Mendoza Care Home IV

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Contreras arrived unannounced to conduct a required annual inspection and was greeted by administrator (admin) Mary Jane Mendoza. Facility is an Adult Residential Care Facility for the Elderly with an approved fire clearance for capacity of 6 (six) residents. There are currently four (4) residents in care. LPA toured the building and grounds which was found to be clean and 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 5/19/2025. Fire alarm and carbon monoxide alarms all tested and operational.Outdoor furniture accessible for resident use. Water temperature check measured within regulation at faucets accessible to residents within the allowable range of 105 to 120 degrees F. Resident bathrooms observed to have bath mat and grab bar. Disaster drills are being conducted quarterly. All bedrooms were equipped with required furnishing .There is a signal system on each resident's bedroom door to alert staff for assistance. One out of four room signal system was not operational. Admin replaced batteries and LPA had conversation to ensure that it is kept on and functioning at all times (Technical Violation given). Facility had an ample supply of linens, towels and extra hygiene products for residents. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable foods. Snacks accessible for residents. Emergency food was observed to meet the 72 hour emergency supply. Emergency water not observed to meet the 72 hour emergency supply (Technical Violation given). Facility kitchen, refrigerators and freezers were clean, and food stored properly. Expiration dates were noted in food items found in refrigerator. Toxins are locked and inaccessible to residents. Sharps and knives were locked. Phone accessible for resident use. continued onto 809C..... continued from 809.... LPA conducted a file review for 4 of 4 residents. All required documentation found to be up to date. LPA conducted file review for 3 staff. All required documentation found to be up to date. LPA and admin conducted a spot check of medication and medication records, all records up to date. Medication is centrally stored and locked. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility Liability Insurance (Retrieved during visit) No deficiencies cited for today's visit. Exit interview conducted and report read with Administratorthe state’s words, verbatim · CDSS document, Apr 21, 2026

Type of visit: Required - 1 Year

At approximately 09:25AM Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct an Annual Required 1 Year inspection and met with Administrator, Mary Jane Mendoza. Upon arrival, LPA was informed that, there are currently 5 residents in care. This facility is licensed for 6 non-ambulatory residents, with hospice waiver approved for 2 of the residents and none of the residents are approved for bedridden. At approximately 10:05AM LPA toured the building and grounds which was found to be clean at a comfortable temperature and in good repair. All walkways and exits were observed to be unobstructed. Client rooms were furnished per regulation. Water temperature accessible to clients in care measured 107.2 degrees F which are within the required regulation range of 105 to 120 degrees F. Extra hygiene products and linens were available. Cleaning supplies are locked and not accessible to clients. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Fire extinguishers were last serviced 05/11/2024. Smoke/Carbon Monoxide detectors were operational. Most recent fire/disaster drill was conducted January 11, 2025 At approximately 11:15PM, LPA reviewed 5 resident records. Administrator stated 2 out of 5, residents R1 and R2 waiting the Appraisal & Needs Service Plan to be signed by the resident representative for R1 and R2 (Technical Advice Given). Every resident has I.D. and Emergency Information document on file. All clients have medical assessments are updated. Continued on LIC809-C… Continued from LIC809… At approximately 11:35AM, LPA reviewed 3 staff records and staff files were containing all required documents per regulation. LPA was presented with proof of current CPR, & 1st Aid certification for all staff. Administrator Certificate for Administrator Mary Jane Mendoza current and expires on 01/08/2027. Certification No: 7006815740(RCFE) Medications and medication records were reviewed. Medication records contained physician's orders for each resident. Medications were centrally stored and locked in medication file cabinet. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on January 11,, 2025. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC 308 Designated LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan LIC 9020 Register of Facility Resident’s Copy of Updated Certificate of Liability Insurance No Deficiencies Cited during Visit. Exit interview conducted. Copy of report discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documentsthe state’s words, verbatim · CDSS document, Apr 7, 2025

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

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, Mary Jane Mendoza. There are currently 5 residents living in this facility. This facility is licensed for 6 non-ambulatory residents, with hospice waiver approved for 2 of the residents and none of the residents are approved for bedridden. LPA toured facility and grounds and observed facility was found to be clean at a comfortable temperature with all exits free from obstruction. Resident rooms have the required furnishings and linens. Medications are stored locked in cabinet in the living room area along with resident files. Facility has at least two days of perishable and one week of non-perishable foods. Fire Extinguisher was found to be charged, and serviced. Smoke alarms and Carbon monoxide detector are operational. Facility last fire drill was conducted on May 1, 2024. Water temperature in bathrooms measured within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. LPA reviewed resident and staff files and staff files had the required training and proof of CPR/1st Aid expiring 6/6/2025. Resident files were reviewed Continue report see LIC809-C Licensee/Administrator to submit the current following documents by 6/15/2024: · LIC 308 Designation of Facility Responsibility · LIC 500 Personnel Report · LIC 610E Emergency Disaster Plan · LIC 9020 Register of Facility Residents Infection Control Plan of Operation (If changes) Liability Insurance No citations issued during todays visit.the state’s words, verbatim · CDSS document, May 17, 2024