Melos Care Home

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:24 a.m. Upon arrival, LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. The Administrator, Edwin Paul Oyasan arrived shortly after and the reason for the visit was explained. Entrance interview. The LPA and Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is a single-story home located in a residential neighborhood. COMMON AREAS: This includes the living room, and dining room. At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 12:30 p.m., hardwire combination of smoke, carbon monoxide detectors and fire doors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 06/26/2026. The emergency exiting plans/sketch are posted in every room. The emergency telephone numbers are posted in the common hallway. The LPA observed required postings throughout the common space. Activities were observed in the common areas. The fireplace in the living room was adequately screened. There is a functioning telephone on the premises. Auditory alarms at the entrances and exits were tested and observed to be functional at the time of the visit. INTERVIEWS: Starting at 9:30 a.m. and throughout the visit one (1) staff and two (2) resident interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interview revealed that no concerns were noted or voiced at the time of the visit. Residents expressed "They are like family here". Report Continued on LIC 809-C PAGE 2... (PAGE 2) Report Continued from LIC 809-C...KITCHEN: The LPA inspected the kitchen/food service area. Knives and sharps were observed in a locked cabinet under the sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 111.6 degrees Fahrenheit. Cleaning supplies and other chemicals are kept in the garage locked and inaccessible to residents in care. LPA observed a fire extinguisher mounted on the wall to be serviced on 6/26/26. BEDROOMS: There are four (4) total bedrooms in the facility; three (3) bedrooms are designated as private, single occupancy, resident rooms and one (1) is designated as a shared, double occupancy resident room. Two (2) out of four (4) resident rooms have exits to the exterior. All passageways were observed to be clear of obstructions. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair. Each bedrooms have its own supply of linens. There is no staff room and Administrator stated that staff remain awake at night. RESTROOMS: There are two (2) total restrooms. One (1) is designated as a shared / common resident restroom, One (1) is designated as a private resident restroom. Resident restrooms were observed to be equipped with a slip resistant surface / mat. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured in all resident restrooms and ranged between 110.3-111.6 degrees Fahrenheit, all within the required range. LPA observed storage space closets in the hallway containing extra clean linens and towels for resident use. GARAGE: LPA observed the garage to be inaccessible to residents in care. LPA observed the garage to contain the facility’s emergency food supplies, the facility’s washer and dryer, and locked storage for laundry chemicals. Additionally, the garage was observed to be utilized as the Administrator’s office. OUTDOOR SPACE: The facility has two (2) emergency exit gates located on either side of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed a secured storage shed that contained miscellaneous care supplies. Report Continued on LIC 809-C PAGE 2... (PAGE 3) Report Continued from LIC 809-C... RECORDS: Resident Records Four (4) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Pre- admission appraisal, LIC627(c) Consent for Treatment form, Home Health records, Hospice records, PRN authorization letters, and current needs and services plan. All records were in order. Personnel Records Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order. INFECTION CONTROL/ EMERGENCY DISASTER PLANNING: During today’s visit the LPA reviewed the facility’s infection control practices and the facilities emergency disaster plan. Both documents were observed to be complete and updated annually as required. The facilities policies and procedures, as they pertain to infection control and emergency planning meet the regulatory standard. The last emergency disaster drill took place on 05/18/2026 and are conducted quarterly. The facility is equipped with fire sprinklers throughout the space. The emergency disaster plan was updated on 04/02/2026 and the infection control was updated on 08/03/2026. MEDICATIONS: Medication review began at approximately 2:21 p.m. Medications are centrally stored and locked in a filing cabinet in the dining room adjacent to the kitchen. Medications for two (2) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were properly documented on the centrally stored medications and destruction record, stored, locked and inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed. No errors observed during review. LPA observed the first aid supplies to be complete, including sterile first aid dressings, bandages, tweezer, a thermometer and a current version of a first aid manual. DOCUMENTS: Documents obtained during the visit include: LIC 500 facility roster, LIC 9020A Resident roster, copy of the Limited Liability insurance, and Emergency Disaster plan, LIC610D. At the time if the visit the LPA reviewed the facilities contact information on file including phone numbers, email and annual fees. Administrator confirmed that all information is accurate. No citations issued. Exit interview conducted. Copy of report reviewed and provided.the state’s words, verbatim · CDSS document, Aug 11, 2026

