Maureen Guest Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced Annual Required inspection of the facility. LPA Tea was greeted and granted entry by Licensee (LE) Victor McKenzie. LPA explained the purpose of the visit. The facility is licensed to serve six (6) non-ambulatory residents and has a hospice waiver for three (3) residents. At the time of the inspection, six (6) residents were in care, of which one (1) was receiving hospice services. LPA reviewed six (6) resident files and two (2) staff files. During the records review, LPA identified discrepancies and missing or incomplete documentation. LPA observed that some residents had outdated Physician's Reports, and one resident did not have a Physician's Report available in the resident's file. LPA was unable to locate current First Aid/CPR training documentation in the staff files reviewed. LPA had previously verified First Aid/CPR training as part of a prior Plan of Correction; however, the documentation was not available in the staff files at the time of today's inspection. LPA also determined that required annual staff training documentation was incomplete. LE McKenzie stated that annual staff training is currently in progress and has not yet been completed. The facility's most recent documented emergency disaster drill was conducted on February 22, 2026. Administrator (AD) Gabrielle Tedjasukmana has completed the required course work and is currently pending administrator certification. LPA, accompanied by LE McKenzie, toured the interior and exterior of the facility. The inspection included resident bedrooms and bathrooms, common areas, kitchen and food service areas, medication storage, first aid supplies, and the exterior grounds. During the inspection, LPA tested smoke detectors and carbon monoxide detectors located in resident bedrooms and common areas and observed that multiple devices were not operational at the time of testing. (Annual report continued on LIC809C) Resident bedrooms contained the required furniture, bed linens, and adequate closet and drawer space to accommodate residents comfortably. However, LPA observed damage to the walls in a resident bedroom. LE McKenzie was advised that the damaged walls require repair and that the facility is required to maintain the physical plant in a safe and good state of repair. Resident bathrooms were inspected. LPA observed that a bathroom was not maintained in good repair, as the main bathroom lighting was not functioning properly. LPA also observed cobwebs and a spider in the bathroom. LE was reminded that the facility is required to maintain the premises in a clean, safe, sanitary, and good state of repair and to address conditions that may contribute to the presence of insects or pests. The toilets and water faucets were operational, grab bars were secure, and the shower area was free of visible mold and mildew. The hot water temperature measured approximately 108 degrees Fahrenheit. Resident bath towels, toiletries, and personal hygiene supplies were adequately stocked at the time of the inspection. The first aid kit was inspected and contained necessary supplies, including dressings, bandages, tweezers, a thermometer, and scissors. LPA inspected the kitchen and food supply. The facility maintained an adequate supply of perishable and nonperishable foods at the time of the inspection. However, during an inspection of the pantry, LPA observed expired canned food stored with the facility's food supply. LPA observed that sharps were secured in a locked kitchen drawer. Toxic substances were also locked and inaccessible to residents in care, including substances stored beneath the kitchen sink and in cabinets near the laundry area. The kitchen fire extinguisher was observed to be fully charged. LPA observed that one stove-top burner was not operational at the time of the inspection. LPA toured the outside grounds. The facility had adequate outdoor seating and shaded areas available for residents. Exit gates located on both sides of the facility were observed to be self-latching and operational. The facility provides activities based on residents' interests, abilities, and health conditions, including light exercise activities. During the inspection, residents were observed eating lunch and watching television. LPA reviewed the facility's medication storage and medication administration practices. LPA observed that residents' medications were not maintained in a secured centrally stored location. Some resident medications were also observed to be improperly stored and accessible at the time of the inspection. LPA further (Annual report continued on LIC809C) observed inconsistencies in the facility's medication documentation and record keeping. Complete and consistent centrally stored medication records were not maintained for medications requiring centralized storage. Based on the records available for review, medications documented as administered were being provided in accordance with physician orders. LPA interviewed residents regarding the quality of care and services provided by the facility. LPA also interviewed staff present during the inspection regarding resident care and facility operations. At the time of annual visit, residents were seen having lunch and watching television. Based on observations, interviews, and records reviewed during today's inspection, deficiencies are being cited in accordance with Title 22, Division 6, Chapter 8 of the California Code of Regulations. Civil penalties are being assessed for repeat deficiencies for which the facility was previously cited and failed to maintain compliance. An exit interview was conducted with Licensee Victor McKenzie. The deficiencies, Plans of Correction, applicable civil penalties, and appeal rights were reviewed with LE McKenzie. A copy of this report, LIC809-D, LIC9102TV, LIC858, LIC859 civil penalty assessment documentation, and Appeal Rights was provided to the facility at the conclusion of the visit.the state’s words, verbatim · CDSS document, Sep 3, 2026

