Mali's Place II

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct the required annual visit at 12:00 P.M. When the LPA arrived, there were two (2) staff members and five (5) residents present. The LPA met with Administrator, Sara Jackson. Entrance interview. At 12:10 P.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. KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food at the time of the visit. All knives were observed to be locked in a kitchen drawer. At 12:15 P.M. hot water measured 115.2 degrees Fahrenheit. LPA observed a fire extinguisher fully charged and recently purchased on 05/08/2026. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 6 (six) bedrooms in total. Room between kitchen and garage is designated as a staff room. RESTROOMS: The LPA observed three (3) restrooms in the facility. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and slip-resistance surfaces. Hot water temperature was measured in all three (3) restrooms and was within the required range of 105 - 120 degrees Fahrenheit. Continued on LIC 809-C Continued from LIC 809 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. A fireplace was noted and was observed to be adequately screened and inaccessible to residents in care. LPA observed multiple portable air-conditioning units throughout the facility. The Administrator stated that the facility’s main air-conditioning system is currently non-operational and that the necessary parts have been ordered to complete the repairs. During today’s visit, the temperature throughout the facility was comfortable. Facility has a fire door, and during the visit the fire door was closed. At 1:25 P.M. hardwire smoke alarms and a separate carbon monoxide detector were tested and found to be functional at the time of the visit. The LPA observed the required postings in the common area. OUTDOOR SPACE: The backyard area contains a shaded area with a table and chairs for residents’ use. There was a shaded area with sufficient room for activities. LPA observed that the black metal side gate was pulled out of the drywall, resulting in the door not closing properly. No bodies of water noted at the time of visit. GARAGE: A locked garage is accessible from the interior and exterior of the building. Inside the garage LPA observed an extra fridge, emergency water, emergency food and extra medical supplies. Here is where the washer and dryer are located. Cleaning supplies and chemicals are safely stored and inaccessible to residents. RECORDS: Records review began at 12:36 A.M. LPA reviewed five (5) residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order, however, LPA observed that Resident #1 (R1), a dementia individual that is not able to administer their own prescribed medication who is not receiving hospice or home health services, is being administered supplemental oxygen without the supervision of a skilled professional. LPA reviewed four (4) personnel records including the Administrators. All files were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Last emergency drill (Earthquake Drill) was conducted on 07/28/2026. Continued on LIC 809-C Continued from LIC 809-C MEDICATIONS: Medications review begin at 1:45 P.M., medications are centrally stored and locked in a cabinet under kitchen counter facing the dining room area; medications are labeled and checked for expiration dates. At the time of the visit, medications were properly documented on the Centrally Store Medication log provided by the pharmacy. LPA observed that medication was being pre-popped in advance of administration. During today’s visit LPA informed the licensee and designee that removing medication from their original packaging in advance of administration (pre-popping) is not permitted. Technical Violation (TV) issued. A first aid kit was observed in the hallway cabinet. Pursuant to Title 22, California Code of Regulations, the following deficiency is 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 3, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87618(a)(2) · Plan of correction due date: Sep 4, 2026

87618 Oxygen Administration - Gas and Liquid(a) Except as specified in Section 87611(a),... requires the use of oxygen...: (2)If intermittent oxygen administration is performed by an appropriately skilled professional. This requirement is not met as evidenced by… Based on observation and interviews, the licensee did not comply with the section cited above as R1, a dementia individual, is receiving supplemental oxygen without the supervision of a skilled professional which poses an immediate health risk to persons in care.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Administrator will contact R1's primary physician or home health regarding their oxygen intake. Home health documentation will be submitted to LPA prior to POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Sep 18, 2026