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a continuation of the required annual visit at 10:59 AM. LPA met with facility staff who contacted the facility Administrator Edwin Paul Oyasan. The Administrator arrived to the facility at 11:10 AM. Entrance interview conducted and the reason for the visit was explained. During today’s visit LPA conducted a brief physical plant tour, conducted staff interviews, conducted a record/medication review, reviewed the facility’s emergency disaster plan/infection control plan, and obtained copies of the facility’s LIC 500, resident roster, and current liability insurance. The following was observed: PHYSICAL PLANT TOUR: During the physical plant tour LPA observed the under-sink storage of the hallway bathroom to be unlocked. LPA observed this storage to contain cleaning chemicals which were unsecured and accessible to clients in care. LPA informed the Administrator who locked the storage during the inspection. The facility’s fire alarms and fire door were tested at 02:21 PM and functioned properly at the time of the inspection. RECORD REVIEW: Record review began at 11:16 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Three (3) staff files were reviewed. All staff files contained all required documents and trainings. Four (4) resident files were reviewed. Resident #1 (R1), resident #2 (R2)’s files were observed to be missing signed copies of the personal rights of residents. LPA informed the Administrator of the missing documents. The Administrator agreed to obtain signed copies of the missing documents. Continued on LIC 809C. MEDICATION REVIEW: Medication review began at 12:45 PM. Medications for two (2) of four (4) residents were observed. All medications were documented appropriately on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review. INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 05/02/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s Administrator. INTERVIEWS: LPA interviewed one (1) staff member. The staff member interviewed was knowledgeable on their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 18, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Jul 18, 2025

87309 Storage Space and Access (a) ... the licensee shall ensure that disinfectants, cleaning solutions, ... are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as cleaning solutions were unsecured in an under-sink cabinet which poses an immediate health and safety risk to clients in care.the state’s words, verbatim · CDSS document, Jul 18, 2025

Plan of correction: Administrator secured the chemicals at the time of the visit. POC cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468(b)(1)(A) · Plan of correction due date: Aug 1, 2025

87468 Personal Rights (b)...a resident...shall be...given a copy... (1) The personal rights of residents... (A) ...the signed copy shall be included in the resident's record. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as two residents did not have signed copies of the personal rights of residents included in their files which poses a potential personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jul 18, 2025

