Lemon Grove Terrace

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Celia Meneses, Licensee/Administrator, to whom LPA discussed the purpose of the visit. According to the facility’s license, the facility has a maximum capacity of six (6) elderly residents, (5) five of which can be non-ambulatory. During today’s inspection, four (4) residents were home. LPAs arrived to the facility at 9:00am. LPA entered home and observed: on kitchen table 7 pre pored (7 day) pill boxes with 6 of 6 residents names on each one, they were full of medication. Next to the pill boxes was one bubble pack with medication pills. On chair next to medication pill containers was 3 (three) more bubble pack with medication pills. On side table located adjacent to kitchen table next to room #3 was a stack of full bubble packs.(9 packs) . On pink chair next to dinning room table: a large bag with bottles of medication and approximately 15 bubble packs medication pill.. (continued on LIC9099C). (continued from LIC9099) LPA, accompanied by the Administrator, toured the interior and exterior of the facility, and inspected each room. During the visit, LPA checked the water temperature in private and common bathrooms for resident and staff use. In the common bathrooms, the hot water temperature measured at 157 and 150 degrees Fahrenheit. LPA requested that Administrator Meneses lower the hot water heater.. During today’s visit, LPA toured the facility, reviewed staff and resident records, and interviewed staff and residents. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection. Based on observations and interviews , two deficiencies regarding hot water temperature and locked medication are being cited per California Code of Regulations Title 22 and noted on the attached LIC809-D page. Administrator cleared both deficiencies during the visit, and LPA provided Administrator with a Letter of Deficiencies Cleared for one citation. An exit interview was conducted with Licensee/Administrator Mensese, whose signature below confirms receipt of a copy of this report, the Letter of Deficiencies Cleared, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Mar 4, 2026

Allegation investigated: Neglect/Lack of Supervision resulting in UTI. Neglect/Lack of Supervision resulting in delayed medical care.

On 02/23/2026, LPA Janet Ngallo conducted a subsequesnt visit to deliver findings regarding the above-mentioned allegations. LPA spoke with Caregiver Jesus Arenas and explained the purpose of the visit. Regarding the allegation of Neglect/Lack of Supervision resulting in delayed medical care causing Resident 1 (R1) to have UTI, RP indicated that R1 was discovered with a clogged foley catheter, and the facility staff never called hospice to notify of the issue. On 10/21/24, Hospice’s Aide (HA) visited R1 and found that R1's foley catheter was clogged, R1 had no urine output for over 24 hours. On the same day, HA conducted a follow-up visit and spoke to the administrator(ADM). ADM told HA that ADM have observed R1s change of condition on 10/19/24 and admitted that ADM noticed the clogged catheter on 10/20/24 but did not notify hospice about these concerns. (Cont. on LIC 9099-C) Substantiated (Cont. from LIC 9099) HA submitted a lab work for R1 on 10/21/24 and results on 10/22/24 revealed R1 was positive for UTI. HA stated that a clogged catheter, no urine output, and no intake could contribute to a UTI. When ADM was interviewed, ADM mentioned not remembering calling hospice. One staff member (S1), confirmed that they observed a clogged catheter and reported it to the ADM. The ADM neglected and/or failed to seek medical services for R1 when ADM acknowledged that R1 had a clogged catheter, with no urine output for 24 hours; and when R1s change of condition was observed. ADMs neglect and failure to seek immediate care for R1 resulted in R1s UTI. At the time of the complaint inspection on 02/23/2026, licensee was informed that the incident is currently under review and a future civil penalty may apply based on Health and Safety Code § 1569.49. Based on interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099D. An Immediate Civil Penalty of $500.00 was also assessed (refer to the LIC421-IM page). An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Caregiver Jesus Arenas, whose signature below confirms receipt of these rights. (Cont. from LIC 9099) Furthermore, RN confirmed that the administrator (ADM) was trained and educated in treating and dressing the wound during the days that hospice did not visit. For the allegation of Licensee refused medical care for resident, RP stated that when R1 returned to facility, R1 had another fall but licensee declined a visit from hospice. According to the records, a notation stating that ADM called hospice about the fall, voiced no injury for R1, refusing help but yelling out for help. ADM stated that hospice is always called every time R1 has a fall and doesn’t deny help for R1. Regarding the allegation of Licensee restrained resident, RP indicated that staff are using chairs to block the residents’ bed to prevent falls. According to ADMs interview, it was stated that chair was used to assist R1 when staff is helping the R1and not restrain. R1 has a waiver to not use bed rails. For the allegation of Licensee did not follow eviction procedures, RP said the ADM wants the resident moved out to another facility but has not issued an eviction notice to R1s responsible parties. Based on the records, initially ADM didn’t want to accept R1 back after R1 was discharged from a hospital visit. ADM was educated about submitting a notice for eviction. ADM accepted R1 back but did not give notice about eviction and continued care for R1. Based on interviews and records review, the department has determined that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.' An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Caregiver Jesus Arenas, whose signature below confirms receipt of these rights.the state’s words, verbatim · CDSS document, Feb 23, 2026 · control 08-AS-20241023094424

