Mendoza Care Home III

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Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Ethel Contreras arrived unannounced for the purpose of a Non-Compliance (NCC) Quarterly visit and was greeted by Administrator Josephine Mendoza. This facility was placed on a non-compliance (NCC) on 6/24/2025 for a two-year term by Community Care Licensing (CCL); Concerns addressed in NCC meeting on 06/24/2025 were: - Facility failed to ensure R1’s personal rights - Reporting Requirements - Administrator Qualifications and Duties - Change of condition for residents regarding LIC602 and updating Needs and Service Plans LPA conducted a health and safety walk through of the facility indoors and around the premises, finding it at a comfortable temperature, clean, odor free, exits free from obstructions and organized. Residents were clean and dressed appropriately. Resident have access to outdoor. There was an ample supply of hygiene products for residents' care. There was also an ample supply of healthy perishable and non-perishable food as required by Title 22. LPA advised admin that refrigerator needed to be wiped and cleaned from any food debris. All toxins and chemicals were locked and secure. Medication cabinet was locked. Food thickener found unsecured in kitchen cabinet. LPA advised admin that it must be locked with medications per regulation. Disaster drills conducted quarterly. LPA conducted a resident file review and all Needs and Appraisal Plans including Medical Assessments were all up to date. No deficiencies cited during today's NCC Visit. Copy of report given and read with administrator.the state’s words, verbatim · CDSS document, Sep 9, 2026

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Ethel Contreras arrived unannounced for the purpose of a Non-Compliance (NCC) Quarterly visit and was greeted by Caregiver, Maria Rivera. Administrator Josephine Mendoza arrived shortly after. This facility was placed on a non-compliance (NCC) on 6/24/2025 for a two-year term by Community Care Licensing (CCL); Concerns addressed in NCC meeting on 06/24/2025 were: - Facility failed to ensure R1’s personal rights - Reporting Requirements - Administrator Qualifications and Duties - Change of condition for residents regarding LIC602 and updating Needs and Service Plans LPA conducted a health and safety walk through of the facility indoors and around the premises, finding it at a comfortable temperature, clean, odor free, exits free from obstructions and organized. Residents were clean and dressed appropriately. Resident have access to outdoor. There was an ample supply of hygiene products for residents' care. There was also an ample supply of healthy perishable and non-perishable food as required by Title 22. All toxins and chemicals were locked and secure. Medication cabinet was locked. Fire and smoke alarms were tested and operational. No deficiencies cited during today's NCC Visit. Copy of report given and read with administrator.the state’s words, verbatim · CDSS document, Jun 10, 2026

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Ethel Contreras arrived unannounced for the purpose of a Non-Compliance (NCC) Quarterly visit and was greeted by Caregiver, Maria Rivera. Administrator Josephine Mendoza arrived shortly after. This facility was placed on a non-compliance (NCC) on 6/24/2025 for a two-year term by Community Care Licensing (CCL); Concerns addressed in NCC meeting on 06/24/2025 were: - Facility failed to ensure R1’s personal rights - Reporting Requirements - Administrator Qualifications and Duties - Change of condition for residents regarding LIC602 and updating Needs and Service Plans LPA conducted a safety and walk through of the facility indoors and around the premises, finding it at a comfortable temperature, clean, odor free, exits free from obstructions and organized. Residents were clean and dressed appropriately. There was an ample supply of hygiene products for residents' care. There was also an ample supply of healthy perishable and non-perishable food as required by Title 22. Some food containers not labeled with food expiration dates. LPA had conversation that even if food is for staff, it needs to be labeled. All toxins and chemicals were locked and secure. Medication cabinet was locked. Fire and smoke alarms were tested and operational. -New resident move in as of 3/25/2026, all documentation found present. No deficiencies cited during today's NCC Visit. Copy of report given and read with administrator.the state’s words, verbatim · CDSS document, Apr 21, 2026

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Ethel Contreras arrived unannounced for the purpose of a Non-Compliance (NCC) Quarterly visit and was greeted by Caregiver, Maria Rivera facility designee (FD) was present at facility. Administrator Josephine Mendoza was available via telephone. This facility was placed on a non-compliance (NCC) on 6/24/2025 for a two-year term by Community Care Licensing (CCL); Concerns addressed in NCC meeting on 06/24/2025 were: - Facility failed to ensure R1’s personal rights - Reporting Requirements - Administrator Qualifications and Duties - Change of condition for residents regarding LIC602 and updating Needs and Service Plans LPA conducted a safety and walk through of the facility indoors and around the premises, finding it at a comfortable temperature, clean, odor free, exits free from obstructions and well organized. Residents were clean and dressed appropriately. There was an ample supply of hygiene products for residents' care. There was also an ample supply of healthy perishable and non-perishable food as required by Title 22. Food labeled with expiration dates. All toxins and chemicals were locked and secure. Medication cabinet was locked. Fire and smoke alarms were tested and operational. LPA reviewed 5 out of 5 resident files and found all LIC602 and Needs and Service Plans to be up to date. LPA reviewed 3 employee files and all training was found to be up to date. No deficiencies cited during today's NCC Visit. Copy of report given and read with FD.the state’s words, verbatim · CDSS document, Feb 12, 2026