Plan of correction: Administrator agreed to obtained signed copies of the personal rights of residents for the identified residents no later than POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 02:16 PM. LPA met with facility staff who contacted the facility Administrator Edwin Paul Oyasan. The Administrator arrived to the facility at 02:23 PM. Entrance interview conducted and the reason for the visit was explained. Beginning at 02:25 PM the LPA, along with facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured under-sink cabinet to contain knives and other sharp objects. Additionally, this locked cabinet was observed to contain cleaning supplies. LPA informed the Administrator that toxins may not be stored in the same storage as kitchen equipment or utensils. Administrator agreed to remove the chemicals and store the items in an alternate locked storage. LPA observed a fire extinguisher mounted on the wall to be serviced on 06/03/2025. The kitchen contained a locked cabinet that contained resident medications. Continued on LIC 809C. COMMON AREAS: This includes the living room, hallway, and dining area. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains a television and activities for resident use. The dining area was observed to be equipped with adequate seating for resident use. The hallway contained storage closets which contained extra linens for resident use and additional care supplies. All furniture throughout the facility was observed to be clean and in good repair. The facility’s combination fire and carbon monoxide alarms were tested at 02:52 PM and were functional at the time of the visit. During the fire alarm test LPA observed the facility’s hallway fire door to fail to close. LPA informed the Administrator that this is a zero tolerance violation of the facility’s fire clearance. LPA informed the Administrator that an immediate civil penalty in the amount of $500 is being assessed on today’s date (07/01/2025). The Administrator agreed to call a repairman to make appropriate repairs to the fire door. All exits in the facility were observed to contain functioning auditory alarms. BEDROOMS: There are four (4) bedrooms in the facility; one (1) is a dual occupancy resident room and three (3) are single occupancy resident rooms. LPA and the facility Administrator toured all four (4) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedrooms #3 & 4 contained a direct exit to the outdoors of the facility. BATHROOMS: There are two (2) bathrooms at the facility. One (1) is designated as a shared/common resident bathroom and one (1) is a private resident bathroom. All resident bathrooms were observed to be clean and were equipped with nonskid surfaces. Both bathrooms contained locked under sink storage cabinets that contained resident grooming supplies. Grab bars were observed in all resident showers and near all resident toilets all were properly secured. The water temperature was measured to be between 108.0 and 110.7 degrees Fahrenheit, which is within the range required by regulation. OUTDOOR SPACE: The facility has two (2) emergency exit gates located on either side of the facility; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed a secured storage shed that contained miscellaneous care supplies. Continued on LIC 809C. GARAGE: LPA observed the garage to be inaccessible to clients in care. LPA observed the garage to contain the facility’s emergency food supplies, the facility’s washer and dryer, and locked storage for laundry chemicals. Additionally, the garage was observed to be utilized as the Administrator’s office. INTERVIEWS: LPA interviewed two (2) residents. Both residents interviewed stated that the staff treat them well and are attentive to their needs. No residents interviewed had concerns with the facility. Due to time constraints an LPA will return at a later date to conduct staff interviews, conduct a record/medication review, review the facility’s emergency disaster plan/infection control plan, and to obtain copies of the facility’s LIC 500, resident roster, and current liability insurance. Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies and civil penalty were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 1, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(24) · Plan of correction due date: Jul 2, 2025

87555 General Food Service Requirements (b) The following...shall apply: (24)... toxic substances shall not be stored...where kitchen...utensils are stored. This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as knives and other sharp objects were stored alongside toxins and cleaning chemicals in a locked under-sink storage cabinet located in the kitchen which poses an immediate health risk to clients in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: Administrator agreed that licensee will relocate the chemicals to a seperate locked storage area no later than POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87202(a) · Plan of correction due date: Jul 2, 2025

87202 Fire Clearance (a) All facilities shall maintain a fire clearance... This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above as the facility's fire door failed to close during a test of the facility's smoke alarms which poses an immediate safety risk to clients in care.the state’s words, verbatim · CDSS document, Jul 1, 2025

Plan of correction: The administrator agreed that licensee will ensure the fire door remains closed until appropriate repairs can be completed. Administrator agreed to submit proof of the fire door functioning properly to CCLD.

Allegation investigated: Staff did not provide emergency personnel with resident's proper documentation. Staff accepted a resident into the facility requiring a higher level of care.

