Marsh's Board & Care

Type of visit: Required - 1 Year

At 9:00am on 06/02/2026, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the facilities annual inspection. LPA was accompanied by Tri Counties Regional Center (TCRC) QA, Adela Cortinas (QA). QA and LPA met with Administrator, Susan Marsh, announced who they are and the reason for the visit. Licensee, Susan Marsh was preparing Resident for a medical appointment at 9:30am, QA and LPA made some observations of the facility and discussed to return at a later date in the near future to continue and complete the annual inspection, so that Licensee does not have to cancel the medical appointment for Resident. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Jun 2, 2026

Type of visit: Case Management - Deficiencies

At 9:00am on 10/30/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct a case management visit pertaining to Tri Counties Regional Center (TCRC) facility visit on 08/08/2025 case management visit where rodents had been observed by QA Adlea Cortinas and LPA. LPA was accompanied by TCRC, Adela Cortinas (QA), who announce who they are and the reason for the visit. LPA also conducted a complaint visit on facility next door (421703748) licensed and administrated by Susan Marsh in addition to this facility. QA and LPA conducted observations of facility and noted, that there were no observed pest during visit. QA asked Administrator about the remaining holes at the kitchen base board. Administrator stated that they are in the process of getting a replacement kicker panel to cover the holes. LPA noted that the kitchen was not clean nor in good repair as noted by the holes in the baseboard. LPA issued a verbal warning based on the Administrators statement of working to get new baseboard installed. QA and LPA finished with case management visit and LPA moved over to next door facility for complaint visit at that facility. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Oct 30, 2025

Type of visit: Case Management - Deficiencies

At 10:00am on 08/08/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct a case management visit pertaining a follow up visit from the Case Management visit on 07/17/2025. from a Tri Counties Regional Center (TCRC) facility visit on 07/01/2025, where a rodent was observed and photographed in the facility kitchen. LPA announced who they are and the reason for the visit. LPA to ascertain if the facility followed the plan of corrections from the deficiency dated 07/18/2025, extermination of rodents. On 08/04/2025, LPA and Tri Counties Regional Center (TCRC), Adela Cortinas (QA), conducted a case management visit to ascertain two violations issued on 07/18/2025. The type B violation of eliminating “ammonia” odor was cleared, however the Administrator had not been successful in employing appropriate rodent abetment contractor. On the case management visit of 08/04/2025, the Administrator stated that they had employed a general contractor, who cleaned out "area with liquid cleaner, wet/dry vacuumed areas, bought and placed traps and cleaned out attic and set traps. During the case management visit QA and LPA saw more than two different rodents on the floor in the kitchen area. On 07/14/2025 LPA sent email to Administrator with contact information of 4 approved rodent abetment contractors that serviced the area of this facility. On 07/22/2025 LPA sent an email for Administrator to have Structural Pest Control Board (SPCB) certification to conduct pest control abatement. On the case management visit on 08/04/2025, Administrator stated that they had difficulty with one of the contractors on the list provided by LPA. On the case management visit of 08/04/2025, due to the difficulty administrator stated having with the rodent abatement contractor that was called from the list LPA provided, LPA provided an extension. Administrator agreed to call the appropriate pest control abatement service in the next 24 hours (08/04/2028) and schedule the next available appointment. CONTINUED on LIC809-C On 08/04/2025, LPA emailed 4 additional contractors that were qualified to conduct rodent abetment in the area of the facility, LPA followed up with a call letting Administrator know of the email was in their email in box with 4 new rodent abatement contractors. Administrator returned response email with the following: “Thanks Mark. So currently I’ve been in contact once again with Justin Clegg dba “ Justin-n-Time” who will come with appropriate documents to satisfy CCL. And meanwhile I will keep working on house as usual. Susan Marsh Sent from my iPhone” On 08/07/2025, LPA contacted Justin Clegg of Just-n-time concrete, who stated that they have not received any calls for rodent abatement and have nothing scheduled for rodent abatement. Mr. Clegg further explained that they are a concrete contractor and don’t do rodent abatement unless it is specifically for concrete work. Based on the information the Administrator has not followed the Plan of Correction for the Type A citation that was written on 07/17/2025. At this time a civil penalty will be assessed for repeat violation, due to the eminent danger, the present of rodents’in place on residents in care. The plan of corrections still remains as a priority for the Administrator to employ the proper contractor to conduct rodent abatement services at the facility until there is formal verification by the abatement company that the rodent infestation has been eliminated by showing monthly invoices of rodent abatement services. Exit interview, report read, civil penalty issued, appeal rights and report provided.the state’s words, verbatim · CDSS document, Aug 8, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(27) · Plan of correction due date: Aug 11, 2025

