Marian Homes 3

Type of visit: Required - 1 Year

On 2/23/26 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced himself, stated the purpose of the visit, and was greet by Administrator (A1) Shannon Steele (A1) LPA was granted entry. 0 residents were present during inspection. Licensee states there will be residents placed here in the future. LPA toured facility with A1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. No resident’s medications were checked because there are no residents present. No clients’ MARS were reviewed. Cleaning chemicals was observed stored and locked in facility cabinet. Fire extinguisher was observed with a service date of: 7/23/25. No fire drill conducted as residents not residing in facility. Clients' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a range of 109 to 109.5 degrees in 2 bathrooms. Outside of facility toured. Outside observed free of debris. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Freezer temperature was maintained at 0 degrees F and refrigerator temperature was maintained at 32 degrees F. Carbon monoxide and smoke detector were tested and observed to be operational. All clients’ files reviewed to have all of the required documents. All staff files were reviewed to have all required documents. No deficiencies observed during inspection. Exit interview conducted. A copy of this report was distributed to Administrator whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Feb 23, 2026

Type of visit: Case Management - Other

On 2/21/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced for a case management visit regarding a Default Decision and Order for Staff 1 (S1). LPA met with Staff (S1) Marcos Garcia. Administrator Shannon Steele was called and arrived shortly and verified Rommel Cortez is not employed. LPA conducted visit to verify an individual that no longer has a criminal record clearance is working at the facility. LPA was informed by Administrator that Staff member is not employed at the facility and no longer associated with the facility. Exit interview was conducted. A copy of this report was provided to A1, whose signature confirms receipt of this report.the state’s words, verbatim · CDSS document, Feb 21, 2025

Type of visit: Required - 1 Year

On 2/5/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced himself, stated the purpose of the visit, and was greet by Administrator (A1) Shannon Steele (A1) LPA was granted entry. 0 residents were present during inspection. 1 resident who resides in facility is currently residing in another facility. This facility is currently conducting renovations inside the property. LPA toured facility with A1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. No resident’s medications were checked because there are no residents present. No clients’ MARS were reviewed. Cleaning chemicals was observed stored and locked in facility cabinet. Fire extinguisher was observed with a service date of: 7/2/24. Fire drill last completed on 1/15/25. Clients' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a range of 107.4 to 108.1 degrees in 2 bathrooms. Outside of facility toured. Outside observed free of debris. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Freezer temperature was maintained at 0 degrees F and refrigerator temperature was maintained at 39 degrees F. Carbon monoxide and smoke detector were tested and observed to be operational. All clients’ files reviewed to have all of the required documents. All staff files were reviewed to have all required documents. No deficiencies issued during this inspection. Exit Interview conducted. LPA is requesting the following documents be submitted to the Fresno CCL office by 2/19/25: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance-RCFE, Emergency and Disaster Plan (LIC 610E -RCFE), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A- RCFE) A copy of this report was provided to A1, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Feb 5, 2025

Allegation investigated: Staff overcharging resident for cigarettes.

On 5/07/2024, Licensing Program Analyst (LPA) V. Gorban and Licensing Program Manager (LPM) S. Moua met with Administratr Sundari "Susan" Kendakur and Care Coordinator Jean to discuss the above allegations and deliver findings. The Department conducted interviews and reviewed records. Based on the records reviewed, the facility failed to provide receipts detailing the breakdown of a carton of cigarettes and how resident’s P&I funds were used to purchase the item. The Department was only provided payment receipts that does not indicate how many cartons and what type of cigarettes were purchased. The ledger provided show discrepancies because the resident was charged $32.75 in 2021, $76.91 in 2023, and then #32.75 in 2023. The preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. See citations on the attached LIC. 9099D. Substantiatedthe state’s words, verbatim · CDSS document, May 7, 2024 · control 24-AS-20240307103125

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87217(g)(1) · Plan of correction due date: May 8, 2024

87217(g)(1) Safeguards for Resident Cash, Personal Property, and Valuable Each licensee shall maintain adequate safeguards and accurate records of cash resources and valuables entrusted to his care…Records of residents' cash resources maintained as a drawing account shall include a ledger accounting (columns for income, disbursements and balance) for each resident, and supporting receipts filed in chronological order…this requirement was not met as evidenced by: Based on records reviewed, the facility failed to provide supporting receipts of the cigarettes purchased and charged to the resident, which poses an immediate health, safety, and personal rights risk to the residents in care.the state’s words, verbatim · CDSS document, May 7, 2024

Plan of correction: POC – Facility administrator agrees to review the resident’s P&I fund ledgers and reimbursed the resident or their responsible party for any overpayment made during the resident’s stay at the facility. A plan as part of the POC will be submitted to the CCL office by the due date.

Type of visit: Case Management - Annual Continuation

On 2/19/24, Licensing Program Analyst (LPA) M. Medina conducted an Annual Continuation Inspection. LPA met with Susan Kendakur, Licensee/Administrator to complete inspection. LPA Medina reviewed both resident and staff files during inspection. Licensee to submit the following documents to Fresno Regional Office no later than 2/29/24: LIC 308, LIC 309, LIC 500, and LIC 610E. No deficiencies cited during inspection visit.the state’s words, verbatim · CDSS document, Feb 19, 2024

Type of visit: Required - 1 Year

On 2/17/2024, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA introduced self and allowed entrance by Caregiver. Shannon Steele, Care Coordinator contacted by telephone and arrived a short time later to conduct inspection. Five (5) residents observed to be present during today's inspection. Facility tour conducted with Care Coordinator. Resident bedrooms tour and observed to have required furnishings. Common areas in facility which includes living room and dining room have adequate seating and lighting for residents. Bathrooms toured, LPA observed grab bars near toilet and in shower. Shower also has shower chair and non-slip mats available. Kitchen toured, LPA observed an adequate supply of food for residents in care. All medications observed to be locked and secured in kitchen cabinet. Medications reviewed and observed to have original labels and to be administered as prescribed. All knives were observed to be locked and secured in kitchen cabinet. Fire extinguisher present and has a service date of 06/07/23. Carbon monoxide detector and smoke detectors present and observed to be operational during today's inspection. Last fire drill conducted 1/29/24 according to facility records. Outside of facility toured. All exits open free of obstruction. No hazards observed. Staff and resident files to be reviewed at Annual Continuation. No deficiencies cited during inspection. Exit interview conducted. A copy of report provided for facility records.the state’s words, verbatim · CDSS document, Feb 17, 2024