licensees, per Title 22 regulation, disaster drills shall be conducted on a quarterly basis. LPA observed the facility's infection control plan, first aid kit, PPE, other emergency supplies, and a back-up generator. There was no emergency water supply present as required per regulation. LPA informed Licensees that they shall purchase water to bring the facility into compliance. LPA reviewed facility's emergency disaster plan last updated April 2023. At approximately 11:00 AM, five (5) staff files and three (3) resident files were reviewed. All staff files reviewed have the required CPR and First Aid training certificates, as well as documentation of all required initial training hours. Two (2) of five (5) staff files reviewed were missing proof of required annual training and annual medication training. LPA provided Licensees a copy of sections 1569.625 and 1569.69 from the California Health and Safety Code as is pertains to required staff annual and annual medication training in RCFEs. This is a repeat violation within a 12-month period. LPA cited California Code of Regulations, Title 22, Division 6, Section 871411(c) and issued civil penalties in the amount of $250. LPA advised Licensees to ensure all required documentation is in staff files and available for inspection upon request. LPA observed two (2) of three (3) resident files missing a signed Individual Service Plan as required per regulation and cited (see LIC809D). LPA observed all remaining required documentation present in all resident files prior to conclusion of today's inspection. Licensee states residents' families coordinate and arrange transportation to and from their medical and dental appointments. Facility does not manage cash resources for residents. LPA reviewed facility's medications and medication records which are not maintained in compliance with regulation, resulting in LPA issuing a citation (see LIC809-D). Updated copies of the following documents are to be submitted to CCL within 30 days of this visit: LIC610- Emergency Disaster Plan Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations, may result in a civil penalty assessment. Appeal rights provided to Licensee. Exit interview conducted with Licensee, whose signature on this document confirms receipt.the state’s words, verbatim · CDSS document, Jul 17, 2024

The state marks this report as 13 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Christi Coppo and LPA Julie Florio arrived unannounced for the purpose of a Non-Compliance (NCC) Quarterly visit and was greeted by Caregiver, facility designee (FD) was present at facility. Administrator Samual Padama was available via telephone. On visit on 1/9/2024, LPA discussed NCC concerns and found that the facility has submitted updated plan and facility sketch to City of Fairfield for building permit. Admin provided CCL all documents submitted to City of Fairfield for building permit, LPA verified building permit work is still going on and Admin verified that they are still working to complete the job. Fire extinguishers serviced 7/11/2023. At approximately 10:00am Admin and FD toured facility, LPA observed that the constructed bedroom in the garage is being used only for storage, LPA confirmed with Admin and FD that staff are not sleeping in the common areas or in the garage. LPA and FD observed the shed in the backyard to be locked and used only for storage. Per LPA interview with FD and Admin there are no pre-poured medications. Per FD they are not pre-pouring, but rather wait until it is time to administer residents' medications and bring them to a designated corner in the kitchen to minimize medication errors. At last visit on 1/9/2024 Admin advised LPA that house managers have quit as of Friday, January 9, 2024. Admin informed LPA that they will take over the managers' duties. After visit on 1/9/2024, Admin provided CCL with training records for caregiver that will help take care of some of the duties that the managers were taking care of; also, Admin provided LPA with updated LIC500 showing Admin will be here a combined total of 20 hours per week, physically present on business days during business hours. LPA conducted a record review of [4] out of [4] staff files. Staff file for S1 did not have training records. Per Title 22 regulation 87411(c) Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (deficiency cited, see 809D). Conituned on 809C... Continued from 809... LPA conducted review of [5] out of [5] resident files. One resident (R1) with move in date of 3/27/2024 did not have an Appraisal Needs and Services Plan. LPA advised FD that all residents must have a preappraisal conducted before admission. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with FD and a copy of this report was given.the state’s words, verbatim · CDSS document, Apr 5, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(c) · Plan of correction due date: Apr 12, 2024

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training... This requirement is not met as evidenced by: Based on LPA and Admin observation staff memeber S1 did not have their annual training current or completed.the state’s words, verbatim · CDSS document, Apr 5, 2024

Plan of correction: Facility to submit LIC9098 self-certifying that S1 has compelted the annual training as required. Facility to submit training log or print out with LIC9098 by POC due date.

