Mary Frances Hat Residential Facility

Type of visit: POC

Unannounced Plan of Correction visit made out to this facility on 02/05/2026 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator Laura Reeves. A brief interview was conducted with the facility designated Administrator at this time. Current census was 5 residents. The purpose of this visit was to follow up on the deficiencies that were cited from a prior annual visit conducted on 01/23/2026. This visit was to follow up on the Plan of Correction that was due. The following deficiency was observed and cited on 01/23/2026: All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. Plan of Correction clearance letter was printed and a copy was provided to the facility designated Administrator at this time. There were no further deficiencies observed or cited during today's Plan of Correction visit. Exit Interviewthe state’s words, verbatim · CDSS document, Feb 5, 2026

Type of visit: Required - 1 Year

Unannounced Annual visit made out to this facility on 01/23/2026 by Licensing Program Analyst (LPA) Charlie Yang. This LPA was met by the facility designated Administrator, Laura Reeves, who was briefly interviewed at this time. Current census was 5 residents. It was learned that there weren't any residents under the care of hospice at this time. This facility does have an approved waiver to be able to accept and retain up to (2) residents under the care of hospice at any given time. It was learned that this facility has a program to be able to accept and retain dementia residents at any given time. It was learned that there weren't any residents diagnosed with dementia at this time. It was learned that there weren't any residents receiving services through home health at this time. Tour of this facility was conducted. Dining area, living area, and all other areas intended for resident use were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Linen closet was reviewed and observed to contain a sufficient supply of towels, sheets, and bedding able to meet the needs of the residents at this time. Kitchen area was toured. Kitchen drawers and cabinets were opened and reviewed. Food supply for 2-day perishable and 7-day nonperishable quantities was reviewed to make sure that they were in compliance at all times. Pantry area was toured. Additional food storage units were observed to be present and functional at this time. Laundry room, located prior to the exit into the other side of the attached facility, was toured. Bleach, detergent, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time. Administrator certificate, # 7033069740, for Laura Reeves was observed to have an expiration date of 03/15/2027 and in compliance at this time. Forms and documents have been completed in order to renew this Administrator certificate at this time. Medication cabinet with cart, located in the facility laundry room, was observed to be locked and made inaccessible to the residents at this time. First aid kit, located in the laundry room, was reviewed. This LPA observed that it did contain all of the required components at this time. Fire extinguisher that was located in the kitchen area was observed to have been annually inspected by the local fire extinguisher company, Cisco Fire Sprinklers Inc, on 02/03/2025 and found to be in compliance at this time. Facility resident bedrooms were toured. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Facility resident restrooms were toured. Grab bars and non skid mats were observed to be present and in good repair at this time. Hot water temperatures were taken to make sure that they were within the allowed range of 105-120 degrees. A tour of the facility exterior grounds was conducted. A review of the facility perimeter fence, side gates, and all other exits was conducted. A review of (5) facility personnel records was conducted and noted on the LIC 859. A review of (5) facility resident records was conducted and noted on the LIC 858. The following forms and documents were requested to be updated and submitted into CCL for review by this LPA: LIC 308 LIC 400 LIC 500 LIC 610 The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes. Appeal Rights were printed and a copy was given to the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Jan 23, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Kesha Lewis arrived at this facility unannounced to conduct a Required 1 Year Annual Inspection Visit. LPA was met by administrator and explained the purpose of the visit. LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry area, living area and other common areas, as well as outside of the facility to ensure compliance with Title 22 regulations. Facility is a 6 bed facility with a current census of 4. There is entry door is leading to the living room, kitchen with a hallway to the bedrooms and bathrooms. Chemicals and medications noted to be locked to residents in care. LPA also conducted the care tool. No bodies of water were observed at the facility. Hot water temperature was measured and is within the required range of 105 to 120 degrees Fahrenheit. All necessary documents were in place. LPA observed the following posted on the facility wall: Facility license, sketch, See Something Say Something poster, Ombudsman poster, Theft and Loss Policy, Resident Bill of Rights, Rights of Resident/Family Councils. The facility submitted a LIC 808 mitigation plan, which was approved. The facility has central entry point. LPA observed the facility to have adequate food supply of 7 days non-perishables and 2 days perishables in place. Resident rooms were sanitary and had the required furniture and furnishings. LPA observed, fire extinguishers inspected on 02/07/2024 and current, smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance. LPA reviewed two (2) staff files. All staff is fingerprint cleared and associated to the facility and staff have current First Aid or CPR certifications on file. Facility is conducting initial and continuing training as required. LPA reviewed two (2) resident facility files, COVID-19 Plan, and survey binder. All necessary documents were in place. Exit interview held with staff and copies of reports left at conclusion of visit.the state’s words, verbatim · CDSS document, Jan 24, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required 1 year annual inspection visit. LPA met with administrator and explained purpose of visit. Administrator certificate expires 9/21/2024. LPA and administrator inspected the physical plant including but not limited to the kitchen, dining room, client bedrooms; client bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. LPA measured the hot water temperature in resident's bathroom at 112.7 degrees Fahrenheit which is within the required range of 105 to 120 degrees. Fire extinguishers last inspected on 2/8/2023. Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to clients. LPA reviewed and compared client medication vs. medication logs. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility. The facility conducted fire/disaster drills with clients on 12/30/2023. LPA reviewed four client files and four staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews. Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies were cited during this visit. Exit interview held with administrator. A copy of report and LIC 811 (Confidential Names) were left at facility.the state’s words, verbatim · CDSS document, Jan 16, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Renee Campbell arrived unannounced to conduct a case management visit on 10/03/23. LPA Campbell obtained information that the resident had resided in the home with a stage 3 pressure wound without an exception request. The Department conducted interviews, reviewed documentation submitted and determined that the resident had a Stage Three Pressure Wound after leaving the hospital on 06/16/2023. Based on interviews with administrator Laura Reeves, the resident was admitted back to the facility despite having no approved exception request from the Department. Licensing was not notified of the prohibited health condition and no exception request was received by licensing. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates, civil penalties may be assessed. The Facility Designee was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.the state’s words, verbatim · CDSS document, Oct 3, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Oct 13, 2023

Prohibited Health Conditions -Persons who require health services for or have a health condition including but not limited to, those specified below, shall not be admitted or retained in a residential care facility for the elderly: Stage 3 and 4 pressure injuries. This requirement is not met as evidence by: Based on LPA Campbell’s observation of file reviews for R1 and Adventist Home Health Nurse’s statement that R1 had a Stage Three Pressure Wound while in the facility for more than 24 hrs. This poses an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Oct 3, 2023

Plan of correction: POC The licensee shall train all staff on prohibited health conditions and submit a signed attendance roster of all employees that were educated on the regulation along with a statement of understanding to LPA by POC due date of 10/13/2023.