Mali's Place I

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct the required annual visit at 9:05 A.M. When the LPA arrived, there was one (1) staff member and three (3) residents present. The LPA was greeted by Caregiver, Araceli Camarillo, and informed them the reason for the visit. Caregiver contacted the Administrator by phone, Sara Jackson. At 9:18 A.M., the Administrator arrived at the facility. At 9:23 A.M., the LPA conducted a tour of the physical plant with the Administrator, to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. This facility doesn’t have a staff room; the facility will provide 24/7 care. The following was observed: Kitchen: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food as well as emergency food. At 9:45 A.M. hot water temperature measured at 119.8 degrees Fahrenheit. Bedrooms: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) bedrooms in total; 4 (four) are private bedrooms and one is designated as a shared room. No bedroom was used as a passageway to another room, bath, or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair. Continued on LIC 809-C Continued from LIC 809-C File review: A review of facility files was initiated at 9:40 A.M. and the following was observed. LPA reviewed three (3) residents files. Files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. All records were in order. Additionally, LPA reviewed three (3) staff files including the administrator’s. All documents reviewed appeared complete and current. Medication review: Began at 1:45 P.M.; medications are centrally stored and locked under the kitchen counter; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. LPA observed that medication was being pre-popped in advance of administration. During today’s visit LPA informed the Administrator that removing medication from their original packaging in advance of administration (pre-popping) is not permitted. Technical Violation (TV) issued. No errors observed during the medication review. INFECTION CONTROL/EMERGENCY DISASTER: LPA also reviewed the facility's Emergency Disaster Plan and Infection Control Plan. Both plans were observed to be complete and updated annually as required. Last electrical safety drill was conducted on 07/20/26. During today’s visit LPA obtained a copy of facility’s Employee Record (LIC 500), Resident Roster and Liability Insurance. Exit interview conducted. No deficiencies issued during today’s visit. A copy of this report was provided. Continued from LIC 809 Restrooms: The LPA observed four (4) restrooms in the facility; two (2) are shared resident restrooms, one (1) is a private restroom, and one (1) half bath is designated for staff and visitor use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and slip-resistance surfaces. Water temperature was measured in the common resident restrooms and was within the required range. Common spaces: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, the living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. The facility maintained a temperature of 71 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. The fire extinguishers are fully charged and recently purchased on 05/08/2026. Hardwired combination smoke/carbon monoxide detectors were tested at 10:11 A.M. and were operational at this time. Facility is equipped with a fire door to enhance safety and prevent the spread of fire. During today’s visit, fire door was observed closed. Outdoor Space: The backyard area contains a shaded area with a table and chairs for resident use. There is a non-functioning fountain, which was observed to be empty at the time of the visit. There were no bodies of water noted. Facility has two total gates; both were observed to be self-closing and self-latching gates with clear passageways for emergency exit use. LPA observed a back house where gardening tools and other supplies are stored. Garage/Office: The garage is where the washer and dryer are held, including emergency food and emergency water. Cleaning supplies, disinfectants, sharps and knives were observed to be locked in a cabinet in the garage. All cleaning compounds were stored in areas separately from food supplies. There is an office area whit a desk and a phone and files are held. Continued on LIC 809-Cthe state’s words, verbatim · CDSS document, Sep 3, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct the required annual visit at 10:45 A.M. When the LPA arrived, there was one (1) staff member and three (3) residents present. The LPA was greeted by Caregiver, Araceli Camarillo, and informed them the reason for the visit. Caregiver contacted the Administrator by phone, Sara Jackson. At 11:30 A.M., the Administrator arrived at the facility. During today’s visit, the administrator was required to attend an emergency and authorized the caregiver to sign today’s report on their behalf. At 11:45 A.M., the LPA conducted a tour of the physical plant with the Administrator, to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. This facility doesn’t have a staff room; the facility will provide 24/7 care. The following was observed: Kitchen: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food as well as emergency food. At 11:55 A.M. hot water temperature measured at 112.2 degrees Fahrenheit. Continued on LIC809-C Continued from LIC 809-C Bedrooms: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) bedrooms in total; 4 (four) are private bedrooms and one is designated as a shared room. No bedroom was used as a passageway to another room, bath, or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair. Restrooms: The LPA observed four (4) restrooms in the facility; two (2) are shared resident restrooms, one (1) is a private restroom, and one (1) half bath is designated for staff and visitor use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and slip-resistance surfaces. Water temperature was measured in the common resident restrooms and was within the required range. Common spaces: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, the living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. The facility maintained a comfortable temperature of 71 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. The fire extinguishers are fully charged and recently purchased on 07/07/2025. Hardwired combination smoke/carbon monoxide detectors were tested at 1:15 P.M. and were operational at this time. Facility is equipped with a fire door to enhance safety and prevent the spread of fire. During today’s visit, fire door was observed closed. Outdoor Space: The backyard area contains a shaded area with a table and chairs for resident use. There is a non-functioning fountain, which was observed to be empty at the time of the visit.There were no bodies of water noted. Facility has two total gates; both were observed to be self-closing and self-latching gate with clear passageways for emergency exit use. LPA observed a back house where gardening tools and other supplies are stored. Continued on LIC 809-C Continued from LIC 809-C Garage/Office: The garage is where the washer and dryer are held, including emergency food and emergency water. Cleaning supplies, disinfectants, sharps and knives were observed to be locked in a cabinet in the garage. All cleaning compounds were stored in areas separately from food supplies. There is an office area whit a desk and a phone and files are held. File review: A review of facility files was initiated at 12:20 P.M. and the following was observed. LPA reviewed three (3) residents files. LPA observed that one (1) resident medical assessment indicated that residents have no capability for self-care, and they are not on hospice, and there were no records indicating that an exception request was submitted to the department. All other required forms were complete. Additionally, LPA reviewed three (3) staff files including the administrator’s. All documents reviewed appeared complete and current. Last fire drill conducted on 07/06/2025. LPA obtained Client Roster, Staff Roster, and Liability insurance. Medication review: Began at 1:45 P.M.; medications are centrally stored and locked under the kitchen counter; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties. Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Sep 9, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:50 A.M. When the LPA arrived, there were two (2) staffs and three (3) clients present. The LPA was greeted by Caregiver Fidel Francisco and informed the reason for the visit. Caregiver contacted the Administrator by phone, Sara Jackson. At 10:10 A.M., Administrator arrived at the facility. At 10:15 A.M., the LPA conducted a tour of the physical plant with Administrator, to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The following was observed: Kitchen: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives were observed to be locked in a kitchen drawer. At 10:17 A.M. hot water temperature measured at 116.9 degrees Fahrenheit. Fire extinguisher is fully charged, and recently purchased on 08/02/2024. Combination smoke alarms and carbon monoxide detectors were tested at 10:49 A.M. and were operational at this time. Bedrooms: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) total bedrooms; 4 (four) are private bedrooms and one is designated as a shared room. LPA observed trash cans with out tight-fitted lids. No bedroom was used as a passageway to another room, bath, or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair. Continues on LIC 809 Continued from LIC 809 Restrooms: The LPA observed four (4) restrooms in the facility; two (2) are shared resident restrooms, one (1) is a private restroom, and one (1) half bath is designated for staff and visitor use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in the common resident restrooms and was within the required range. Common spaces: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. The facility maintained a comfortable temperature of 75 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. Outdoor Space: The backyard area contains a shaded area with a table and chairs for resident use. There is a non-functioning fountain, which was observed to be empty at the time of the visit. Passageways were observed to be clear and free of hazards. There were no bodies of water noted. Garage/Office: The garage is where the washer and dryer are held, including emergency food and emergency water. Cleaning supplies and disinfectants are kept in locked cabinets in the garage all cleaning compounds were stored in areas separately from food supplies. There is an office area whit a desk and a phone and files are held. File review: A review of facility files was initiate at 11:45 A.M. and the following was observed. LPA reviewed three (3) residents files and three (3) staff file including the administrator’s. All documents reviewed appeared complete and current. Last fire drill conducted on ­­­­­­05/01/2024. LPA obtained Client Roster, Staff Roster, and Liability insurance. Continued on LIC 809-C Continued from LIC 809-C Medication review: Began at 12:30 P.M.; medications are centrally stored and locked under the kitchen counter; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. Interviews: Between 1:15 P.M. and 1:45 P.M. the LPA conducted two (2) staff and one (1) residents’ interviews. No deficiencies cited at this time. Exit interview conducted. Report issued and provided to Administrator.the state’s words, verbatim · CDSS document, Aug 21, 2024