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Feb 24, 2026

(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical...care appropriate to the conditions and needs of residents. This was not met as evidenced by: Based on interviews and records review, Licensee’s neglect and failure to seek immediate care for R1 resulted in UTI which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: Staff will provide proof of scheduled incidental medical care training with all staff within 24 hours to LPA via email. Training will be completed and submitted to LPA with sign-in sheet and training topic clearly noted via email by 03/13/2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Feb 24, 2026

The licensee shall ensure that residents are regularly observed for changes in physical, mental...and brought to the attention of the resident's physician and the resident's responsible person, if any. This was not met as evidenced by: Based on interviews and records review, Licensee failed to seek medical services for R1 when R1 had a clogged catheter and when R1s change of condition was observed which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 23, 2026

Plan of correction: Staff will provide proof of scheduled change of condition training with all staff within 24 hours to LPA via email. Training will be completed and submitted to LPA with sign-in sheet and training topic clearly noted via email by 03/13//2026.

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Celia Meneses, Licensee/Administrator, to whom LPA discussed the purpose of the visit. LPA, accompanied by the Administrator, toured the interior and exterior of the facility, and inspected each room. During the visit, LPA checked the water temperature in private and common bathrooms for resident and staff use were complaint. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.LPA interviewed staff and clients, and reviewed facility records. The files reviewed by LPA contained required documents. Confidential records were stored in locked areas. An exit interview was conducted with Licensee/Administrator Meneses, whose signature below confirms receipt of a copy of this report, and the Licensee Appeal Rights (LIC9058 3/22)the state’s words, verbatim · CDSS document, May 14, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Celia Meneses, Licensee/Administrator, to whom LPA discussed the purpose of the visit. According to the facility’s license, the facility has a maximum capacity of six (6) elderly residents, (5) five of which can be non-ambulatory. During today’s inspection, four (4) residents were home. LPA, accompanied by the Administrator, toured the interior and exterior of the facility, and inspected each room. During the visit, LPA checked the water temperature in private and common bathrooms for resident and staff use. In the common bathrooms, the hot water temperature measured at 143.8 and 131.5 degrees Fahrenheit. LPA requested that Administrator Meneses lower the hot water heater and the hot water was later measured at 113.9 and 116.2 degrees Fahrenheit. LPA observed a front door lock, which utilized a keypad reversed so the keypad is used to exit the facility. The secured screen door key deadbolt was reversed so a key needed to be used to exit the facility. Also, there were pad locks on exterior fence gates. Records review and interviews indicated that a locked perimeter for this facility is not approved by fire clearance. LPA requested the key pad and deadbolt be removed and replaced to reflect Tittle 22 regulations for exiting a facility. LPA also had licensee staff remove pad locks from outside gates. Therefore, two deficiencies regarding hot water temperature and Locked perimeter are being cited per California Code of Regulations Title 22 and noted on the attached LIC809-D page. Administrator cleared both deficiencies during the visit, and LPA provided Administrator with a Letter of Deficiencies Cleared. An exit interview was conducted with Licensee/Administrator Mensese, whose signature below confirms receipt of a copy of this report, the Letter of Deficiencies Cleared, and the Licensee Appeal Rights (LIC9058 3/22).the state’s words, verbatim · CDSS document, Mar 26, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was greeted and allowed entry into the facility by Celia Meneses, Administrator, to whom LPA discussed the purpose of the visit. According to the facility’s license, the facility has a maximum capacity of six (6) elderly residents, all ambulatory. During today’s inspection, four (4) residents were home. LPA, accompanied by the Administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was comfortable. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas. [CONTINUED ON LIC 809-C] [CONTINUED FROM LIC 809] No pools or bodies of water on the premises. Per Administrator Meneses, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher has been serviced. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPA interviewed staff present. There were 4 residents at the facility during the visit. LPA reviewed multiple staff and client records/files. Files reviewed contained required documents. Confidential records were stored in locked areas. Administrator presented proof of current/active business liability insurance and surety bond. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted with Administrator Celia Meneses, to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Feb 28, 2024