87555(b)(27)General Food Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement was not met by evidence of rodents observed in the facility kitchen, which poses an eminent risk to residents in care.the state’s words, verbatim · CDSS document, Aug 8, 2025

Plan of correction: Administrator agreed to contact Pest Control Company, certificated for rodent abatement by the end of this business day (08/08/2025) to employ them to abate the rats observed in the kitchen immediately (soonest appointment available). Administrator will contact LPA as to the time and date of the schedule and additionally, send a copy of the Bill for the exact services provided on a monthly basis until Pest Control confirms by documentation that rodents have been eliminated from the facility.

Type of visit: Case Management - Deficiencies

At 10:00am on 08/04/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct a case management visit pertaining a follow up visit from the Case Management visit on 07/17/2025. from a Tri Counties Regional Center (TCRC) facility visit on 07/01/2025, where a rodent was observed and photographed in the facility kitchen. LPA was accompanied by TCRC, Adela Cortinas (QA), who announce who they are and the reason for the visit. QA and LPA are to ascertain if the facility was cleaned to eliminate "ammonia" smell from the facility and the the extermination of rodents. QA and LPA made initial observations and noted that the "ammonia" smell is not present in the facility today. The facility is cleaner than the case management visit on 07/17/2025, however the facility still need to be cleaned per Community Care Licensing Regulations Standards, under the infection control regulations. QA and LPA did observe rodents present in the kitchen. Administrator stated that they had employed an general contractor, who cleaned out "area with liquid cleaner, wet/dry vacuumed areas. bought and placed traps and cleaned out attic and set traps. LPA sent email to Administrator on 07/22/2025 to have Structural Pest Control Board (SPCB) certification to conduct pest control abatement. Administrator agreed to call the appropriate pest control abatement service in the the next 24 hours and schedule the next available appointment. LPA will follow up with Administrator and QA by phone or visit. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, Aug 4, 2025

Type of visit: Case Management - Deficiencies

At 9:00am on 07/17/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct a case management visit pertaining to Tri Counties Regional Center (TCRC) facility visit on 07/01/2025, where a rodent was observed and photographed in the facility kitchen. LPA was accompanied by TCRC, Adela Cortinas (QA1), who announce who they are and the reason for the visit. On 07/14/2025 LPA contacted the Administrator by phone and provided local pest control companies who verified by phone that they do rodent abatement. The Administrator requested that LPA email that information to the Administrator and LPA did so on 07/14/2025 with pest control companies contact information and a request that Administrator call one of them as soon as possible in order to abate rodents from facility. On 07/17/2025, QA1 and LPA observed a rat head poking out a hole below the kitchen cabinets, Administrator, QA1 and LPA heard rat scratching, and Q1 and LPA heard rat crying sound during case management visit. Based on this case management visit observations and photographic evidence with reliable witnesses on the TCRC 07/01/2025 visit of the presents of rodents in the facility, LPA Jeffries issued a citation under regulations 87555(b)(27) General Food Requirements, that all kitchen areas shall be kept clean and free of litter, rodents, vermin, and insects. Additionally, on 07/01/2025, TCRC QA2 reported to LPA that the kitchen presented a strong “ammonia” smell. During this case management visit, On 07/17/2025, QA1 and LPA both noted a strong “ammonia” smell when walking through the entrance of the facility, which is the living room and continued through the dining room and into the facility kitchen area. There are two holes and an empty space where the dishwasher was in the past. These observations resulted in a citation of 87303(f) Maintenance and Operations all waste shall be located, stored, and disposed of a manner that will not transmit … orders, pose a risk to health and safety, or provide a breeding place for food source for insects or rodents. LPA issued two citations as a result of this case management visit. Exit interview, report read, citations issue, appeal rights and report provided.the state’s words, verbatim · CDSS document, Jul 17, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 8755(b)(27) · Plan of correction due date: Jul 18, 2025