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: Oct 2, 2026

Other Provisions .. (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Based on LPA's observation, staff annual training was incomplete and pending as licensee is still conducting training. This poses as a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Facility will complete annual training for staff. Licensee will provide proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: HSC1569.311 · Plan of correction due date: Oct 2, 2026

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8. The department shall account for the presence of these detectors during inspections. This requirement is not met as evidenced by: Based on LPA's observation, some resident room's smoke detectors were no longer operational. This poses as a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Facility will replace the smoke alarms in resident rooms and provide proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Oct 2, 2026

Maintenance and Operation .. (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: During the physical plant tour, LPA observed several areas of the facility that were not maintained in good repair. LPA observed damage to the walls in resident bedrooms. In the bathroom, LPA observed cobwebs and the presence of insects, and the main bathroom light was not operational. Additionally, one of the stovetop burners in the did not ignite independently and required the use of an external flame igniter. These conditions pose a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Facility will repair the wall damages, facility repair bathroom light fixtures, facility will repair stove top burner and provide to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87465(h)(6) · Plan of correction due date: Oct 2, 2026

Incidental Medical and Dental Care ... 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 is not met as evidenced by: Based on LPA's review of medication records, the facility did not properly maintain accurate and current Centrally Stored Medication and Destruction Records. LPA observed that medication records for some residents were not consistently updated to reflect current medication information. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Facility will created a centrally stored medication list for each resident that lists routine and PRN medication for every month. Creating a new medication list for each month, and keep the old ones for record keeping by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(b) · Plan of correction due date: Oct 2, 2026

Medical Assessment (b) The licensee shall obtain an updated medical assessment when required by the Department. This requirement is not met as evidenced by: During LPA's review of resident records, LPA observed that residents' Physician's Reports were not current. Additionally, one resident did not have a current Physician's Report available in their file at the time of the inspection. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Facility will obtain updated physician's reports for residents and submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(b)(8) · Plan of correction due date: Oct 2, 2026

General Food Service Requirements (b)(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by During the inspection of the facility's food supply, LPA observed expired canned food stored in the pantry. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: Facility will discard and replace expired canned goods. And submit proof to LPA by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(3) · Plan of correction due date: Sep 4, 2026

Postural Supports (a)(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: During the physical plant tour, LPA observed residents with full-length bed rails. One resident receiving hospice services had documentation authorizing the use of full-length bed rails. However, LPA observed other residents utilizing full-length bed rails without physician's orders supporting their use. The unauthorized use of full-length bed rails poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: LPA advised the Licensee that appropriate documentation authorizing the use of bed rails must be maintained in each applicable resident's file and that full-length bed rails are permitted only under applicable hospice requirements. During the visit, the Licensee removed the bed rails from residents who did not have the required authorization or documentation on file.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(h)(2) · Plan of correction due date: Sep 4, 2026

Incidental Medical and Dental Care Services ... (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Based on LPA's observation the medication was stored in boxes in the living room and not in a locked secured centrally stored location. This poses as an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2026

Plan of correction: The Licensee immediately secured the medications in a locked cabinet. LPA reminded the Licensee that all centrally stored medications must be properly secured and inaccessible to residents in care, as required