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced for the purpose of a Non-Compliance (NCC) Quarterly visit and was greeted by Caregiver. Administrator Samuel Padama arrived at approximately 9:50am. LPA discussed NCC concerns and found that the facility has submitted updated plan and facility sketch to City of Fairfield for building permit. Admin will provide CCL with all documents submitted to City of Fairfield for building permit. Fire extinguishers serviced 7/11/2023. At approximately 10:00am Admin and LPA toured facility, LPA observed that the constructed bedroom in the garage is being used only for storage, LPA confirmed with Admin that staff are not sleeping in the common areas or in the garage. LPA observed the shed in the backyard to be locked and used only for storage. Per LPA interview with Admin there are no pre-poured medications. LPA measured water temperature: water temp measured 118.8 and 115.7, respectively which are both within regulation of 105 to 120 F. Admin advised LPA that house managers have quit as of Friday, January 9, 2024. Admin informed LPA that they will take over the managers' duties. Admin to submit to CCL a written plan on how they plan to provide the services that the managers were providing. Admin will provide LPA with updated LIC500 showing Admin will be here a combined total of 20 hours per week, physically present on business days during business hours. LPA conducted a record review of [4] out of [4] staff files. Staff files complete. Proof of respective required staff training present in respective staff files. LPA conducted review of [5] out of [5] resident files. All required documents present and complete. LPA advised Admin that they need to also call 911 and/or a resident's physician when appropriate, not just contact the resident's family. Admin confirmed they understand No deficiencies cited during this inspection.the state’s words, verbatim · CDSS document, Jan 9, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Christi Coppo arrived unannounced for the purpose of a case management. LPA was greeted by Caregiver. Administrator Samuel Padama arrived at approximately 9:50am. On 1/08/2024 CCL received Incident Report for incident occurring on 1/04/2024 indicating resident R1 had a pressure ulcer on their right hip. RN for R1 arrived to facility while LPA was present. Per LPA interview with R1's RN, the purpose of RN's visit today is to stage the ulcer. LPA advised Admin that stages 3 and 4 pressure ulcers are prohibited. Per Title 22 regulation 87615(a)(1): Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. Per LPA interview with R1's RN, the pressure ulcer is currently unstagable. Per RN, they cannot determine what is under the ulcer's slough. Per RN, there is a yellow slough on the skin which covers the wound bed of the ulcer, and as such, RN is unable to determine at what stage the ulcer is under the slough. Per RN, the presence of a slough does not necessarily mean the ulcer below the slough is at stage 3 or 4, it could be at stage 2. RN cannot see the wound bed. Once slough is removed then the wound can be staged. RN will be treating the pressure ulcer with Medihoney with calcium alginate in order to remove the slough and cover the ulcer with foam dressing, every week, twice a week. Resident will be reassessed for staging in approximately 4-6 weeks. Family member of R1 was present during LPA visit. Family member reported to LPA that R1 is receiving prompt medical care when needed. Family member feels that the Admin and caregivers are attentive at providing care. Admin ensured that resident is being moved every two hours, per RN orders, in order to mitigate pressure on right hip. Continued on 809C... Continued from 809... Upon arrival, at approximately 9:40am LPA observed medication closet in hallway that houses centrally stored medications to be unlocked, medications accessible. LPA advised Caregiver that medicine closet must remain locked at all times. Approximately five minutes later LPA walked back through hallway, LPA observed medicine closet to still be unlocked. LPA again advised caregiver to keep medication closet locked. Per Title 22 regulation 87465(h)(2)-- Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication (deficiency cited, see 809D). Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Jan 9, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(2) · Plan of correction due date: Jan 22, 2024

87465(h)(2) Incidental Medical and Dental Care: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement is not met as evidenced by: Based on LPA observation medication closet housing centrally stored medications was left unlocked, which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 9, 2024

Plan of correction: Admin to administer staff training to ensure that staff know how to properly store centrally stored medication per regulation 87465(h)(2). Admin to submit LIC9098 self-certifying training completed. Admin to submit LIC9098 by Plan of correction due date of January 22, 2024.