87555(b)(27) General Food Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement was not met by evidence of rodents observed in the facility kitchen, which poses an eminent risk to residents in care.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: Administrator agreed to contact Pest Control Company to employed them to abate the rats observed in the kitchen. Administrator will send a copy of the BIll for the exact services provided. By 07/18/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(f) · Plan of correction due date: Jul 31, 2025

87303(f) Maintenance and Operation (f) All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. This requirement was not met by evidence of “ammonia” odor present in facility, which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: Administrator agreed to have employed staff help to clean facility to elevate "ammonia" smell out of facility. LPA will conduct a case management visit on or after 14 days of this citation to confirm smell is abated from facility.

Type of visit: Case Management - Annual Continuation

At 4:00pm on 05/19/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct a continuation of the facilities annual inspection.. LPA met with Administrator, Susan Marsh, announce who he is and the reason for the visit. This is a four bedroom, two bathroom, living room, kitchen and dining room, laundry room and garage. LPA noted that the dish washer is currently removed and Administrator is considering adding shelves where dishwasher was placed. Administrator will proved an updated to LPA within 14 days of the annual inspection as the construction of the shelves or putting back the dishwasher back in its original location.. Medications are locked in a cabined in the dining room. First Aide Kit is located on the top of the medication cabinet. LPA noted that the fire extinguisher in green and in the prime and is located in the kitchen, LPA noted that the facility has at least two days of perishable foods and seven days of non-perishable foods on hand for residents and staff. LPA noted that the facility has popper linins and bedrooms have furniture in accordance to regulations requirements. LPA noted that there are smoke detectors located throughout the facility and carbon monoxide detector located in the hallway and was tested, and functioning. LPA noted that the single resident currently at the facility has a complete file and has been a resident at the facility approximately 24 years continuous. LPA did to issue any violations or citation as a result of the facility physical tour. Administrator and LPA conducted a full review of the annual care tools module and did not find any violations or citations. LPA note that there were no violations or citations issued as a result of this facilities annual inspection Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, May 19, 2025

Allegation investigated: Staff violated client's personal rights.

At 8:20am on 05/05/2025, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to issue final findings to the allegation to this complaint. LPA was accompanied by Tri Counties Regional Center (TCRC) QA, Miguel Magana (QA). QA and LPA met with Administrator, Susan Marsh, announced who they are and the reason for the visit, to issue final findings to the allegation to this complaint. As to the allegation of, “Staff violated client's personal rights.” It was alleged that during a doctor’s visit Resident 1 (R1) was treated rough by staff in removing R1’s sweater, and staff slapped R1 on the face. It was discovered through interviews conducted by LPA Jeffries on 02/05/2025, with facility Administrator, Susan Marsh stated that during a recent doctor’s visit, she had difficulty pulling R1’s sweater off due to R1’s glasses getting caught in the sweater and may have appeared to be forceful. Administrator denied slapping R1. In an interview by LPA Jeffries of a reliable witness (W1) (a person with medical license indicating expertise training and experience) by phone on 02/06/2025, W1 stated that, CONTINUED on LIC9099-C Substantiated “Ms. Marsh used R1’s arms as leverage and pulled R1’s sweater off in a forceful and rough manor.” W1 also stated that she, “heard a slap and when I (W1) turned around, I witnessed her (Ms. Marsh) slap R1 on the face.” When LPA asked if W1 if they were certain that it was a slap on R1’s face, W1 stated, “1000%”. W1 also stated that there was a medical evaluation after the slap occurred and there were no red marks on the face. On 02/07/2025, LPA Jeffries conducted a phone interview with Health Care Worker (W2) who stated, they did not see the slaps but did witness the sweater being pulled of R1 “very roughly”. On 02/05/2025, QA Magana interviewed R1, with limited verbal answers 4 of 10 questions, that yielded “no response” answers to questions regarding this incident. At this time, based on the 02/05/2025 interview of the credible witness, there is enough evidence to support the allegation of,” Staff violated client's personal rights.” and is substantiated at this time. Exit interview, report read, citation issued, appeal rights and report provided.the state’s words, verbatim · CDSS document, May 5, 2025 · control 29-AS-20250204162504

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 19, 2025

87468.1(a)(1) Personal Rights of Residents in All Facilities. (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met by evidence of a reliable witness observed Administrator slap R1 on the face, which poses a potential risk to residents in care.the state’s words, verbatim · CDSS document, May 5, 2025

Plan of correction: Administrator will conduct 2 hours of personal rights training with a vender approved by Tri Counties Regional Center (TCRC) and Community Care Licensing (CCL) within two weeks of this citation. Administrator will report to TCRC and CCL with certificate of completion of training.