Type of visit: POC

Licensing Program Analyst (LPA) Michael Tea made an unannounced visit for the purpose of conducting a Plan of Corrections Inspection for deficiencies issued on 09/09/2025 during the required annual inspection conducted by LPA Tea. LPA was greeted and granted entry by Licensee Victor Mckenzie. LPA discussed the purpose of the inspection with the administrator. LPA Tea toured the facility to check the deficiencies that have been corrected with the administrator. There are fire alarms in each room and common areas. LPA checked the screen door leading to the backyard patio, facility fixed the screen door and now it opens and closes properly. LE Mckenzie showed proof that qualifying Administrator Garbrielle Tejasukmana is enrolled in an RCFE administrator course and is working on obtaining her administrator certificate. LE Mckenzie provided proof of completed CPR/First Aid certificate for caregivers. LPA confirmed that facility created updated centrally stored medication lists for each resident. LPA went to the kitchen to confirm emergency food and water supply for a 72-hour time period in the kitchen and pantry. LPA Tea will periodically check up on the facility to ensure compliancy. Based on LPA Tea's observation on today's visit, the Plan of Corrections has been fulfilled by the assigned POC due date, thus clearing the Type B deficiencies CCR 87303(c), 87411(c)(1), 87465(h)(6) and HSC 1569.311, 1569.618(a), 1569.695(a)(2). An exit interview was conducted with Licensee Victor Mckenzie and a copy of this report was provided to the facilitythe state’s words, verbatim · CDSS document, Oct 14, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by Licensee (LE), Victor McKenzie and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, with a hospice waiver for three. Currently there are five residents, of which three are on hospice during today's visit. LPA Tea reviewed five resident files and two staff files. Resident files had the required documentation. There were discrepancies in staff files. LPA observed outdated First Aid/CPR training. There is current staff training for one staff last conducted in November 2024. Licensee misplaced the current training for the other staff. There is currently no qualified administrator. The designated administrator nor licensee does not have a valid administrator certificate. LPA Tea along with the licensee toured the facility. LPA toured the physical plant, checked food service, and the first aid kit. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms were missing and some did not operational. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. At first the bathrooms did not have good up keeping but caregivers cleaned up the restrooms afterwards. LPA reminded licensee to maintain the cleanliness of the bathroom and facility. There should be no cobwebs, spiders and other insects at all. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured around 119.3 Fahrenheit degrees. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. First aid kit had all the required elements including dressing, bandages, tweezers, thermometer, and scissors. Kitchen was (Annual report continued on LIC809C) inspected. Perishable and non-perishable food supply was checked and adequately stocked at the time of visit. LPA observed sharps locked in a kitchen drawer. LPA also observed toxin substances to be locked and inaccessible to residents in care under the kitchen sink and in cabinets by the laundry area. The fire extinguisher in the kitchen is fully charged. The kitchen appliances are operational. LPA toured the outside grounds and there is ample seating with shade and two exit gates on both sides of the facility are self-latching and operational. LPA observed not enough emergency supplies for 72-hour reliance. The emergency food was expired. There was not enough water for residents during an emergency disaster. Facility provides activities based on resident interests and health conditions. They play small ball games and do body exercises, especially chair exercises. At the time of annual visit, residents were seen having lunch, watching television in the living room and family visitors came to visit. LPA reviewed medication storage and administration. Medications are not stored in a secured centrally stored location. Medications are being administered per physician order. Medications are not tracked properly or have proper consistent record keeping like with a centrally stored medication list. LPA interviewed residents regarding their quality of care and spoke to staff present regarding the care provided. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Licensee Victor McKenzie and a copy of these reports were given to the facility along with a copy of the LIC 858; 859;809-D, 9102TV and Appeal Rights.the state’s words, verbatim · CDSS document, Sep 9, 2025

The state marks this report as 10 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by House Manager (HM), Victor McKenzie and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, with a hospice waiver for three. Currently there are four residents, of which one is on hospice during today's visit. LPA Tea along with the house manager toured the facility at 2:31 PM. LPA toured the physical plant, checked food service, and the first aid kit. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms and are operational. 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 77.0 F degrees and over 130 F degrees. HM McKenzie was adjusting the boiler, lowering the temperature. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. LPA also observed toxin substances to be locked and inaccessible to clients in care locked and secured in cabinets by the laundry area. The fire extinguisher in the kitchen is fully charged. The kitchen stove had one working burner at the time of visit. LPA toured the outside grounds and there is ample seating with shade and two exit gates on both sides of the facility is self-latching and operational. LPA observed emergency supplies, food and water supply in a cabinet in the family room. Facility provides activities based on resident interests. At the time of annual visit, residents were seen having snacks and watching television in the family room. LPA Tea reviewed four resident files and two staff files. There were discrepancies noted in the review of resident and staff files. Administrator (AD) Eduardus Junanto certificate expires on June 05, 2025. Annual report continued on LIC809C LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order. LPAs interviewed residents regarding their quality of care and spoke to staff present regarding care provided. The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with House Manager, Victor McKenzie and a copy of these reports were given to the facility along with a copy of the LIC 858; 859;809-D, and Appeal Rights.the state’s words, verbatim · CDSS document, Sep 17, 2024