Type of visit: Office

Acting Regional Manager – Bethany Moellers, Licensing Program Manager - Kimberley Mota and Licensing Program Analyst – Ethel Contreras met with Licensee/Administrator Josephine Mendoza to address areas of non-compliance. On June 24, 2025, the Department received a complaint alleging a Personal Rights violation due to a staff hitting a Resident (R1) – Based on the complaint investigation the Department substantiated the allegation Personal Rights. The facility did not report this incident to Community Care Licensing. The following areas of non-compliance were addressed during the meeting today: - Facility failed to ensure R1’s personal rights - Reporting Requirements - Administrator Qualifications and Duties - Change of condition for residents regarding LIC602 and updating Needs and Service Plans. In this meeting, it was discussed: R1’s elopement risk, reporting requirement, administrator duties and qualifications. Facility is being cited Facility is being put on a two-year non-compliance plan. Facility will be referred to Technical Support Program. Resources were provided. Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted. Plan of Corrections reviewed and developed with Licensee/Administrator. Copy of report (LIC809), LIC809-D, and Appeal Rights discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Nov 19, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Nov 19, 2025

87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, the following:(1)A written report shall be submitted to the licensing agency & to the person responsible for the resident within 7 days of the occurrence of any of the events specified This requirement has not been met as evidence by: Based on interview & records review the facility failed to submit written incident report to licensing for resident (R1) after a staff violated R1’s personal rights, which possess potential health, safety, personal rights risk to clients in carethe state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: Licensee to submit a plan of how facility will ensure future compliance regarding required written reports by 12/1/25.

Type of visit: Case Management - Annual Continuation

At approximately 1:15, Licensing Program Analyst (LPA) Contreras arrived unannounced to complete required annual inspection and was greeted by Administrator (admin) Josephine Mendoza. Fire extinguishers were observed to have been updated as of 9/24/2025 LPA reviewed 5 of 5 resident records. All required documentation was present. Physician reports were up to date. LPA reviewed 4 staff records. All required documentation was present. LPA and Admin conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies. Centrally Stored Medication Log (CSML) up to date, one medication to be missing prescription number and one PRN not listed in CSML. LPA had conversation with admin to make sure CSML is carefully being inputted (Advisory given). Following forms gathered during visit: LIC9020- Register of Residents LIC 610- Emergency and Disaster Plan LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance No Deficiencies cited during today's visit. Exit interview conducted and report read with Administrator.the state’s words, verbatim · CDSS document, Oct 15, 2025

Allegation investigated: Resident sustained unexplained injury while in care

At approximately 09:30AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this faciity unannounced to conduct an investigation into the above allegation. LPA met with Licensee Josephine Mendoza, toured the building, interviewed staff and reviewed records. LPA received copies of documents. Based on interviews conducted and records reviewed, LPA was not able to find evidence as to where or how the injury occurred. Resident, R1, was receiving Hospice services and a Hospice Aid was assisting R1 on 08/29/2025. Staff noticed R1's shirt sleeve was tight on 08/31/2025 and assisted R1 with changing the shirt. During this interaction, staff observed bruising and swelling on the arm. Based on interviews conducted, there were no prior signs of injury or pain. Staff notified the Licensee upon discovery. Hospice was contacted early, on 09/01/2025, and the duty nurse was spoken to. Hospice personnel arrived at approximately 3:45PM and assessed R1 on 09/01/2025 and ordered a mobile xray. The xray occurred on 09/09/2025, discovering a fracture. Licensee notified CCLD on 09/10/2025 of the incident. R1 did sustain an unexplained injury while in care, however, there is no indication how it occurred. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 14, 2025 · control 21-AS-20250911143745

