Marshfield Villa

Type of visit: Post Licensing

At approximately 11:50 AM, Licensing Program Analyst (LPA) Magdaleno arrived unannounced to conduct a Post Licensing inspection and was greeted by staff. Administrator Grace Larcena was called and arrived at approximately 12:15 PM. Facility is a Residential Care Facility for the Elderly (RCFE) with two (2) residents in care. Facility has a Dementia Care Plan, a Hospice waiver for six (6), with zero (0) Hospice residents currently in care, and is approved for four (4) non-ambulatory residents in rooms 3 and 4 only. LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation. At approximately 12:20 PM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is a one (1) story home, was a comfortable temperature, and passageways were free from obstructions. Fire extinguishers were last inspected 2/25. Smoke and Carbon Monoxide detectors were inspected 10/25. Administrator adjusted water temperature to within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, hygiene, incontinent care, and paper products available for residents. Residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations. Cabinets containing cleaning supplies and other items that could pose a risk were locked. LPA observed at least a two (2) day supply of perishable and seven (7) day supply of non-perishable food, as well as an emergency water supply. Food was found to be stored in a safe manner with open items covered. There is a shaded seating area in the backyard with outdoor space for activities. LPA observed supplies for both indoor and outdoor activities including a piano, board games, art supplies, and miniature golf green. Facility has an internet access device and internet available to residents in care. Updated facility phone number was acquired during this visit. Continued LIC809C... Continued from LIC809... Facility conducts quarterly disaster drills, and the most recent drill was conducted 10/25. LPA reviewed emergency disaster plan which was last updated 10/25. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights. At approximately 12:55 PM LPA conducted review of two (2) staff records. All required documentation present. At approximately 1:05 PM LPA conducted a review of two (2) resident records. All required documentation present. At approximately 1:20 PM LPA and Administrator conducted a spot check of medication and medication records. Medication is centrally stored and locked. Grace Larcena Administrator Certificate 6069070740 expires 5/7/2027. All fees are current as of this time. Updated copies of the following documents were gathered during this visit: Liability Insurance No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Jan 30, 2026

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Prelicensing

At approximately 9:00 AM, Licensing Program Analyst (LPA) Robert Frank arrived announced to conduct a Pre-Licensing Inspection and met with Applicant, Grace Larcena. Facility has applied to be licensed as a Residential Care Facility for the Elderly (RCFE). Upon arrival, LPA was informed that there were currently no residents in care. Facility has an approved fire clearance dated 03/12/2025 that allows for a total capacity of six (6) Residents, where two (2) can be ambulatory and four (4) can be non-ambulatory. The facility has a Dementia Care Program on file. The facility has an approved hospice waiver for six (6) residents At approximately 9:25 AM, LPA initiated a tour of the facility and observed the following: Facility is a one story home, was at a comfortable temperature, and passageways were free from obstructions. Water temperature in residents' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. Applicant had non-slip mats and grab bars in place. LPA observed a supply of clean linens, hygiene products, and paper products available for residents. Residents' bedrooms have all the appropriate furnishings as outlined in Title 22 regulations. LPA observed dishes and cooking supplies for resident use with sharps and other hazardous items kept secured in various designated drawers and cabinets. Cabinets in communal areas of the facility containing cleaning supplies and other items that could pose a risk were observed locked. Applicant agrees to keep keys to these locked areas in facility safe, secured and inaccessible to residents in care. Licensee agrees to maintain at least seven (7) days of perishable foods and 72 hours worth of non-perishable foods and an emergency water supply in case a "shelter in Place" order is given. The required posters were observed hanging in the main entrance area. Continued on 809-C... ...Continued from 809 Facility has sufficient items for cooking and eating. Staff and resident files, and resident medications will be located in the locked cabinet in the kitchen. LPA observed multiple binders for residents and staff records as well as individual bins for storing medications. Facility has indoor/outdoor areas for visiting and activities. Facility's two (2) fire extinguishers were last inspected in 2/2025 and were observed to be fully charged. Facility's combination smoke and carbon monoxide detectors were tested and operational. LPA confirmed that contents of the facility's First Aid Kit were sufficient. During walk through, LPA and Applicant discussed the following item: reversing the lock on the garage door or otherwise securing the garage area. Applicant will submit proof of liability insurance once facility has been licensed . LPA observed a facility sketch which accurately reflects the floor plan. Component III orientation was conducted at facility with Grace Larcena. Grace Larcena’s Administrator Certification 6069070740 is current with an expiration date of 5/7/2027. No Deficiencies or Advisories given during visit. Pre-Licensing completed. Facility is ready to be Licensed as a Residential Care Facility for the Elderly (RCFE). LPA will submit Pre-Licensing Application Report to the Application Unit Analyst in Sacramento. Application Unit Analyst will notify Applicant of Status. Exit interview conducted. Copy of report discussed and provided to Applicant/Administrator Larcena. Signature on form confirms receipt of document.the state’s words, verbatim · CDSS document, Oct 2, 2025

Type of visit: Office

Component II completion: Successful Facility Type: RCFE Application Type: INITIAL Capacity: 6 Census (if any clients in care): 0 COMP II Participants: Grace S. Larcena CEO/Administrator Interview Method: Telephone interview On September 12, 2025, Applicant/Administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of the following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-Licensing Readinessthe state’s words, verbatim · CDSS document, Sep 12, 2025