Mary's Loving Care A

Type of visit: Required - 1 Year

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for six non-ambulatory residents. Facility has an approved hospice waiver for three residents and the home currently has three residents, with two residents on hospice. House Manager (HM) Mary You assisted with visit. LPA along with HM toured the facility at 9:20 AM. LPA toured the physical plant, checked food service, and facility documentation. The home consists of four resident bedrooms, living room, dining room, kitchen, four bathrooms and an attached garage. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 105.3 degrees F and 115.3 degrees F in all bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 12/18/2025. Outside grounds were toured. Walkways around the home were clear of hazards. There is shaded outdoor seating for residents. LPA observed the emergency food and water supply. First aid kit contained all required items including tweezers, scissors and thermometer. LPA reviewed three resident files and three staff files. Two out of three resident files contained all required documentation including admission agreements, physician reports, and resident appraisals. Staff files reviewed contained required documentation including, medical assessment/ TB, criminal record clearance and proof of CPR training. Two out of three staff files did not include evidence of 20 hours of required annual training. LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order. Based on the observations made during today’s visit, a deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.the state’s words, verbatim · CDSS document, Mar 24, 2026

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 3 residents and the home currently has 3 residents. Facility Manager (FM) Mary You arrived later to assist with the visit. Administrator Xu Han has a valid certificate that expires on 10/15/2026. Liability insurance expires on 7/24/2025. LPA along with staff member Gilda toured the facility at 9:15 AM. LPA toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 4 resident bedrooms, living room, dining room, staff room, and kitchen as well as 4 bathrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly and shower was free of mold/mildew. Water temperature measured between 115.3 degrees F and 117.5 degrees F in all bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguisher was fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 11/18/2024. LPA reviewed three resident files and two staff files. All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders. Staff files reviewed contained medical assessment/ TB, criminal record clearance and proof of CPR training. LPA reviewed medication storage and administration. Medications are stored in a locked cabinet by the kitchen with the sharps. Continued on LIC809C dated 3/6/2025 Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.the state’s words, verbatim · CDSS document, Mar 11, 2025

The state marks this report as 7 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management visit to gather additional information for an exception request that was made. During the visit, LPA Haley conducted interviews 4 staff members and 2 residents. Relevant documents were provided. The information gathered during today’s visit will be reviewed by the department. An exit interview was conducted, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 19, 2024

Allegation investigated: Staff is operating beyond the scope of the license.

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of intiiating the 10-day complaint investigation into the above allegation. LPA was greeted and granted entry by Caregiver Carolina Flores Perez and stated the purpose of the visit. House Manager Mary (Xiaofen) You arrived at the facility approximately 10:30am, and LPA advised Administrator Emma (Xu) Han by telephone of the visit. On today's date, LPA observed five (5) residents in care and two (2) staff on duty. Resident #1 (R1) was observed to be sitting and singing on the recliner chair in the living room playing with their toys. During the course of the investigation, LPA interviewed two staff and obtained copies of the following pertinent documentation: Resident Roster, Face Sheets, Physician's Reports for all residents in addition to the Preplacement Appraisal Information, Care Plan, and Admission Agreement for R1. The investigation revealed the following: It is alleged that the staff is operating beyond the scope of the license. [Continued on LIC9099-C] Substantiated Per review of the Identification and Emergency Information (LIC601), R1 is under sixty (60) years old and does not meet the age requirement. Two out of the two staff interviews indicated that R1 was previously attending a group home vendored by the Regional Center of Orange County and was removed from their previous group home. It is determined that licensee is not operating within the limitations specified on the license. Therefore, based on the observation, interviews which were conducted, and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Staff is operating beyond the scope of the license is deemed SUBSTANTIATED as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. A deficiency is being cited on the attached LIC9099-D. At 11:54am, an exit interview was conducted by telephone with Administrator Emma Han and in person with House Manager Mary You, and a copy of this report was provided along with the LIC9099-C, LIC9099-D, and the appeal rights were provided at the end of the visit.the state’s words, verbatim · CDSS document, Jun 4, 2024 · control 22-AS-20240528111223

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87204(a) · Plan of correction due date: Jun 5, 2024

87204 Limitations - Capacity and Ambulatory Status (a) "A licensee shall not operate a facility beyond the conditions and limitations specified on the license..." This requirement was not met as evidenced by: Based on observation, interviews, and record review, R1 does not meet the age requirement specified on the license which poses an immediate risk to the Heath, Safety, or Peronal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 4, 2024

Plan of correction: Administrator stated that they will move out and/or relocate R1 immediately and to submit an age exception request to the Department (should the licensee desires to continue to provide care) along with the Acknowledgement of Understanding of the said deficiency to LPA via email by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year annual inspection. LPA Haley was greeted and granted entry by staff and explained the reason for the visit. Administrator (AD) Xu Han’s Administrator certificate was posted on the wall and expires October 15, 2024. Mary’s Loving Care A is a one-story community with four bedrooms and four bathrooms. The facility capacity is 6 and the census was 5 during today’s visit. Residents were observed in the living room watching TV or in their bedroom. During the inspection, LPA Haley observed all resident bedrooms and bathrooms. All resident bedrooms had the necessary elements and were in compliance with regulation guidelines. Resident bathrooms were clean and organized. Hot water temperatures were measured in the range of 113.1 degrees Fahrenheit and 118.2 degrees Fahrenheit. No hazardous items were observed in the resident bathrooms, and all grab bars were tightly secured to the wall. In Bathroom #1 LPA Haley observed a cabinet with a supply of clean linen. In the kitchen knives and sharp objects are kept locked in a cabinet next to the refrigerator. Resident medications are kept locked in the same cabinet. All four burners on the stove were operational. Hazardous cleaning items were kept locked under the sink. A first aid kit with all the required elements is locked in a cabinet next to the refrigerator. In the garage, an additional supply of hazardous cleaning items was observed on the shelves. An extra refrigerator was observed in the garage with a supply of perishable food supply that meets regulation requirements. A supply of nonperishable food items was observed on the shelves. An emergency supply of COVID items (surgical mask, gloves, sanitizer) was observed as well. Continued on LIC809C Walkways were clear and free of obstruction. Additional cleaning supplies, an extra bedframe, mattress, and adult diapers were observed in the garage as well. The backyard was clean, organized, and walkways were free of obstruction. A shaded patio area with tables and chairs was observed. The side exit gate is self closing and self latching. Smoke detectors/Carbon monoxide detectors tested operational and were observed in all resident rooms, and the hallway. A fully charged fire extinguisher was observed on the floor in the living room area in between two resident rooms. Emergency evacuation drill will be conducted this month and will continue to be conducted quarterly for staff on each shift. Deficiencies are being cited as a result of todays visit. An exit interview conducted, and a copy of this report was provided to Licensee/Administrator Xu Han.the state’s words, verbatim · CDSS document, Mar 12, 2024