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by… Based on observation and interviews, the Administrator did not comply with the section cited above as the side metal gate is not self-closing which poses a potential health risk to persons in care.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Administrator will repair the side gate and send photos to LPA prior to POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived unannounced to conduct a one year required annual at 9:15 A.M. Upon arrival, the LPA was greeted at the door by caregiver, Marietta Acosta and contacted the administration via telephone. At 9:39 AM the Administrator, Sara Jackson arrived at the facility and the reason for the visit was explained. Entrance interview conducted. At 9:35 A.M., the LPA along with the administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following observed: KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food at the time of the visit. All knives were observed to be locked in a kitchen drawer. At 9:40 A.M. hot water measured 116.8 degrees Fahrenheit. LPA observed a fire extinguisher fully charged and recently purchased on 07/07/2025. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 6 (six) bedrooms in total. Room between kitchen and garage is designated as a staff room. RESTROOMS: The LPA observed three (3) restrooms in the facility. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. During the physical plant tour, LPA observed that the sink located in the hallway bathroom, situated between bedroom #2 and bedroom #3, was not draining properly (TA issued). Hot water temperature was measured in all three (3) restrooms and was within the required range of 105 - 120 degrees Fahrenheit. Continued on LIC 809-C Continued from LIC 809 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. A fireplace was noted and was observed to be adequately screened and inaccessible to residents in care. The LPA observed the required postings in the common area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a comfortable temperature of 76 degrees Fahrenheit. Facility has a fire door to contain a fire from one side of the house to the other side. At the time and during the visit fire door was closed. At 10:25 A.M. hardwire smoke alarms were tested and found to be functional at the time of the visit. However, a separate carbon monoxide detector did not contain batteries. The administrator inserted new batteries, but the detector continued to beep. Subsequently, the administrator purchased and installed a new carbon monoxide detector. LPA tested the newly installed detector and confirmed it was functional. OUTDOOR SPACE: The backyard area contains a shaded area with a table and chairs for residents’ use. There was a shaded area with sufficient room for activities. Exit gates were observed to be self-closing and self-latching. Passageways were observed to be clear and free of hazards. No bodies of water noted at the time of visit. GARAGE: A locked garage is accessible from the interior and exterior of the building. Inside the garage LPA observed an extra fridge, emergency water, emergency food and extra medical supplies.Washer, dryer, cleaning supplies and chemicals are safely stored and inaccessible to residents. Continued on LIC 809-C Continued from LIC 809-C RECORDS: Records review began at 11:06 A.M. LPA reviewed four (4) residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Also, LPA reviewed five (5) personnel records including administrator. All files were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. LPA observed a Personnel Record Form (LIC 500) posted at the main entrance with a revision date of 09/06/2024. LPA asked the administrator if the posted version was current and contained accurate information, and the administrator confirmed that it did. LPA then compared the LIC 500 with the Guardian background check system and absorbed that Staff# 1 (S1) is listed on the LIC 500 as a live-in caregiver, however, S1 is not associated with this facility in the Guardian background check system. All files were in order. Last emergency drill (Active Shooter) was conducted on 07/02/2025. MEDICATIONS: Medications review begin at 12:45 P.M., medications are centrally stored and locked in a cabinet under kitchen counter facing the dining room area; medications are labeled and checked for expiration dates. Medications are properly documented on the Centrally Store Medication log provided by the pharmacy at the time of the visit. A first aid kit was observed in the hallway cabinet. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D) An immediate civil penalty of $500 was issued and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code §1569.49(f). Exit interview conducted. Citations issued. A Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 29, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Valeria Conway arrived unannounced to conduct a one year required annual at 10:00 A.M. Upon arrival, the LPA was greeted at the door by caregiver, Marietta Acosta. The Administrator, Sara Jackson arrived shortly after and the reason for the visit was explained. Entrance interview conducted. At 10:35 A.M., the LPA along with Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following observed: KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food at the time of the visit. All knives were observed to be locked in a kitchen drawer. At 11:00 A.M. hot water measured 115.4 degrees Fahrenheit. LPA observed a fire extinguisher fully charged and recently purchased on 08/02/2024. The facility has both smoke detectors and separate smoke detector/carbon monoxide detector, which were tested at 11:30 A.M. and were functional at the time of the visit. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 6 (six) total bedrooms. Room between kitchen and garage is designated as a staff room. Continued on LIC 809-C Continued from LIC 809 RESTROOMS: The LPA observed three (3) restrooms in the facility. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. During the physical plant tour, water temperature was measured in all three (3) restrooms and was within the required range of 105 - 120 degrees Fahrenheit. 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. A fireplace was noted and was observed to be adequately screened and inaccessible to residents in care. The LPA observed the required postings in a hallway next to room #3. LPA asked Administrator to move posters into the common area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Facility has a fire door to contain a fire from one side of the house to the other side. At the time and during the visit fire door was kept open with a stopper. At 11:58 A.M. Administrator contacted Richard Martinez, fire inspector. During their conversation, Mr. Martinez stated that during his inspection visit, instructed staff not to use stopper to keep door open. Continued on LIC 809-C OUTDOOR SPACE: The backyard area contains a shaded area with a table and chairs for resident use. There was a shaded area with sufficient room for activities. Exit gates were observed to be self-closing and self-latching. Passageways were observed to be clear and free of hazards. No bodies of water noted at the time of visit. GARAGE: A locked garage is accessible from the exterior of the building. Inside the garage LPA observed an extra fridge, emergency water, emergency food and extra medical supplies. The exterior passageways were clean and clear of any obstructions. Washer, dryer, cleaning supplies and chemicals are stored and inaccessible to residents. Continued on LIC 809-C Continued from LIC 809C RECORDS: Records review began at 12:30 P.M. LPA reviewed three (3) residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. During record review, LPA observed Resident #1 had an incomplete Needs and Service plan and Resident #2 (R2) had an outdated Needs and Service plan dated on 05/2023. All other records were in order. Also, LPA reviewed five (5) personnel records including licensee. Per the Guardian website, all four staff were not associated to this facility. During records review, LPA observed that staff #1 (S1), staff #2 (S2), staff #3 (S3) and staff #4 (S4) were all separated on 10/20/2023. Licensee, Joseph Jose, associated all four (4) staff today before annual visit concluded. All files were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. Last emergency drill (Fire) was conducted on 08/06/2024. MEDICATIONS: Medications review began at 2:00 P.M., medications are centrally stored and locked in a cabinet under kitchen counter facing the dining room area; medications are labeled and checked for expiration dates. Medications are properly documented on the Centrally Store Medication log provided by the pharmacy at the time of the visit. A first aid kit was observed in the hallway cabinet. Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 809-D) Exit interview conducted. Citations issued. A Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 16, 2024