Licensing Program Analyst (LPA) Sandra Urena arrived unannounced for a subsequent complaint visit to deliver the findings for the allegations listed above. The LPA met with Administrator Paul Oyasan and explained the reason for the visit. On 07/26/2023, Licensing Program Analyst (LPA) Elsie Campos arrived unannounced for an initial complaint visit to investigate the above allegations at 3:20 p.m. The LPA met with Administrator Paul Oyasan and explained the reason for the visit. During today’s visit, the LPA conducted a physical plant tour at 3:25 p.m., interviewed resident at 3:38 p.m., interviewed administrator at 4:03 p.m., and collected pertinent documents at 4:10 p.m. Continues on LIC 9099C... Substantiated Pg. 2 Staff did not provide emergency personnel with resident's proper documentation. On the allegation that staff did not provide emergency personnel with resident’s proper documentation, it is the concern of the reporting party (RP) that the staff at the facility had no information regarding the resident (R1) when EMT personnel arrived to provide care for the resident and were unable to get any information regarding the resident’ medical history or contact information for R1. On 07/26/2023 LPA Campos interviewed the administrator, and the administrator stated that when EMT arrived to provide care to R1 and asked for R1’s personal information, the administrator gave the EMT personnel a copy of the Physician’s Report. Furthermore, the Administrator stated that on a previous EMT visit, the Administrator gave by mistake the original R1’s personal information, so the administrator did not have a copy. The Administrator stated that they gave the EMT, R1’s Conservator’ card and telephone number. On 10/11/2024, LPA Urena interviewed the Administrator, and the administrator stated that they did not recall why R1 was taken to the hospital, and that the protocol when EMT’s arrive to provide care, staff are to give them the residents’ personal contact information (LIC 601), the resident’s physician’s report, and centrally stored medication list, however these documents were not provided to the EMT personnel on 07/16/2023. The physician’s report obtained by LPA Urena was incomplete as it stated to see ‘attachment’ for the diagnosis, however, the attachment was not included/attached to the physician’s report. Staff interviewed stated that they could not exactly remember if the requested documents were available at the time R1 was taken to the hospital. LPA Urena was unable to interview the reporting party, and R1’s Conservator. Based on the information obtained through interviews, the staff did not provide the EMT personnel with the R1’s medical history, and medication information. Therefore, the allegation that staff did not provide emergency personnel with resident’s medical and history documentation, is deemed Substantiated at this time. Continues on LIC 9099C... Pg. 3 Staff accepted a resident into the facility requiring a higher level of care. On the allegation that staff accepted a resident into the facility requiring a higher level of care, it is the concern of the reporting party (RP) that (R1) was extremely ill and was taken to the Intensive Care Unit (ICU) on the day EMT transported R1 to the hospital. On 07/26/2023, LPA Campos interviewed the Administrator, and the administrator stated that facility staff did everything for R1: Feeding, medications, eyedrops, vitamins, bathing, incontinent care. Staff stated that they would crush the medication and would put in in R1’s food. The LPA did not receive or found doctor’s orders for medication to be crushed and put in R1's food. R1 was not receiving hospice services while residing at the facility. The Administrator stated that the first time R1 was taken to the hospital, it was due to pneumonia. Administrator did not know why R1 was taken to the hospital the second time. On 10/11/2024, LPA Urena interviewed the Administrator and the administrator stated that R1 was receiving Home Health Services, PT (physical therapy) for mobility and transferring from chair to bed and vice versa. . Per Home Health communication with Administrator, R1 was seen by nurse with weekly visits from 12/28/22- 7/16/23 totake vitals, and was seen twice a week for physical therapy from 1/18/23- 2/22/23. On 10/11/2024, LPA Urena reviewed R1’s physician’s report dated 12/26/2022, and discharge papers from Health Care Center. Diagnosis Intestinal fibrosis, dysphasia, emphysema. R1 was to be admitted to facility with 24-hour caregiver services. Per staff interviews R1 was not receiving 24-hr, or one-to-one care. Furthermore, staff stated that home health was coming to check vitals and check sugar levels of R1. Staff does not recall if R1 was receiving PT for transferring from chair to bed and bed to chair. Based on the information obtained through record review, R1 required 24-hour care, and one person assist at all times. Therefore, the allegation that staff accepted a resident into the facility requiring a higher level of care, is deemed Substantiated at this time. Pursuant to Title 22, California Code of Regulations (CCR), the following deficiencies are cited (refer to LIC 9099-D). Citations were issued. Exit interview was conducted. A copy of the report and Appeal Rights were issued.the state’s words, verbatim · CDSS document, Oct 28, 2024 · control 29-AS-20230717142820

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87458(a) · Plan of correction due date: Nov 1, 2024

87458(a) Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a full medical assessment, signed by a physician. This requirement is not met as evidenced by: Based on records review the licensee did not comply with the section cited above as one (1) out of the five (5) resident records reviewed did not have a complete Physicians' Report (LIC 602), which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 28, 2024

Plan of correction: The Administrator has agreed to do the following: To keep full packet of Emergency Documents in case of emergencies and to hand to EMT at request, review regulation cited and send a statement of understanding to LPA via email by 11/01/2024 at COB. Administrator provided proof of correction at time of the visit.