Allegation investigated: Staff did not ensure assistance was provided to resident in care Staff was asleep while at work Staff dispensed medication not as prescribed to resident in care Staff financially abused resident in care

On 10/20/2023, Licensing Program Analyst, Carol Fowler arrived unannounced for the purpose of opening a 10-inital complaint investigation and delivering findings. LPA was greeted by Caregiver, Ramilgilbert Razon. LPA toured the facility with House Manager, conducted interview with resident (R1), Staff (S2, S3 & S4) LPA called S1 but was unsuccessful and unable to leave a voicemail. LPA received text messages and emails from RP. LPA conducted facility file/e-MAR review and made observations. Complaint alleges: Staff did not ensure assistance was provided to resident in care. During a tour of the facility, LPA observed a staff member assisting a resident with ADL's and another staff assisting a resident to her chair after breakfast. Based on interviews with staff and resident that was conducted, LPA learned of no concerns regarding the care of residents in care. Therefore, the allegation is UNSUBSTANTIATED. Continue on LIC9099C Unsubstantiated Continue from LIC9099 Complaint alleges: Staff was asleep while at work. LPA interviews with staff and resident revealed that there is no staff sleeping while on duty. House Manager Imelda Garcia stated that staff have breaks in the garage and on occasions leave the facility, S2 and S3 stated that staff take turns for breaks in the garage and for long breaks they leave the facility. Staff stated sleeping on the job is not expected of staff or allowed. Staff also stated that they have not observed staff sleeping on the job. Therefore, the allegation is UNSUBSTANTIATED. Complaint alleges: Staff dispensed medication not as prescribed to resident in care. LPA conducted record review e-MAR and interviews with staff and resident which revealed that the facility has not had any medication errors or issues. Based on the medication record and physician's orders on file, residents have received their required medications. Therefore, the allegation is UNSUBSTANTIATED. Complaint alleges: Staff financially abused resident in care. LPA interviewed staff and resident it is revealed that the facility is not responsible for residents finances. Interview conducted with resident (R1) revealed that staff has never asked R1 for money. Therefore, the allegation is UNSUBSTANTIATED. Report was reviewed with House Manager Imelda Garcia and copy was provided. No deficiencies cited during visit.the state’s words, verbatim · CDSS document, Oct 20, 2023 · control 21-AS-20231017145432

Type of visit: Case Management - Legal/Non-compliance

On 10/12/2023 Licensing Program Analyst (LPA) Carol Fowler arrived unannounced for the purpose of a Non-Compliance (NCC) Quarterly visit and was greeted by Caregiver, Raamil Gilbert. House manager Imelda Garcia arrived at 10:36am. LPA discussed NCC concerns and found that the facility has submitted updated plan for building permit and serviced fire extinguisher, service date 7/11/2023 to CCLD. LPA C. Fowler and House Manager Imelda Garcia toured the facility, LPA observed that the constructed bedroom in the garage is being used for storage, LPA was informed by House Manager that no staff is sleeping in the common areas. The shed in the backyard is locked and being used for storage. There are no pre-poured medications, water temperature is 119.6 within regulation of 105 to 120 F. LPA conducted a record review staff files have been updated with health screenings (TB tests) and current training's. R1, R3, R5 files have been updated, R4 has been discharged from the facility. No deficiencies cited during today's visit.the state’s words, verbatim · CDSS document, Oct 12, 2023