Mary's House #2

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Required - 1 Year visit and met with Armando Guba, Administrator. During visit, LPA Marrufo toured the facility inside and out. LPA toured the kitchen area and observed there to be a perishable food supply of at least two days and a non-perishable food supply of at least seven days. There were locked cabinets for sharp objects and cleaning supplies. The first aid kit was observed and found to be complete. LPA toured two out of two resident bathrooms. Each bathroom had working lights and available soap and paper towels. The water temperatures in the bathroom sinks measured at 108 F and 119 F. LPA toured four out of four resident bedrooms. Each bedroom had working lights and available bedding and clothing storage areas. LPA tested the smoke detectors in four out of four resident rooms and in the hallways and all detectors functioned properly when tested. Two out of two fire extinguishers have service tags dated 08/18/2026. LPA toured the outdoor area of the facility. Both outdoor exits were clear of obstructions. During visit, staff S1 was found to be background cleared but not associated to the facility. See LIC809-C page for more information. Page 1 of 2. LPA reviewed the Centrally Stored Medication Records (CSMDR) for residents R1-R6. R1's CSMDR was missing four medications, R2's CSMDR was missing one medication, R3's CSMDR was missing six medications, R4's CSMDR was missing one medication, R5 did not have a CSMDR on file, and R6's CSMDR was missing six medications. LPA reviewed the resident records of residents R1-R6. R1's, R3's, R4's, R5's, and R6's resident records were missing an Appraisal/Needs and Services Plan. R5's resident record was also missing a Consent for Medical Treatment Form and an LIC613C Personal Rights Form. LPA reviewed the staff records and found them to be complete. The Emergency Disaster Drill Log indicates the last drill occurred on 06/01/2026. LPA Marrufo requests that the following documents be updated and copies sent to the department by 08/27/2026: LIC500 Personnel Report LIC308 Designation of Administrative Responsibilities LIC610E Emergency Disaster Drill Log Liability Insurance Administrator Certificate Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information. A civil penalty is being assessed for the amount of $200 ($100 per day x 2 days = $200) for staff S5 working in the facility without association. This report was reviewed with Administrator Armando Guba and a copy of this report and appeal rights were provided. Page 2 of 2 END REPORTthe state’s words, verbatim · CDSS document, Aug 20, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Aug 21, 2026

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement was not met as evidenced by: Licensee did not ensure that staff S5 was associated to the facility during visit, which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 20, 2026

Plan of correction: Licensee agrees to associate S5 to the facility and submit an updated LIC500 Personnel Report to the department by 08/27/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6) · Plan of correction due date: Aug 27, 2026

(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement was not met as evidenced by: Licensee did not ensure that R1's Centrally Stored Medication and Destruction Record (CSMDR) was not missing four medications, R2's CSMDR was not missing one medication, R3's CSMDR not missing six medications, R4's CSMDR was not missing one medication, R5 did have a CSMDR on file, and R6's CSMDR was not missing six medications, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 20, 2026

Plan of correction: Licensee agrees to submit completed and accurate copies of R1-R6’s current Centrally Stored Medication and Destruction Records by 08/27/2026.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Aug 27, 2026

Resident Records 87506(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement was not met as evidenced by: Licensee did not ensure that R1's, R3's, R4's, R5's, and R6's resident records were not missing an Appraisal/Needs and Services Plan, and R5's resident record was not missing a Consent for Medical Treatment Form and LIC613C Personal Rights Form, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 20, 2026