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.72(1) · Plan of correction due date: Nov 1, 2024

1569.72 Residents requiring skilled nursing or intermediate care; bedridden residents (1) The resident requires 24-hour, skilled nursing or intermediate care. This requirement is not met as evidenced by: Based on records review the licensee did not comply with the section cited above as R1 required 24 hour care, and administration of medication.the state’s words, verbatim · CDSS document, Oct 28, 2024

Plan of correction: The Administrator has agreed to do the following: Review regulation cited and send a statement of understanding to LPA via email by 11/01/2024 at COB.

Allegation investigated: Staff is utilizing resident's room as storage. Staff does not ensure resident is provided a bed. Staff creates a barrier in common room for resident in care. Staff does not ensure facility is kept clean.

Licensing Program Analyst (LPA) Sandra Urena arrived unannounced for a subsequent complaint visit to deliver the findings for the allegations listed above. The LPA initially met with facility staff; Administrator Edwin Paul Oyasan arrived shortly thereafter. The LPA met with the Administrator and explained the reason for the visit. On 07/26/2023, Licensing Program Analyst (LPA) Elsie Campos arrived unannounced for an initial complaint visit to investigate the above allegations at 3:20 p.m. The LPA met with Administrator Paul Oyasan and explained the reason for the visit. During today’s visit, the LPA conducted a physical plant tour at 3:25 p.m., interviewed resident at 3:38 p.m., interviewed administrator at 4:03 p.m., and collected pertinent documents at 4:10 p.m. Continues on LIC 9099C... Unsubstantiated Pg 2. Staff is utilizing resident's room as storage. On the allegation that staff is using the residents’ room as storage; it is the concern of the reporting party (RP) that they observed the resident’s (R1) bedroom crowded with various items and used as a storage area. On 07/26/2023, LPA Campos interviewed the Administrator, and residents. LPA Campos conducted a tour of the physical plant areas inside and outside to ensure there are no health and safety hazards. The LPA observed the residents’ rooms to be free of clutter. The residents’ interviews revealed that they were happy with their rooms, and that their rooms were not used for storage. On 10/15/2024, LPA Urena interviewed residents, and residents’ representatives, and the interviews revealed that they were very happy with the way facility staff kept their rooms clean. On 10/11/2024, LPA Urena conducted a tour of the physical plant at approximately 11:01 a.m. and found the facility to be free of clutter and in compliance with Title 22 Regulations. LPA Urena was unable to interview the reporting party. Although the allegation may have happened or is valid, based on the interviews, and observation, there is insufficient evidence to prove the alleged violation did occur. Therefore, the allegation that staff is utilizing resident's room as storage, is deemed Unsubstantiated at this time. Staff does not ensure resident is provided a bed. On the allegation that staff does not ensure resident is provided a bed, it is the concern of the reporting party (RP) that they witnessed a resident sleeping in the living room on two recliners pushed together. 07/26/2023, LPA Campos conducted a physical plant tour, and observed beds in each bedroom for residents living at the facility. On 10/15/2024, LPA Urena conducted a physical plant tour, and observed that residents have a room and a bed designated for their use. Bedrooms one (1), two (2) and three (3) are private rooms; and bedroom four (4) is a shared room. Each bedroom was observed to have a bed(s) and required furniture. On 10/15/2024, LPA Urena interviewed staff, and they stated that sometimes residents do fall asleep on the recliners by the window in the living room area, but that all residents have a bed in their bedroom, and staff will encourage the residents to sleep on their beds. Residents’ representatives’ interviews revealed that they know that sometimes the residents may fall asleep on their recliners, however, they do have a bed in their room. LPA Urena was unable to interview the reporting party. Based on the information gathered through observation and interviews, the allegation that Staff do not ensure resident is provided a bed, is deemed Unsubstantiated at this time. Continues on LIC 9099C... Pg3. Staff creates a barrier in common room for resident in care. On the allegation that staff creates a barrier in common room for residents in care; the reporting party (RP) reported that they observed a barrier between the living room area and the common area, creating a barrier for the resident(s) while they are in the living room area and preventing them from going to other areas of the facility. On 07/26/2023, LPA Campos conducted a physical plant tour of the common areas and did not observed barriers of any type. Residents’ interviews revealed that they had not experienced any obstructions within the facility preventing them from moving from the common area to their rooms. LPA Urena interviewed residents’ representatives, and the representatives stated that they had not witnessed barriers preventing residents from moving freely throughout the facility. The Administrator denied staff creating barriers to prevent residents from leaving the common room. The staff denied creating barriers to keep residents secluded in the living room area. LPA Urena was unable to interview the reporting party. Although the allegation may have happened or is valid, based on the interviews, and observation, there is insufficient evidence to prove the alleged violation did occur. Therefore, the allegation that staff creates a barrier in common room for residents in care, is deemed Unsubstantiated at this time. Staff does not ensure facility is kept clean. On the allegation that staff does not ensure facility is kept clean; it is the concern of the reporting party (RP) that the facility was observed to be dirty. On 07/26/2023, LPA Campos interviewed the Administrator, and residents. LPA Campos conducted a tour of the physical plant areas inside and outside to ensure there are no health and safety hazards. The LPA observed the facility to be clean and in order. The residents’ interviews revealed that they were happy with the cleanliness of facility and their room. On 10/15/2024, LPA Urena interviewed residents, and residents’ representatives, and the interviews revealed that they were very happy with the way the facility staff keep their rooms clean. On 10/11/2024, LPA Urena conducted a tour of the physical plant at approximately 11:01 a.m. and found the facility to be clean and in compliance with Title 22 Regulations. LPA Urena was unable to interview the reporting party. Although the allegation may have happened or is valid, based on the interviews, and observation, there is insufficient evidence to prove the alleged violation did occur. Therefore, the allegation that staff does not ensure facility is kept clean, is deemed Unsubstantiated at this time. No citations were issued. Exit interview was conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, Oct 28, 2024 · control 29-AS-20230726084730