Allegation investigated: Licensee did not refund fees overcharged to resident’s authorized representative in a timely manner.

Licensing Program Analyst (LPA) Kelly Dulek conducted an initial complaint investigation for the allegation listed above. LPA arrived at the facility at 01:25PM and met with facility staff Fidel Francisco. Administrator Sara Jackson was contacted via telephone at 01:28PM and was unavailable during today's visit. Administrator verbally authorized facility staff to sign today's reports. Entrance interview conducted. During today's visit, LPA interviewed Administrator via telephone at 01:28PM and again at 01:55PM, interviewed staff at 01:50PM, toured the facility at 01:52PM, and attempted to contact Licensee via telephone and text message. No immediate health and safety concerns were identified during today's facility tour. The following was then determined: Interviews revealed that Resident #1 (R1) had passed away in October 2023. At that time, billing discontinued. Then in January 2024, the facility changed accounting and R1 was charged monthly fees in REPORT CONTINUED ON LIC 9099-C Substantiated January, February, March, and now again in April. Licensee indicated a refund check was issued to R1's estate, however as of today's date has not been cashed. Administrator indicated they had spoken with R1's family member as of 04/01/2024 and the total amount due to R1's estate is $21,000, however the check issued was for $14,000. Fees have been charged since January 2024, but the refund check was not issued until mid-March 2024, and since the resident passed away in October 2023, no fees should have been charged following R1's death. Based on record review and interview, the allegation "Licensee did not refund fees overcharged to resident’s authorized representative in a timely manner" is deemed SUBSTANTIATED at this time. Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 9099-D). Administrator was informed telephonically failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Apr 2, 2024 · control 29-AS-20240326143505

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.652(a) · Plan of correction due date: Apr 16, 2024

§1569.652 (a) A residential care facility for the elderly shall not require...upon the death of a resident. No fees shall accrue once all personal property belonging to the deceased resident is removed from the living unit. This requirement is not met as evidenced by: Based on interview and record review, R1 passed away on 10/19/2023, and fees were charged in January, February, March and likely April 2024 after the resident had passed away, which posed a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 2, 2024

Plan of correction: Administrator agreed to send a copy of the check issued to R1's estate and provide proof of the refund being received and processed by POC due date.