Plan of correction: Licensee agrees to submit the Appraisal/Needs and Services Plans for residents R1, R3, R4’s, R5’s, and R6’s and R5’s Consent for Medical Treatment Form and LIC613C Personal Rights Form to the department by 08/27/2026.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility's requires - 1 year annual inspection. LPA met with Administrator, Armando Guba. During visit, LPA toured the facility to include the resident bedrooms, bathrooms, living room, kitchen, garage and backyard. All fire exit routes were free and clear of obstruction. There were 2 staff present to 3 residents. 2 out of 3 residents are under hospice care. The 2 staff present are fingerprint cleared, but 1 out of the 2 staff are not associated to the facility. Administrator admitted that 1 staff member was not associated to the facility as the staff was added to the schedule last minute. The Administrator immediately submitted the LIC9182 form to the Department to associate the staff to the facility roster. A technical violation was provided per Section 87355(e)(3) reminding the facility to ensure all staff working are requested a transfer of a criminal record clearance prior to work. Facility temperature maintained at 78 degrees F. Fire extinguisher last serviced on 08/01/2025. Emergency lighting observed in the hallway. Smoke detector and carbon monoxide detector was tested and observed operable. Bathroom hot water temperature maintained at 117.8 degrees F. The bathroom shower observed with non-slip mats and grab bars. Facility has at least 2 days worth of perishables and 7 days worth of non-perishables foods. Refrigerator temperature maintained at 35.6 degrees F. Freezer temperature maintained at -4 degrees F. Page 1 of 4. Sharp objects, chemicals, disinfectants, and medications were not locked during the visit but the staff was present in the kitchen area. LPA advised the staff to ensure these items are locked when staff leave the area. Staff immediately locked the cabinets and drawers during visit. Resident bedrooms equipped with proper furniture, lighting, night stand, and dresser. 1 resident who is under hospice care observed using oxygen. Oxygen in use sign observed posted on the door. 1 resident (R1) bedroom observed with full bed rails. The resident is not under hospice care. Based on review of the facility's file, the facility did not submit any exception regarding the use of full bed rails. LPA reviewed the resident's records and did not observe a physician's order for the full bed rails. LPA observed a letter from the resident's responsible party supporting the use of full bed rails as the resident is fall risk. Administrator was advised of Title 22 regulation Section 87608. A type A deficiency was cited today per Section 87608(a)(5)(B) wherein 1 resident who is not under hospice care is utilizing full bed rails without prior approval from the Department. LPA observed the garage is being used as a sleeping quarters for 2 staff members (S1 - S2). Photographs of the garage were taken. Based on the facility sketch and fire clearance, the garage is not approved to be used as a living quarter for staff. Staff stated there was a total of 3 live-in staff members. The other staff member (S3) is using the living room couch as a sleeping area. A type A deficiency was cited today per Section 87307(a) wherein the live-in staff are residing in the garage and living room which is not related to the facility's functions per the facility sketch. LPA reviewed 3 resident files. 3 out of 3 resident files were not complete and up to date. 3 resident files contained an admission agreement, consent form, personal rights, and identification and emergency contact information. However, 1 resident (R1) did not have a medical assessment on file prior to admission. Resident (R2) has dementia and the last medical assessment was last completed on 09/08/2023. Resident (R3) who was placed under hospice care on 12/27/2024, medical assessment was last completed on 08/08/2022. A type B deficiency was cited today per Section 87463(h) wherein 1 resident did not have a medical assessment on file and 2 resident's medical assessments were not updated within the last 12 months. Page 2 of 4. 2 out of 3 residents did not have a reappraisal completed. 1 out of 3 residents had a reappraisal, however the reappraisal was not signed by the resident and/or resident's responsible party. A type B deficiency was cited today per Section 87463(a) wherein 2 residents reappraisals was not updated as necessary and 1 resident's reappraisal was not signed by the resident/resident responsible party. LPA reviewed 3 residents centrally stored medications and centrally stored medication records. LPA observed that 3 residents centrally stored medication records were not complete as there was 16 medications from R1 - R3 that were not written in the centrally stored medication record (CSMR). A type B deficiency was cited today per Section 87465(h)(6) wherein there was 16 medications from R1 - R3 that was not maintained in the resident's CMSR. LPA observed that that residents require PRN medications at the facility. Based on the facility's record review and confirmed by the Administrator, the facility does not have a PRN log in the resident's records to include the date/time PRN was taken, dosage, and resident's response to the PRN. A technical violation was provided per Section 87465(c)(3). LPA reviewed 4 staff members files. 4 out of 4 staff members has a fingerprint clearance. 4 out of 4 staff members does not have a 1st aid certification. A type B deficiency was cited today per HSC 1569.618(c)(3) wherein 4 staff members does not have a 1st aid certification. 3 out of 4 staff members does not have a TB result. A type A deficiency was cited today per Section 87411(f) wherein 3 staff members does not have a complete health screening to include a TB result on file prior to working in the facility. 4 out of 4 staff members does not have any initial or annual training provided per Title 22 regulations. A type B deficiency was cited today per Section 87411(c) wherein 4 staff members who assist residents with activities of daily living has not received initial and annual training. Page 3 of 4. The facility has not completed any emergency disaster drills. A type B deficiency was cited today per HSC 1569.695(c) wherein the facility has not conducted any emergency drills. The following documents were requested by 08/26/2025 to be sent to the licensing general email to include: LIC500, emergency disaster plan, LIC308, and Administrator certificates. Deficiencies were cited today per California Code of Regulations, Title 22. See LIC809D. Advisory note provided. This report was reviewed with Administrator, Armando Guba and a copy of the report and appeal rights were provided. Page 4 of 4.the state’s words, verbatim · CDSS document, Aug 19, 2025

The state marks this report as 13 pages; the online copy we transcribed has 11. You can request the full file from the county licensing office.

Allegation investigated: Resident did not have a complete annual assesment Facility neglected residents dental care needs

Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with the Administrator, Armando Guba and stated the purpose of today’s visit. On 8/24/2023, the Department received a complaint with the above allegations. On 9/1/2023, the Department conducted an initial investigation at the facility. Continuation on LIC 9099-C, Page 1 of 2. Unfounded Page 2 of 2. Resident did not have a complete annual assessment. It was alleged the facility did not complete an annual assessment for R1. Based on review of R1’s Physician's Report dated 12/20/2021, R1 does not have neurocognitive disorder wherein R1 would require an annual assessment. Based on interview of facility staff, R1 did not have a change of condition which would require facility staff to assess the resident. Based on facility records, R1's file did contain Appraisal/Needs and Services Plan dated 1/20/2022. Facility neglected residents dental care needs. It was alleged R1 was not taken to a dental appointment. On 9/1/2023, the Department interviewed 4 staff (S1-S4). Four of the four staff stated R1’s family is responsible to call the doctor and dental appointments. S3 and S4 stated R1’s responsible party is setting up dental appointment and transporting R1 to the dental appointments. On 9/1/2023, the Department interviewed 2 residents (R1-R2). Two out of two residents stated the facility staff provides dental care needs and their responsible parties arrange for dental appointments. R1 and R2 stated they do not have any concerns about the staff assisting them with dental care needs. The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator, Armando Guba and a copy of the report was provided. Page 2 of 2. Facility neglected residents grooming and hygiene needs. It was alleged the facility staff did not provide R1 grooming and hygiene needs. On 9/1/2023, the Department interviewed 4 staff (S1-S4). S2 stated three out of four residents are seen by the podiatrist that comes to the facility. R1’s responsible party is responsible to find a podiatrist and R1 has routine appointment to see podiatrist set up by R1’s responsible party. S3 stated the residents are bathed three times a week. On 9/1/2023, the Department interviewed 2 residents (R1-R2). Two out of two residents stated the facility provides grooming and hygiene needs and they do not have any concerns about the staff. Based on review of R1’s Functional Capability Assessment dated 5/2/2022 and Appraisal/Needs and Services Plan dated 1/20/2022, R1 needs help with bathing and toileting and staff will encourage R1 to call for assistance for toileting needs. Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator, Armando Guba and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 28, 2024 · control 26-AS-20230824110123

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) David Marrufo and Santino Fortes conducted an unannounced Required 1 Year visit and met with Armando Guba, Administrator. During visit, LPAs toured the facility inside and out. LPAs toured the facility kitchen area. LPAs observed a prescription inhalation mediation left unsecured on the kitchen island surface. Staff placed the unsecured medication in the locked medication storage cabinet during visit. LPAs observed an uncovered container containing a cut lemon and another food item inside the refrigerator. Staff removed the uncovered container from the refrigerator during visit. LPAs observed the locked cabinet where sharp objects are stored. LPAs observed the locked storage cabinet used to store medications and records. LPAs observed the first aid kit and found it to be complete. LPAs toured 2 out of 2 resident bathrooms and observed each bathroom had working lights and available soap and paper towels. The showers in each bathrooms had grab bars and anti-slip mats. The water temperatures in the bathroom sinks measures at 118 F and 115 F. LPAs toured 5 out of 5 resident bedrooms and found each bedroom to have working lights and available bedding and clothing storage areas. LPAs tested the smoke detectors and carbon monoxide detectors in the hallways and each resident rooms and found them to function properly when tested. LPAs toured the outside area and found the exits were clear of obstructions. LPAs reviewed the Centrally Stored Medication and Destruction Records (CSMDRs) for 4 out of 4 residents. Resident R1 had 2 medications missing from the CSMDR. Resident R2 had 2 medications missing from the CSMDR. R3 had 5 medications missing from the CSMDR and 2 medications did not have a prescription label. R4 had two medications missing from the CSMDR. LPAs reviewed 4 out of 4 staff records. R1-R4 were missing Safeguard for Property and Valuables Forms and R3-R4 were missing Pre-Appraisal Forms. LPAs reviewed 1 out of 1 staff records and found it to be complete. See LIC809-C for more information. Page 1 of 2. During visit, Administrator Armando Guba stated that volunteer V1 did not have a health statement or health screening form on record. Advisory Notes were issued. See LIC9102 pages for more information. Deficiencies were cited as per California Code of Regulations Title 22. See LIC809-D pages for more information. This report was reviewed with Administrator Armando Guba and a copy of this report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 14, 2024

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Aug 21, 2024

(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D) The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication. This requirement was not met as evidenced by: Licensee did not ensure that 4 out of 4 reviewed resident Centrally Stored Medication and Destruction Records did not have centrally stored medications that were not recorded. R1 had 2 unrecorded medications, R2 had 2 unrecorded medications, R3 had 5 unrecorded medications, and R4 had 2 unrecorded medications, which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2024

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Aug 21, 2024

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement was not met as evidenced by: Licensee did not ensure that resident R3 did not have two medications that did not have a prescription label, which poses a potential safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2024

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Aug 21, 2024

(b) Personnel records shall be maintained for all volunteers and shall contain the following: (1) A health statement as specified in Section 87411(f). (2) Health screening documents as specified in Section 87411(f). This requirement was not met as evidenced by: Licensee did not ensure that Volunteer V1 had a health statement and health screening on record, which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2024

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Aug 21, 2024

(b) Each resident’s record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables. This requirement was not met as evidenced by: Licensee did not ensure that residents R1-R4 had Safeguard for Property and Valuables Forms in their resident records, which poses a potential personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2024

From the deficiency page — Deficiency type: Type B · Plan of correction due date: Aug 21, 2024

(b) Each resident’s record shall contain at least the following information: (17) Documents and information required by the following: (A) Section 87457, Pre-Admission Appraisal; This requirement was not met as evidenced by: Licensee did not ensure that residents R4 and R5 had Pre-Admission Appraisal forms in their resident records, which poses an potential safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 14, 2024