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 10:54AM. LPA initially met with facility staff; Administrator Edwin Paul Oyasan arrived shortly after the visit began. Entrance interview conducted. Beginning at 11:03AM, the LPA, along with Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Hardwired combination smoke and carbon monoxide detectors were tested at 01:09PM and were functional at the time of the visit. Fire extinguisher was observed to be fully charged and last serviced on 04/25/2024. BEDROOMS: There are 4 (four) total bedrooms; 3 (three) are for private resident use and 1 (one) is designated for shared use. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. 2 (two) full bedrails were observed on Resident #1 (R1)'s bed and 1 (one) full bedrail was observed on Resident #2 (R2)'s bed. Neither R1 nor R2 are on hospice. RESTROOMS: The LPA observed 2 (two) restrooms in the facility; 1 (one) is for shared use and 1 (one) is designated for private resident use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in both resident restrooms and measured within the required range. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed in the living room to be adequately screened and inaccessible to residents in care. Auditory exit alarms were functional at the time of the visit. Report Continued on LIC 809-C OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. All exits and passageways were observed to be free of hazards. No bodies of water were observed on the premises. KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. A locked garage was observed adjacent to the kitchen and contained extra food, emergency food & water supply, storage, and laundry area. RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 5 (five) resident records were reviewed. 2 (two) residents with a diagnosis of dementia did not have current annual medical assessments. The medical assessment for Resident #3 (R3) was dated 04/28/2023 and the medical assessment for Resident #4 (R4) was dated 08/15/2023. 5 (five) staff files reviewed were complete and contained all required documents. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually, as required. Emergency drills are conducted quarterly. MEDICATION REVIEW: Medications for 2 (two) residents were observed. Both 2 (two) of 2 (two) residents' medications were observed to be maintained and administered in compliance with regulation. LPA provided Administrator with the Department's RCFE Medication Guide via email. INTERVIEWS: Throughout the visit, LPA interviewed 2 (two) residents and 2 (two) staff. No concerns were identified. During today's visit, LPA obtained a copy of the facility's liability insurance. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or CA Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted with Administrator. A copy of the report and appeal rights were provided.the state’s words, verbatim · CDSS document, Aug 21, 2024