Type of visit: Required - 1 Year

At approximately 1:40 Licensing Program Analyst(LPA) Contreras arrived unannounced to conduct a required annual inspection and met with administrator(admin) Josephine Mendoza. Facility is a Residential Care Facility for the Elderly with a fire clearance approved for five non-ambulatory residents with a hospice waiver approved for 5 residents. LPA and admin toured the building and grounds which was found to be clean and in good repair. Facility was at a comfortable temperature. LPA observed all walkways and exits to be unobstructed. All required postings were in a highly visible area. Fire extinguishers were charged and last inspected 9/11/2024. Admin to update fire extinguishers before the end of month. Fire alarms and carbon monoxide detectors were tested and operational. Outdoor emergency exit clear from obstruction. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable foods. Facility kitchen, refrigerators and freezers were clean, and food was stored properly with expiration dates noted. Toxins are stored in a locked cabinet and inaccessible to residents. Sharps and knives were locked in kitchen drawer. Emergency water and food supply was stored in garage. Facility had an ample supply of linens, towels and extra hygiene products for residents. All bedrooms were equipped with lighting, a night stand and chest of drawers. All bedrooms were clean and in good repair. Resident bathroom had required bath mat and grab bar. Disaster drills are conducted monthly with the last drill conducted on 7/2025. LPA will return to complete visit at another date. No deficiencies or advisories given during today's visit.the state’s words, verbatim · CDSS document, Sep 23, 2025

Allegation investigated: Personal rights

Licensing Program Analyst (LPA) Loera arrived unannounced and met with Maria Rivera, House Manager to deliver findings of a complaint investigation-initiated June 27, 2025. During the course of this investigation, outside records were reviewed, observations made, police report and body worn camera reviewed, interviews conducted. Complaint alleges a personal rights violation due to staff (S1) slapping Resident (R1). Based on interviews that were conducted with facility staff, outside parties and records reviewed, it was determined that during the investigation S1 admits to hitting R1 on the forehead to get them to sit in the chair. Licensee stated that R1 was not slapped and that it was a misunderstanding. S1 used their hand to push R1 on the forehead to sit back into their chair to avoid R1 from wandering away from the facility and the slap was the chair hitting the wall. S1 stated that they used their hand to push R1 on the forehead to sit back into their chair and lost their balance falling forward and hitting the wall with their hands causing the slapping sound. Although there are inconsistencies regarding R1 being slapped, there is sufficient evidence that R1’s personal rights were violated by being pushed on the forehead to sit in their chair. continued on LIC9099C Substantiated Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 1, and/or Health and Safety Code is being cited on the attached LIC 9099D. Appeal rights given.the state’s words, verbatim · CDSS document, Jul 17, 2025 · control 21-AS-20250624132401

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(10) · Plan of correction due date: Aug 11, 2025

1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all the following rights: (10) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse...... This requirement was not met as evidence by: R1 being pushed down on the forehead to remain seated by S1. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 17, 2025

Plan of correction: Licensee to schedule training with all care staff regarding personal rights of residents. Licensee to provide scheduled training date to CCL by POC due date of 7/30/2025. Proof of training to include type of training along with staff names and signatures. Training to be submitted by POC due date of 08/11/2025.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Araceli Canela arrived unannounced to conduct a Required - 1 Year inspection and met with Administrator Josephine Mendoza. There are currently 6 residents in care with 2 staff at the time of inspection. This facility is licensed for 6 non-ambulatory residents, with hospice waiver approved for 5 of the residents and no approval for bedridden. There are currently 2 residents receiving hospice services. LPA toured facility and grounds and observed all required signs posted in common areas. Infection control practices are present. Facility was found to be at a comfortable temperature with all exits free from obstruction. Facility has at least two days supply of perishable and one week of non-perishable foods and items are stored properly. Fire Extinguishers were fully charged, and have proof of service on 9/11/24. Smoke detectors and carbon monoxide detectors were tested and operational. Fire drills are conducted and the last one was documented on 10/2/2024 . Water temperature in the resident bathroom was tested and found to be within appropriate range of 105-120 degrees. Exit doors have auditory alarms to alert staff. The bedrooms are all furnished as required. Bathrooms were clean and sanitary with non-skid mats/floors and grab bars. The outside grounds have plants, fruit trees, and provide easy access for the residents to enjoy fresh air. The shed in the back yard is for storage of equipment only. Resident and staff files are located and locked in cabinet. LPA reviewed resident files and were found complete and organized. Staff files were complete, organized, with proof of required annual training and CPR/1st Aid certificates expiring 3/14/2025. Continue report see LIC809-C Administrator certificate for Josephine Mendoza # 6018160740 expired 7/9/2024, but it was renewed and waiting for new certificate. Licensee/Administrator submitted all the below documents to LPA, during visit. · LIC 308 Designation of Facility Responsibility · LIC 500 Personnel Report- · LIC 400 Affidavit Regarding Client/Resident Cash Resources · LIC 610E Emergency Disaster Plan · LIC 9020 Register of Facility Residents Copy of Liability Insurance- exp 7/1/2025 No citations issued during todays inspection.the state’s words, verbatim · CDSS document, Nov 1, 2024