Type of visit: Required - 1 Year

At 8:20am on 05/05/2025, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct the facility annual inspection. LPA was accompanied by Tri Counties Regional Center (TCRC) QA, Miguel Magana (QA). QA and LPA met with Administrator, Susan Marsh, announced who they are and the reason for the visit, to conduct the facilities annual inspection and to issue final findings on a separate complaint. Administrator has a pre scheduled appointment at the facility next door. LPA Jeffries had enough time to start the facility annual inspection, however will need to return at a later date to finish the facility annual inspection. Exit interview, report read, and report provided.the state’s words, verbatim · CDSS document, May 5, 2025

Type of visit: Required - 1 Year

On 06/26/2024, Licensing Program Analyst (LPA) Brian Phillips arrived unannounced for an unscheduled visit to conduct a required Annual site inspection visit at the facility above. When the LPA arrived, they were greeted by Administrator/Licensee Sue Marsh, and informed them of the reason for the visit. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. This is a Residential Care Facility for the Elderly (RCFE), with an approved fire clearance capacity of Five (5) residents. The facility is currently occupied by Two (2) residents. KITCHEN: The facility maintains a kitchen room/area within the interior of the facility. The LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored inaccessible to residents. Kitchen appliances were in operable condition and in good repair. The LPA observed perishable items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which would last over a week (7 days). The hot water temperature was measured in the kitchen at an appropriate temperature as per the regulation between 105-120 degrees Fahrenheit. Items that could constitute a danger to clients are kept inaccessible to clients in the kitchen area. The kitchen was sanitary, with covered trashcans and operating ventilation systems. However, LPA observed that kitchen cabinets, counters and tables were not clean. Dust and several flies were observed. No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. The freezer and refrigerator were both the appropriate temperate Fahrenheit for the storage of food and prevention of spoiling. There is enough tableware and utensils for all clients living in the facility, and enough equipment for the storage, preparation, and service of food. COMMON AREAS: At the time of the visit, the common areas of the facility were observed to be furnished with appropriate furniture, with all furniture in fair condition. Continued on 809-C There is a fireplace in the facility, which is inaccessible to residents. There is also a communal television in the living room of the facility. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector(s) were operational at the time of the visit. The facility has fire extinguishers that were fully charged and serviced annually. This facility contains extra storage areas for additional perishable food, closets/rooms in the hallways of the facility containing extra linen/bedsheets/pillows, and storage areas for resident personal hygiene equipment constituting the interior areas of the facility. The LPA observed required postings throughout the common spaces including Resident Personal Rights and Contact information for Ombudsman as well as Licensing. All window screens were in good repair. There is appropriate lighting in the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all inclines are well-lit with no stairwells/stairs for resident use. The common areas of the facility had specific areas that were in need of various stages of repair, but did not constitute a danger to residents in care. All rooms are maintained at a comfortable temperature and all window screens are in good repair and free of insects, dirt, and/or debris. OUTSIDE/LAUNDRY/MISCELLANEOUS: The front outdoor area of the facility consists of cement walkways and grass areas along with a parking area in front of the main entrance to the facility. The facility outdoor areas are maintained with no observable hazards to residents in care. The backyard/patio room is conducive for outdoor visitation. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. The backyard of the facility has an outdoor/outside activity area for residents with a patio in the backyard, furniture, and shade. There are no bodies of water noted on the facility property. Laundry cleaning products are stored locked and inaccessible to residents. Any hazardous/toxic laundry material is kept locked at all times. There was emergency food and water in a storage area in the back of the facility and in the extra perishable food storage area which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to residents are kept in areas inaccessible to residents. There is a first aid kit that includes sterile dressings, bandages, thermometers, scissors, tweezers, and a first aid manual. The vehicles used to transport residents are in safe operating condition with appropriate insurance information. LPA did not observe any noticeable outdoor hazards in areas accessible to residents. The facility Licensee/Administrator maintains two dogs that were very well trained as observed by the LPA. There is a main entrance walkway into the facility and an administrative entrance area for visitors. BEDROOMS: The facility consists of two (2) bedrooms, with all bedrooms being for individual residents. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Continued on 809-C The bedrooms have storage areas for clean linens, towels, pillows, etc. Each resident’s bedroom has two single beds, nightstands, and lights/nightstand lamps to provide sufficient lighting. Each closet in all the resident rooms has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any resident. The resident bedrooms are big enough for all the beds, furniture, and any resident assistive device a resident might need such as a wheelchair or a walker. Each room has sufficient lighting for each resident. RESTROOMS: There are Two (2) resident restrooms in the facility. Facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms/showers inspected had assistive equipment for residents including grab bars and/or non-skid surfaces. The restrooms were sufficiently stocked with soap, paper towels, and additional supplies; towels and washcloths are not shared. The hot water temperature was measured in the restrooms within the appropriate temperature regulations. Nightlights are installed in the hallways outside of the resident restrooms. The restrooms both had sufficient required postings. One of the restrooms had damage to the toilet as well as the wall behind the toilet, but this was not observed by LPA to constitute a danger to resident(s). RECORDS: The facility keeps confidential storage of resident file(s) at the facility, and Staff member records on-site at the facility as well as the facility next door operated by the same Licensee/Administrator. Staff member records were reviewed for, but not limited to Health Screening Report/Tuberculosis (TB) Clearance for facility personnel, Personnel Record (employment application), verification of age over 18 years old, education, and experience, approved Certification for the Administrator, verification of first aid training, Criminal Record Statement, Criminal Record Clearance/Exemption, Verification of Staff training, Employee Rights, and Abuse Reporting Requirements. Staff personnel records reviewed by LPA had the appropriate documentation. The administrator of the facility has an active Residential Care Facility for the Elderly (RCFE) Administrator Certificate that will expire on 11/02/2024. Resident records were reviewed for, but not limited to Pre-Admission/Placement appraisals, Resident Appraisals, Appraisal Needs and Services Plan (ANS), Physicians’ Reports, Identification and Emergency Information, Current Admission Agreement with signatures, Personal Rights for Residents, Record of Residents safeguarded cash resources, Record of Resident personal property/valuables, Responsible Person or Conservator of Resident, Self-management of medications if applicable, Medication Orders, and Medication Logs. All resident records reviewed by the LPA had the appropriate documentation with no missing or incomplete information. MEDICATIONS: Facility maintains a locked centralized storage area for medications. Contd. on 809-C Centrally Stored Medications are stored in a locked cabinet in the dining room area of the facility. There is a signed and dated order from physician for prescriptions and PRN medications. LPA observed the medication assessment record (MAR) and that the medication is given per physician's orders. The medications remain locked at all times, inaccessible/locked to residents. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record, The Medication Administration Record, and the record of Controlled Medications. LPA audited the medications for residents and noticed no irregularities or issues concerning the dispensing of medications or the logging of medications. The medications in the facility were labeled appropriately with no additional or prohibited markings by the facility. INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening and a sanitation station. The staff members will keep up signs that promote good hand hygiene and symptoms of COVID. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate. FACILITY DOCUMENTATION: There are required postings throughout the facility, including emergency exit plans with necessary telephone numbers. The facility keeps posted copies of facility documentation such as the facility Personnel Report, Plan of Operation, Emergency Disaster Plan, Facility Infection Control Plan/Mitigation Plan, Certificate of Liability Insurance, Valid Administrator Certificate, and a Facility Sketch. Provider Information Notices are available and able to be presented to Staff, residents, visitors, and accessible to LPA upon request during the inspection process. All vehicles used to transport residents are maintained in safe operating condition. LPA noted that there were several technical violations issued, but no citations were issued during this annual inspection at this time. No deficiencies cited. Exit interview conducted. A copy of the report was issued to the facility.the state’s words, verbatim · CDSS document, Jun 26, 2024

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.